Oral/dental items in the resident assessment instrument - minimum Data Set 2.0 lack validity: results of a retrospective, longitudinal validation study

Integration of a dental hygienist into the interprofessional long-term care team

BACKGROUND

To address poor oral health of residents in long-term care homes (LTCH), this study explored the process of integrating an educational resource and a dental hygienist on the interprofessional care team.

METHODS

This convergent mixed-methods study took place at a 472-bed LTCH in Toronto, Canada from February to August 2018. Nurses employed at the LTCH participated in the study. During the study period, a dental hygienist was integrated into an interprofessional LTCH team. Nurses completed an online eLearning module about using the Oral Health Assessment Tool (OHAT) when referring residents' oral health concerns to a. Pre/post knowledge quizzes, module feedback and satisfaction surveys were administered. A retrospective chart review examined OHAT use and compared nurse and dental hygienist oral health assessments. Two cycles of semi-structured interviews with five nurses explored experiences with the eLearning module, OHAT and integration of the dental hygienist into the team.

RESULTS

Nurses scored well on the knowledge quizzes and reported comfort in using the OHAT to refer oral concerns to a dental hygienist; however, actual use was minimal. oral health issues were under-reported by nurses on the Resident Assessment Instrument-Minimum Data Set (RAI-MDS); the dental hygienist reported significantly more debris, teeth lost and carious teeth (all P < 0.0001). Qualitative analysis indicated that the nurses valued dental hygienist integration into the team. Using knowledge mobilisation practices, a new oral health referral tool was developed.

CONCLUSIONS

This study highlights the feasibility and desirability of an oral health eLearning module, practical assessment tools and participation of a dental hygienist on the LTCH interprofessional care team.

Oral health assessment in institutionalized elderly: a scoping review

When elderly become frail and in need for complex care, they can no longer live independently at home and may be admitted to nursing homes. Various studies have shown that oral health in this population is remarkably poor, which may lead to distressing situations and impacts quality of life. A variety of definitions or descriptions for oral health is used. Without a uniform parameter, it is impossible to determine whether oral health in institutionalized elderly is actually improving or deteriorating over time, as well as the effect of (preventive) interventions. In search for an adequate and clinically applicable parameter to determine oral health in this specific patient group, this scoping review aims to give an overview of the currently used parameters for determining oral health in institutionalized elderly. Ninety different parameters were identified, and 50 parameters were solely used by one study. Only 4 parameters were frequently used (in > 20 studies). The relevance of these parameters for this specific patient group is discussed. To aid the planning and commissioning of future research and patient care, there is an urgent need for an adequate and uniform parameter for oral health determination in institutionalized elderly.

Development of a Minimum Data Set for Dental Implants Registry

Objectives: Registries are powerful tools for the collection and distribution of valid and reliable data. The initial step in health information management is to design a minimum data set that can improve the collection of high-quality data from the registry. The present pilot study aimed to determine the optimal minimum data set for dental implants to effectively utilize at Tehran University of Medical Sciences, Tehran, Iran. Materials and Methods: This descriptive cross-sectional study was conducted in 2019 at Tehran University of Medical Sciences. A minimum data set checklist was developed based on our previous systematic review. The content validity of the minimum data set was approved by the recruited experts and the final minimum data set was established using the Delphi technique. Results: The minimum data set for dental implants consists of two separate sections - administrative and clinical data. The administrative portion includes two main segments: patient demographic data and clinic data, consisting of 12 data elements. The clinical part includes five main segments (patient clinical data, implant data, implant complications, implant loss, and implant follow-up), and contains 96 data elements. Conclusion: This study suggests a minimum set of data for dental implants that can aid in efficient management of information, facilitate evidence-based decision-making, and enable high-quality clinical research, evaluation of treatment results, monitoring, and benchmarking of care.

