Patient-Centered Care for an Aging Population

In modern dental practice, new screening efforts are helping clinicians extend patient care beyond preventive treatment and other traditional chairside services. As part of supportive and individualized patient management, dentists are assuming a larger role on the extended healthcare team and are increasingly acting as portals to interdisciplinary referrals. For example, as the U.S. population continues to age, this approach may allow oral health professionals to promote active and healthy aging.

By 2050, the number of older adults will exceed the number of young individuals worldwide; referred to as population aging, this development is without precedent in human history.¹ Given these projections, dental teams may consider expanding their scope of practice to include assessments that allow early detection of overall health risks and referral to health promotion resources and services that may support the effective management of health conditions in older adults.

Among this patient cohort, musculoskeletal injuries, such as hip, vertebral or distal forearm fractures, present significant health problems. In 2010, the annual rate of hospitalization for musculoskeletal conditions ranged from 3% among those ages 65 to 74 to 5% among individuals ages 75 to 84, while it rose to 8% in those 85 and older.

Older women are more likely than older men to be hospitalized for musculoskeletal conditions.² Each year, 2% of noninstitutionalized individuals age 65 and older report a fracture and 2% experience a dislocation or sprain.² Fractures due to a fall are even more frequent among nursing home residents. People with musculoskeletal conditions often have physical limitations that impede their ability to perform routine oral healthcare activities, ultimately contributing to increased healthcare needs.²

PERSON-CENTERED ORAL HEALTHCARE

In the United States, more adults tend to see the dentist each year than their physician.³ Patients regularly visit the dental office for preventive care, but may see a physician only when ill. Often, patients develop a long-term relationship with their oral health professionals. These practice patterns provide an opportunity in dental settings to expand access to, or facilitate delivery of, preventive healthcare services that could promote and sustain healthy aging.

Given that the incidence of chronic disease and emergence of other health concerns increase over the lifespan, early identification of health issues provides an opportunity for those at risk to benefit from primary prevention activities. These may include initiating behavior changes that could modify risk factors (e.g., dietary modifications, increased physical activity, or pharmacological therapy); delaying disease onset; or controlling disease severity. Research has documented patients’ willingness to undergo screening for health conditions as part of a dental visit to aid in disease prevention, assist in controlling disease progression, and prevent complications.⁴

A growing body of research is documenting the feasibility, acceptability and value of integrating screening for various conditions — including diabetes, cardiovascular disease and obesity — as part of oral health services and community outreach activities.^3–6 Physicians have acknowledged the utility of this multidisciplinary approach as a means of identifying individuals at risk for adverse health events.^3,5 In 2004, Columbia University College of Dental Medicine and its partners instituted the ElderSmile program.⁵ This initiative integrated health screenings with oral health outreach activities at a community senior center, which strongly demonstrated the public health value of this integrated service. The program goals were to improve access to, and delivery of, oral healthcare for older adults and establish and operate a network of prevention centers.⁶ Health screenings delivered through ElderSmile identified older adults with undiagnosed hypertension (25%) and diabetes (8%), as well as individuals whose diagnosed hypertension (38%) and diabetes (38%) were not under control.⁶ The ElderSmile program is a replicable model for community-based oral and general health screening.^5,6

SCREENING FOR FALL RISK

A preliminary investigation was conducted to assess the feasibility and utility of initiating screening and referral for fall risk in community dental clinics. A history of falling and associated risk factors were collected from a convenience sample of patients age 65 and older visiting the New York University College of Dentistry’s low-cost clinic. About one in five (18%) reported a fall in the previous year. The older adults who had fallen were more likely to be women, at advanced age (85 and older), and not currently married (Table 1). In terms of functional status, individuals with a history of falling were more likely to report needing assistance when traveling to appointments compared to those who did not report a fall (33% versus 9%). Additionally, these patients were more likely to misplace items and forget appointments than those without a history of falling (33% versus 3%).

Regarding physical health status, those who reported falling were more likely than those who did not fall to have been hospitalized or undergone surgery in the past five years (57% versus 31%). In addition, they were almost twice as likely as those without a fall to report balance problems (29% versus 16%). Similarly, those who had fallen were more likely to be taking medications, vitamins or herbal supplements (86% versus 66%). They were also more likely to report having chronic health conditions, such as arthritis (71% versus 47%), allergies (71% versus 26%), or osteoporosis (57% versus 14%).

Overall, the insights from this preliminary exploration support the feasibility of dental screening for fall risk (Figure 1). Such an initiative would expand the reach of evidence-based fall-prevention programs to older adults who could benefit from earlier access to such interventions. These include those who have fallen, but have not experienced a serious fall, and those who have one or more factors increasing their fall risk (e.g., a problem with balance), but have not yet fallen. Early implementation of a fall prevention program for at-risk individuals could forestall a serious injury.^7–9

PROCESS OF HEALTH BEHAVIOR CHANGE

As postulated by the Precaution Adoption Process Model,¹⁰ health behavior change is a dynamic process with many determinants, accomplished in a series of cognitive-behavioral stages over time. Informed by this framework, the process of screening patients and making them aware of their health risk acts as a catalyst to move patients from Stage 1 (being unaware of the issue) to Stage 7, in which a decision is made to not only act, but to maintain the action and/or behavior.¹⁰

Individuals move from Stage 1 toward Stage 2, where they are aware, but unengaged in the issue. During Stage 3, the contemplation stage, the patient is undecided about acting, then progresses to the decision stages, where the patient has either decided not to act (Stage 4) or decided to act, but is not yet in action (Stage 5). In Stage 5, the decision has been made to act, and in Stage 6 action begins. Most important, in Stage 7 the decision is forged to maintain the action.¹⁰ Progressing to this final stage of sustained health behavior change could extend the period of active aging and promote longevity. Providing ongoing screening opportunities for a health condition provides a stimulus that may move an individual toward action or to reconsider an earlier decision not to act.

