Oral health of institutionalised elderly: a qualitative study of health caregivers’ perceptions in Brazil

Establishing an empirical conceptual model of oral health in dependent adults: Systematic review

AIM

This qualitative evidence synthesis was performed to establish a conceptual model of oral health in dependent adults that defines the construct of oral health and describes its interrelationships based on dependent adults' and their caregivers' experiences and views.

METHODS

Six bibliographic databases were searched: MEDLINE, Embase, PsycINFO, CINAHL, OATD, and OpenGrey. Citations and reference lists were manually searched. A quality assessment of included studies was conducted independently by two reviewers using the Critical Appraisal Skills Programme (CASP) checklist. The 'best fit' framework synthesis method was applied. Data were coded against an a priori framework and data not captured by this framework were thematically analyzed. To assess the confidence of the findings from this review, the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach was used.

RESULTS

Twenty-seven eligible studies were included from 6126 retrieved studies. Four themes were generated to further understand oral health in dependent adults: oral health status, oral health impact, oral care, and oral health value.

CONCLUSION

This synthesis and conceptual model offer a better understanding of oral health in dependent adults and subsequently provide a starting point to guide establishment of person-centred oral care interventions.

Oral healthcare provision at long-term care facilities in eThekwini: Perspectives of coordinators

BACKGROUND

The prevalence and impact of oral disease among long-term institutionalised residents highlight the need for a scale-up of preventive and promotional oral health services that include oral health education and training for caregiving staff. However, opportunities to improve oral healthcare services are met with challenges.

AIM

This study was undertaken to establish coordinator perspectives on oral health provision.

SETTING

Seven long-term care facilities in the eThekwini district, South Africa.

METHODS

An in-depth exploratory study was conducted with 14 purposively selected coordinators (managers and nurses). Semi-structured interviews were conducted and focused on coordinators' experience and perspectives on oral healthcare. Data were analysed using thematic analysis.

RESULTS

The following themes emerged from the study: A lack of comprehensive oral health care practices, inadequate support from the dental sector, insufficient oral health prioritisation, limited funding for oral health, and challenges associated with coronavirus disease (COVID-19). All respondents reported that no oral health initiatives existed. Plans for oral health training workshops presented with coordination and funding challenges. Oral health screening initiatives have ceased since COVID-19.

CONCLUSION

The study findings indicated that prioritisation of oral health services was inadequate. There is a need for continual oral health in-service training for caregivers and support from coordinators in guiding the implementation of oral health training programmes.Contribution: It is envisaged that the findings of this study will bring about greater coordinator involvement and collaboration with the public and private dental sectors to improve oral healthcare at long-term care facilities.

Perspectives of community-dwelling older adults with dementia and their carers regarding their oral health practices and care: rapid review

AIM

To review evidence on oral health practices, beliefs/views and experiences of community-dwelling older adults living with dementia, including their carers.

MATERIALS AND METHODS

A search of key terms across six databases including Pubmed, Web of Science and OVID (Embase, MEDLINE [R] and PsycINFO) and Google Scholar was conducted, supplemented by reference screening. The Mixed Methods Appraisal Tool (MMAT) 2018 was used to assess the methodological quality.

RESULTS

Eighteen studies reported across 19 papers were included in the review. Papers largely focused on normative needs (n = 13), whilst also reporting oral health-related experiences (n = 2), practices (n = 7), and beliefs/views (n = 9), of community dwellers with dementia. Generally, people living with dementia presented with poor oral and dental health, the exception being one study where dental care was integrated with memory clinic services. Maintenance of oral health focused only on toothbrushing. Overall, people living with dementia have reduced capacity for self-performed oral hygiene and high reliance on caregivers. There was a paucity of evidence on their perceptions of oral health and quality of life, the findings of which were equivocal, with weak evidence suggesting possible difficulty in identifying and communicating their needs. Experiences of accessing dental care, when explored, appear to be system dependent.

CONCLUSION

There was limited research evidence on oral health-related practices, beliefs/views and experiences of people with dementia. Recommendations for future research are presented.

An Interprofessional Approach to Oral Hygiene for Elderly Inpatients and the Perception of Caregivers Towards Oral Health Care

OBJECTIVE

The objective of this study was to investigate the effect of an interprofessional oral hygiene support program for elderly inpatients and the perception of caregivers of the elderly towards oral health care.