International Delphi Study to Optimize the Oral Health Section in interRAI

Introduction: The oral health (OH) of care-dependent older people is generally poor. Since caregivers are mainly responsible for older people's daily care, they can be considered important intermediaries to improve their OH by performing regular OH assessments. The interRAI instruments are introduced in 37 countries to assess care needs and facilitate care planning across different health care settings. The oral health section (OHS) within the interRAI instrument used in long-term care facilities was optimized for the Belgian context to identify residents who need assistance with daily oral care and/or need to be referred to a dentist. This Delphi study evaluated whether the OHS is also relevant and useful in other countries and modified the OHS accordingly until an international consensus was reached. Participants were experts in OH for older people. During 2 rounds of online questionnaires, experts rated the content, assessment process, triggering of Clinical Assessment Protocols, and accompanying guidelines and instruction videos of the optimized OHS. Based on the experts' comments and suggestions collected during the first round, the OHS was adjusted and presented to the experts in the second round for re-evaluation. The first and second questionnaires were completed by 48 and 42 oral health experts from 29 and 27 countries where the interRAI instruments are introduced, respectively. Five experts from 5 countries where interRAI is not introduced also participated in both rounds. After the second round, a consensus of over 86% was reached on all criteria. International consensus on the OHS was reached, considering national and cultural differences that may affect OH. The next step in this research is to evaluate the assessment process to identify potential barriers and facilitators to achieving reliable OH assessments internationally. Furthermore, the effect of the OHS at the level of the resident and of the caregivers will be evaluated.

Psychometric characteristics of comprehensive geriatric assessments (CGAs) for long-term care facilities and community care: A systematic review

BACKGROUND

Comprehensive Geriatric Assessments (CGAs) have been incorporated as an integrated care approach effective to face the challenges associated to uncoordinated care, risk of hospitalization, unmet needs, and care planning experienced in older adult care. As they assessed different dimensions, is important to inform about the content and psychometric properties to guide the decisions when selecting and implementing them in practice. This systematic review provides a comprehensive insight on the strengths and weaknesses of the CGAs used in long-term care settings and community care.

METHODS

A systematic search was conducted in PubMed, CINAHL, and Web of Science Core Collection. Studies published up to July 13, 2021, were considered. Quality appraisal was performed for the included studies.

RESULTS

A total of 10 different CGAs were identified from 71 studies included. Three instruments were reported for long-term care settings, and seven for community care. The content was not homogenous and differed in terms of the detail and clearness of the areas being evaluated. Evidence for good to excellent validity and reliability was reported for various instruments.

CONCLUSIONS

Setting more specific and clear domains, associated to the special needs of the care setting, could improve informed decisions at the time of selecting and implementing a CGA. Considering the amount and quality of the evidence, the instrument development trajectory, the validation in different languages, and availability in different care settings, we recommend the interRAI LTCF and interRAI HC to be used for long-term facilities and community care.

Association between denture use and food form in older adults requiring long-term care: A multicenter cross-sectional study

PURPOSE

This study aimed to determine whether denture use contributes to maintaining and improving food forms in long-term care facility (LTCFs) residents.

METHODS

In 888 residents of 37 LTCFs in Japan, the following were investigated: nutritional intake status, food forms, age, sex, Barthel index (BI), clinical dementia rating (CDR), number of teeth present, number of occlusal supports, swallowing function, and use of dentures. Among all residents, those who were well-nourished and had ≤9 occlusal supports were analyzed. Based on standardized criteria, the food forms consumed by the subjects were divided into two groups: dysphagia and normal diet, which were further classified into four levels. Analysis was performed using a generalized estimation equation with the four levels of food forms as dependent variables and age, sex, BI, CDR, presence of dysphagia, number of teeth present, and use of dentures as independent variables.

RESULTS

The final analysis included 622 (70.0%) residents. Of these, 380 (61.1%) used dentures. The analyses revealed that food form was significantly associated with age (adjusted odds ratio [OR], 0.98), BI (OR, 1.04), number of teeth present (OR, 1.03), presence of dysphagia (OR, 0.44), and use of dentures (OR, 2.82).

CONCLUSION

Denture use was associated with food forms among Japanese LTCF residents. This indicates that the use of dentures is related to the maintenance of food forms, even in the elderly who participate in few activities of daily living, have reduced cognitive function, and require long-term care.

A systematic review of measurement instruments for oral health assessment of older adults in long-term care facilities by nondental professionals

BACKGROUND

Regular oral health assessment of older adults living in Long-term Care Facilities (LTCF) can improve their oral health.

AIMS

This study aimed to systematically review studies describing the development of instruments employed by nondental professionals to assess the oral health of older adults in LTCF and to evaluate their measurement properties.

MATERIAL & METHODS

Electronic searches were conducted in the MEDLINE (PubMed), Embase, Web of Science, Scopus, and LILACS databases. Measurement properties of the identified instruments were evaluated using the Consensus-based Standards to select health Measurement Instruments (COSMIN) checklist. Studies assessing at least one measurement property (validity, reliability, or responsiveness) of instruments used to assess oral health of older adults living in LTCF by nondental professionals were considered. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) checklist was used to evaluate the quality of evidence.