INTERVENTION AND REFERRAL

Despite the high rate of fall-related morbidity and mortality, limited research and evidence-based programming have focused on community-based fall prevention.^7,8 In the United States, falls are the leading cause of injury and injury-related death for older adults. Each year, about 30% of community residents age 65 and older experience a fall, with about one in five falls resulting in hospitalization.⁷ With the aging of the population, the magnitude of this public health issue will continue to grow, as the highest fatality rates from falls occur in those age 85 and older.⁹

The U.S. Centers for Disease Control and Prevention recommends that healthcare providers conduct a fall risk evaluation on any community-dwelling adult age 65 and older to assess modifiable risk factors and recommend interventions to reduce these risks.⁹ Similarly, in a joint statement, the American Geriatrics Society and British Geriatrics Society recommend that an assessment be done on anyone age 65 and older who presents for medical attention because of a fall, demonstrates balance issues or difficulty walking, or reports recurrent falls in the past year.¹¹ The risk of a fall increases with age, with the potential for serious fall-related injury increasing exponentially.⁷ While the majority of falls occur indoors and/or at home, outdoor falls are common.¹²

Fall-prevention efforts that target multiple risk factors have been found to be effective in reducing the frequency and severity of falls.⁹ However, these programs have typically targeted older adults who have fallen and sustained an injury. Conversely, individuals who have not experienced a serious fall, but are at risk of falling, would also benefit from referral to assess modifiable risk factors and available resources.⁹ Healthcare providers, including dental teams, should strive to take an active role in injury prevention efforts. Toward this goal, dental settings are ideally suited to provide expanded screening to promote older adults’ safety and well-being. Dental clinics have established resources and affiliations that could facilitate referral to preventive services prior to an injury event — effectively delaying or preventing fall-related mishaps.

CONCLUSION

Population aging is defining the 21st century. Advances in longevity are fundamentally impacting society — and this presents both challenges and opportunities. Collectively, the dental team can play an integral role in health outreach efforts targeting older adults. While there is a tendency to explain disease and functional decline as a natural part of the aging process, adopting an interdisciplinary approach and patient-centered care can help promote active aging that allows patients to reap the benefits that an extended lifespan offers.

Early detection of risk factors by oral health professionals and timely access to medical resources and services may prevent or delay debilitating conditions from developing and also facilitate effective management. Integrating tailored health promotion and preventive interventions with the delivery of accessible oral care offers a synergistic solution to optimizing function, promoting longevity, and facilitating a pathway to healthy aging.

Given the incidence of chronic disease in aging populations and the comorbidities of oral conditions with other health concerns, the value of providing holistic, patient-centered care is evident. This approach can help sustain function, prevent or delay disability, and improve quality of life for older adults. Some of the inevitable aspects of aging — such as falling — can be largely prevented if questions related to falls and other conditions are included in dental screenings. In this respect, comprehensive dental assessments and integrated care are key to supporting healthy, active aging.

Acknowledgment: The authors thank Kim Attanasi, PhD, MS, RDH, for her assistance with this manuscript.

REFERENCES

1. Projected Age Groups and Sex Composition of the Population: Main Projections Series for the United States, 2017–2060. Washington, DC: U.S. Census Bureau; March 2018.
2. Lamster IB, Northridge M. Improving Oral Health for the Elderly: An Interdisciplinary Approach. New York: Springer; 2008.
3. Glick M, Greenberg BL. The potential role of dentists in identifying patients’ risk of experiencing coronary heart disease events. J Am Dent Assoc. 2005;136:1541–1546.
4. Bin Mubayrik A, Al Dosary S, Alshawaf R, et al. Public attitudes toward chairside screening for medical conditions in dental settings. Patient Prefer Adherence. 2021;15:187–195.
5. Greenberg BL, Thomas PA, Glick M, Kantor ML. Physicians’ attitudes toward medical screening in a dental setting. J Public Health Dent. 2015;75:225–233.
6. Marshall S, Northridge ME, De La Cruz LD, Vaughan RD, O’Neil-Dunne J, Lamster IB. ElderSmile: A comprehensive approach to improving oral health for seniors. Am J Public Health. 2009;99:595–599.
7. Marshall SE, Cheng B, Northridge ME, Kunzel C, Huang C, Lamster IB. Integrating oral and general health screening at senior centers for minority elders. Am J Public Health. 2013;103:1022–1025.
8. Panel on Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatric Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59:148–157.
9. Moreland B, Kakara R, Henry A. Trends in nonfatal falls and fall-related injuries among adults aged ≥ 65 years — United States, 2012–2018. MMWR Morb Mortal Wkly Rep. 2020;69:875–881.
10. Weinstein ND, Sandman P, Blalock SJ. The precaution adoption process model. In: Glanz K, Rimer BK, Viswanath K, eds. Health Behavior and Health Education. 4th ed. San Francisco: Jossey-Bass; 2008:23–47.
11. Burns E, Kakara R. Deaths from falls among persons aged ≥ 65 years — United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2018;67:509–514.
12. Chippendale T, Raveis V. Knowledge, behavioral practices, and experiences of outdoor fallers: implications for prevention programs. Arch Gerontol Geriatr. 2017;72:19–24.

From Decisions in Dentistry. May 2023;9(5):30-33.