MATERIALS AND METHODS

Participants comprised 37 elderly inpatients requiring nursing care (17 males, 20 females; mean age, 83.3 ± 4.9 years) and 29 registered nurses who participated in the interprofessional oral health care support program as a caregiver (4 males, 25 females; mean age, 45.2 ± 10.3 years). In this program, inpatients received daily oral cleaning by registered nurses based on each patient's oral health care plan. The number of microbes on the tongue surface of the inpatients was measured once a week for 12 weeks. Additionally, as an investigation of the perception of the caregivers towards oral health care, a questionnaire about the required frequency and duration for oral cleaning was conducted with registered nurses before and after the program to investigate the perception of the caregivers towards oral health care.

RESULTS

Significant differences were observed in the number of microbes on the tongue surface between baseline and at every measurement after the beginning of this program, except for the first week. The mean required frequency and duration for oral cleaning by registered nurses at baseline were 1.5 ± 0.8 times and 3.8 ± 2.2 minutes, whereas those after the program were 2.7 ± 0.7 times and 5.8 ± 2.9 minutes, respectively.

CONCLUSION

Implementation of the program decreased the number of microbes on the tongue surface of the elderly inpatients and improved the perception of their caregivers towards oral health care.

Barriers and facilitators for provision of oral health care in dependent older people: a systematic review

OBJECTIVES

Provision of oral health care (OHC), including oral hygiene (OH) or oral/dental treatment, to dependent older people (DOP) is frequently insufficient. We aimed to assess barriers and facilitators perceived by different healthcare professionals towards providing OHC to DOP.

MATERIALS AND METHODS

A systematic review was performed. Studies reporting on knowledge, attitudes, and beliefs acting as barriers and facilitators for provision of OHC were included. One database (PubMed) was searched and data extraction independently performed by two reviewers. Thematic analysis was used and identified themes translated to the domains and constructs of the theoretical domains framework (TDF) and aligned with the domains of the behavior change wheel (BCW). Analyses were stratified for the two target behaviors (providing oral hygiene and providing oral/dental treatment) and according to different stakeholders' perspective. For quantitative analysis, frequency effect sizes (FES) were calculated.

RESULTS

In total, 1621 articles were identified and 41 (32 quantitative, 7 qualitative, 2 mixed method) studies included. Within these 41 studies, there were 7333 participants (4367 formal caregivers, 67 informal caregivers, 1100 managers of care, 1322 dentists, 340 DOP). Main barriers for providing OH were "lack of knowledge" (FES 65%, COM-B domain: capability, TDF domain: knowledge) and "patients refusing care" (62%, opportunity, environmental context and resources). Main facilitators were "OHC training/education" (41%, capability, skills) and "presence of a dental professional" (21%, opportunity, environmental context and resources). Main barriers for provision of dental treatment were "lack of suitable facilities for treatment/transportation of patients" (76%) and "patients refusing care" (53%) (both: opportunity, environmental context and resources). Main facilitators were "regular visiting dentist" (35%) and "routine assessment/increased awareness by staff" (35%) (both: opportunity, environmental context and resources).

CONCLUSIONS

A number of barriers and facilitators for providing different aspects of OHC were identified for different stakeholders.

CLINICAL RELEVANCE

Our findings help provide the evidence to develop implementation strategies for providing high-quality systematic OHC to DOP.

REGISTRATION

This review was registered at Prospero (CRD42017056078).

Xerostomia and hyposalivation in orthogeriatric patients with fall history and impact on oral health-related quality of life

Purpose

Falls are a common cause of morbidity and mortality in older people, and identification of risk indicators and risk factors to prevent falling is essential. Dry mouth (xerostomia and hyposalivation) can exacerbate conditions known to be fall risk indicators, such as nutritional status and sarcopenia. But there is little evidence regarding whether it is an independent risk factor for falling. We explored xerostomia prevalence and intensity and objective salivation rates in hospitalized geriatric patients to determine whether they were associated with an increased risk of falling.

Patients and methods

Hospitalized geriatric patients with and without a fall history were compared. We investigated several oral health issues including xerostomia, stimulated and unstimulated salivation rates, total number of teeth and prosthetics, periodontal status, and oral health-related quality of life.

Results

Forty patients were included, 28 in the fall history group and 12 in the control group. All patients had oral health issues that impacted on their oral health-related quality of life. However, there were no significant differences between the groups, including xerostomia and hyposalivation, apart from increased dysphagia and less flavor in food in patients with a fall history.