RESULTS

Fifteen studies reporting measurement properties of seven instruments were selected. The ohr-interRAI and the OHAT were considered to have sufficient content validity, with high and moderate evidence quality, respectively. OHAT, BOHSE, and DHI showed acceptable results on reliability but with very low quality of evidence. DHI and OHSTNP also showed acceptable results for criterion validity, but, with low quality of evidence, insufficient or unclear results were observed for the remaining measurement properties. Studies evaluating the validity criteria of BOHSE and hypotheses testing of ohr-MDS were considered to have high evidence quality.

DISCUSSION AND CONCLUSION

The ohr-interRAI can be provisionally recommended for use until further evidence is provided. Further methodologically rigorous studies are needed to assess the measurement properties of the existing instruments.

The Effects of Physical Exercise on the Quality of Life of Healthy Older Adults in China: A Systematic Review

Objective

To systematically evaluate the effects of physical exercise on the quality of life (QOL) of healthy older adults in China.

Methods

Relevant articles published until December 2021 were retrieved from China National Knowledge Infrastructure, Wanfang, China Science and Technology Journal Database, PubMed, EBSCO, Web of Science, and the Library of Congress. Inclusion criteria were studies in which the subjects were healthy Chinese older adults (aged ≥ 60 years), the reported sample size was clear, and the study design was a randomized controlled trial or a research study. In addition, studies were included if they reported the use of at least one QOL questionnaire and investigated at least one form of physical exercise.

Results

In total, 19 studies met the inclusion criteria, which included six studies that used comprehensive physical exercise type as an intervention and 13 studies that used regular physical exercise as an intervention. All 19 studies compared intervention and control groups, of which 12 (63%) were investigative studies and seven (37%) were experimental studies. Of the experimental studies, five used a positive control group and two used a negative control group. All 19 studies reported that physical exercise had varying degrees of positive effects on the QOL in older adults. Body-mind exercise was effective in improving the physical and mental health (MH) of older adults, whereas Xiyangcao only had a positive effect on physical health. Compared with no exercise or other exercise (exercise not used in the intervention group), the exercise group in the survey had a positive effect on the QOL of older adults. Regardless of the type of control group used, the exercise group in the experimental studies showed a positive effect of exercise on the QOL of older adults.

Conclusion

Physical exercise has a positive impact on the QOL of healthy older adults. However, due to the wide and varied scope of the included studies, more randomized controlled trials are needed to examine the effects of different types, intensities, durations, and the frequency of exercise on QOL.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=220115], identifier: [CRD42020220115].

Instrument development and validation of the comprehensive ability of older people assessment scale

Aim

The study is aimed to develop and psychometrically test the Comprehensive Ability of Older People Assessment scale and classify the ability grades.

Design

A cross‐sectional design was used for instrument development.

Method

The Comprehensive Ability of Older People Assessment scale was developed by a sample of 971 older people from 4 long‐term care institutions in China. The data were collected between April 2018 and March 2020. One‐way analysis of variance and multiple regression analysis was used to screen scale items, while focus group interviews were used to integrate the subjective and objective items. Confirmative factor analysis and expert judgment were applied to explore construct validity. Reliability was explored through internal consistency estimation using Cronbach's alpha and homogeneity evaluation using corrected item‐total correlations. Cluster analysis and discriminant analysis were used to segment the comprehensive ability assessment scores and discriminant function was established to determine the boundary value of each segment, using correlation analysis to perform reverse verification.

Results

Factor analysis yielded 40 items with six dimensions, including “mentation and cognitive,” “perception and communication,” “emotional problems,” “mental and behavioural problems,” “daily life and social participation,” and “skin and oral status.” The Cronbach's α was 0.951, while the dimensions showed Cronbach's α values ranging from 0.760–0.946. The rationality and scientificity of this scale were proved by the correlation analysis of reverse validation.

Conclusion

The 4‐grade Comprehensive Ability of Older People Assessment scale is proved to be with good validity and reliability and should be considered for institutional assessors.

Impact

Assessors can accurately evaluate older people's health status and nursing needs through this scale in long‐term care institutions, communities and hospitals, so as to provide accurate and high‐quality nursing services. It will become a scientific basis for the government to offer accurate pension subsidies, purchase pension services scientifically for older people and establish third‐party objective evaluation and supervision.