Conclusion

Dry mouth does not appear to be an independent risk factor for falling in this population, but oral health was impaired. Thus, it is important that dentists and geriatricians are aware of and investigate these conditions in their patients and that appropriate action is taken to reduce the consequences of impaired oral health, including a potential reduction in falls.

Looking after the mouth - Evaluation of a pilot for a new approach to training care home carers in Kent, Surrey and Sussex

Objective This pilot study aimed to produce and evaluate training resources and training in oral health care, including oral hygiene, for carers in care homes in Surrey and Medway.Methods During two training days, for carers from these homes, short, interactive presentations were given on a range of topics relevant to oral health care and oral hygiene of older people, followed by practical training. Prior to any training all attendees completed a 39 question questionnaire to establish their baseline knowledge of oral health and hygiene. At the end of the training day they completed an evaluation form. Fourteen weeks later, they were visited at their place of work and completed the same questionnaire again. Differences in responses between baseline and after 14 weeks were statistically tested using the chi-squared test.Results Sixty-six carers attended the training sessions and 44 were followed up 14 weeks later. The results showed an improvement in carer knowledge at follow up. The majority of carers (36/44) spoke English as their first language. They had a mean age of 41 years, 37 were female and 7 male. They had worked as carers for a mean of 10.9 years (range 4 months-34 years). Over 90% stated that the training day fully met or exceeded their requirements and expectations.Conclusions The results indicated improvements in carer knowledge. However, the carers were atypical of carers in general, as they were self-selected and well-motivated. Nevertheless the content of the training day and the questionnaire should inform future work in this area.

Validity and reliability of the oral health-related caregiver burden index

OBJECTIVE

This study developed the Oral Health-related Caregiver Burden Index (OHBI), which contains nine questions with five response options each. As a secondary objective, we aimed to clarify the relationship between oral health-related caregiver burden and general caregiver burden.

BACKGROUND

There are a few reports of the oral health-related caregiver burden.

METHODS

Between January 2016 and February 2016, 155 participants enrolled in the study. We conducted the survey to examine the validity and reliability of OHBI. Additionally, the cut-off score for this scale was calculated, and the relationship between OHBI and general caregiver burden (BIC-11) was examined by binomial logistic regression.

RESULTS

Survey 1 was completed by 102 caregivers, of whom 58 (56.9%) were female. Survey 2 was completed by 40 caregivers, of whom 22 (55.0%) were female. Factor analysis revealed four factors in OHBI. Cronbach's α was .691-.866. OHBI scores were significantly associated with scores for each factor of the BIC-11. OHBI had a cut-off score of 10 (AUC=.881, sensitivity=.828, specificity=.744). A good-poor analysis revealed significant differences for discriminant validity. ICC, an indicator of reliability, was .449-.842. There was a significant relationship between caregiver burden and oral health-related caregiver burden according to binomial logistic regression analysis (P<.05).

CONCLUSION

We developed the OHBI as a multidimensional care burden scale, which comprises nine items covering five domains. Further, we verified the relationship between general caregiver burden and oral health-related caregiver burden.

Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta-analysis

BACKGROUND

Oral health of nursing home residents is generally poor, with severe consequences for residents' general health and quality of life and for the health care system. Care aides in nursing homes provide up to 80% of direct care (including oral care) to residents, but providing oral care is often challenging. Interventions to improve oral care must tailor to identified barriers and facilitators to be effective. This review identifies and synthesizes the evidence on barriers and facilitators care aides perceive in providing oral care to nursing home residents.

METHODS

We systematically searched the databases MEDLINE, Embase, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. We also searched by hand the contents of key journals, publications of key authors, and reference lists of all studies included. We included qualitative and quantitative research studies that assess barriers and facilitators, as perceived by care aides, to providing oral care to nursing home residents. We conducted a thematic analysis of barriers and facilitators, extracted prevalence of care aides reporting certain barriers and facilitators from studies reporting quantitative data, and conducted random-effects meta-analyses of prevalence.

RESULTS

We included 45 references that represent 41 unique studies: 15 cross-sectional studies, 13 qualitative studies, 7 mixed methods studies, 3 one-group pre-post studies, and 3 randomized controlled trials. Methodological quality was generally weak. We identified barriers and facilitators related to residents, their family members, care providers, organization of care services, and social interactions. Pooled estimates (95% confidence intervals) of barriers were: residents resisting care=45% (15%-77%); care providers' lack of knowledge, education or training in providing oral care=24% (7%-47%); general difficulties in providing oral care=26% (19%-33%); lack of time=31% (17%-47%); general dislike of oral care=19% (8%-33%); and lack of staff=22% (13%-31%).

CONCLUSIONS

We found a lack of robust evidence on barriers and facilitators that care aides perceive in providing oral care to nursing home residents, suggesting a need for robust research studies in this area. Effective strategies to overcome barriers and to increase facilitators in providing oral care are one of the most critical research gaps in the area of improving oral care for nursing home residents. Strategies to prevent or manage residents' responsive behaviors and to improve care aides' oral care knowledge are especially needed.

Does enhancing personal care assistants' own oral health influence their attitudes and practices towards oral care for residents - a pilot study

OBJECTIVES

To investigate whether, within a residential care facility, increasing personal care assistants' (PCAs) awareness of their own oral health status and self-care skills would alter existing attitudes and behavioural intentions related to the oral health care of residents.

METHODS

PCAs (n = 15) in the dementia care unit of a residential care facility in Melbourne, Australia, were invited to participate in a small research project that appeared to test the effectiveness of a work-place oral health educational programme in enhancing their own oral health whilst masking the actual outcome of interest, namely its effect on PCAs oral healthcare attitudes and practices towards the residents.

RESULTS

Post-intervention, the self-reported confidence of the PCAs to identify their personal risk for oral health problems, identifying common oral health conditions and determining the factors contributing to their personal oral health was increased significantly (P < 0.05). Post-intervention, the self-reported confidence of the PCAs to feeling confident to identify factors that could contribute to poor oral health of residents, identify resident's higher risk for poor oral health and feeling confident in identifying common oral health conditions in residents was also increased significantly (P < 0.05).

CONCLUSION

The results of this pilot study show that the educational intervention to increase the personal care assistants' (PCAs) awareness of their own oral health status and self-care skills increased the confidence of the carers to identify oral health risks in the residents, as well as increasing their self-reported confidence in providing oral care to residents.

Culturally and linguistically diverse (CALD) carers' perceptions of oral care in residential aged care settings in Perth, Western Australia

OBJECTIVE

The aims of the study were twofold: to explore African migrant carers' perceptions of oral health who worked in residential aged care and to investigate their perspectives of oral care for aged care residents.

BACKGROUND

Culturally and linguistically diverse (CALD) carers are strongly represented in Australian residential aged care facilities.

METHODS

Exploratory qualitative research targeted carers from African backgrounds working in residential aged care facilities in Perth, Western Australia. Fifteen African carers were recruited through community networks and participated in semistructured interviews. Data were analysed for key themes related to the study's aims noting similarities and differences between participants.

RESULTS

All participants considered oral health important to individual well-being and quality of life. Most had limited knowledge of prevention and early detection of oral disease resulting from regular dental check-ups with the majority visiting dental professionals only for dental pain. Yet participants considered oral health care for residents needed improvement. Suggestions included dental professionals on staff and training and professional development for all staff not just in oral health care but also in working respectfully and sensitively with residents and staff from CALD backgrounds.

CONCLUSION

Our findings suggest that, to ensure residents receive high quality oral health care, ongoing professional development is required, not only for CALD carers in oral health but also for non-CALD staff in care that is respectful of cultural differences.

Association between oral health and body cell mass in hospitalised elderly

OBJECTIVE

To examine whether oral health in hospitalised elderly was associated with body cell mass (BCM) measured with Bioimpedance spectroscopy.

BACKGROUND

Body cell mass is the tissue producing the metabolic work necessary for all body functions. BCM is mainly muscle tissue. Low BCM is associated with diseases, ageing and poor nutritional status. Reduced oral health is also associated with these parameters; thus, BCM and oral health may be related.

METHODS

Body cell mass was measured using Bioimpedance spectroscopy in 138 acutely hospitalised elderly ≥70 years. The number of own teeth, posterior occluding tooth pairs and decayed teeth were registered. Oral hygiene was registered with Mucosal-Plaque Score, an index based on assessment of plaque accumulation and mucosal/gingival inflammation. Mini Nutritional Assessment-Short Form, body mass index and handgrip strength were used as nutritional indicators. Comorbidity was assessed with Cumulative Index Rating Scale.

RESULTS

Mean age was 83.2 ± 5.9 years, ranging from 70 to 101 years. Dentition status was significantly and positively associated with BCM. Reduced oral hygiene was significantly associated with low BCM. These findings remained significant after adjusting for confounders.

CONCLUSION

These results show that compromised oral health was significantly associated with reduced BCM in hospitalised elderly.