Assessment of oral health in older adults by non-dental professional caregivers-development and validation of a photograph-supported oral health-related section for the interRAI suite of instruments

OBJECTIVES

An optimized oral health-related section and a video training were developed and validated for the interRAI suite of instruments. The latter is completed by professional non-dental caregivers and used in more than 40 countries to assess care needs of older adults.

METHODS

The optimized oral health-related section (ohr-interRAI) consists of nine items and a video training that were developed in consecutive phases. To evaluate psychometric properties, a study was conducted in 260 long-term care residents. Each resident was assessed by a dentist and by four caregivers (two who received the video training, two who did not).

RESULTS

Mean kappa values and percent agreement between caregivers and dentist ranged between κ = 0.60 (80.2%) for dry mouth and κ = 0.13 (54.0%) for oral hygiene. The highest inter-caregiver agreement was found for dry mouth with κ = 0.63 [95% CI: 0.56-0.70] (81.6%), while for the item palate/lips/cheeks only κ = 0.27 [95% CI: 0.18-0.36] (76.7%) was achieved. Intra-caregiver agreement ranged between κ = 0.93 [95% CI: 0.79-1.00] (96.4%) for dry mouth and κ = 0.45 [95% CI: 0.06-0.84] (82.8%) for gums. Logistic regression analysis showed only small differences between caregivers who watched the video training and those who did not.

CONCLUSIONS

Psychometric properties of the optimized ohr-interRAI section were improved compared to previous versions. Nevertheless, particularly the items based on inspection of the mouth require further refinement and caregiver training needs to be improved.

CLINICAL RELEVANCE

Valid assessment of oral health by professional caregivers is essential due to the impaired accessibility of regular dental care for care-dependent older adults.

The development and psychometric properties of oral health assessment instruments used by non-dental professionals for nursing home residents: a systematic review

BACKGROUND

Globally, oral health status of the geriatric population residing in nursing homes is poor. The integration of non-dental professionals is vital to monitor oral health, early identification and triaging of oral health problems, and timely referral to dental professionals. The aims of this systematic review were to provide a summary on the development and characteristics of oral health assessment instruments currently used by non-dental professionals for nursing home residents, and to perform a critical appraisal of their psychometric properties.

METHODS

This review was conducted as per the PRISMA guidelines. CINHAL (EBSCO), Medline (Ovid), and EMBASE (Ovid) were searched systematically. Two reviewers independently screened the title, abstract, and full text of the studies as per the eligibility criteria. Studies describing oral health assessment instruments used to assess oral health of nursing home residents by non-dental professionals were included. Using a methodological framework, each instrument was evaluated for purpose, content, and psychometric properties related to validity, reliability, feasibility, generalisability, and responsiveness. Additionally, the reporting quality assessment of each included study was performed according to the SURGE guidelines.

RESULTS

Out of the 819 screened articles, 10 studies were included in this review. The 10 identified instruments integrated 2 to 12 categories to assess oral health, which was scored on a 2 to 5-point scale. However, the measurement content varied widely, and none were able to comprehensively measure all aspects of oral health. Three measurement approaches were identified: performance- based assessment, direct inspection of the oral health status, and interview measures. Only eight instruments provided quality assessment on the basis of validity, reliability, feasibility and generalisability, whereas three instruments- Brief Oral Health Status Examination, Dental Hygiene Registration, and Oral Health Assessment Tool reported good methodological quality on at least one assessment criteria.

CONCLUSIONS

None of the instruments identified in this review provided a comprehensive assessment of oral health, while three instruments appeared to be valid and reliable. Nonetheless, continuous development of instruments is essential to embrace the complete spectrum of oral health and address the psychometric gaps.

Interrater reliability and concurrent validity of oral/dental items in the resident assessment instrument minimum data set 2.0

OBJECTIVE

To examine interrater reliability and concurrent validity of oral/dental items in the Resident Assessment Instrument Minimum Data Set (RAI-MDS) 2.0.

BACKGROUND

RAI-MDS is a standardised instrument used in nursing to determine health status and nursing needs. The extent to which oral/dental items in the RAI-MDS describe dental treatment needs concerning oral health has been questioned.

MATERIALS AND METHODS

This study evaluated the interrater reliability (dentist vs. nurse) and validity of oral/dental items in the Swiss version of RAI-MDS 2.0 (areas: K-nutritional status, L-oral/dental status) using professional oral examinations as a benchmark. Data of 168 residents of five long-term care facilities in the canton of Zurich, Switzerland, were collected within 1 year between October 2017 and December 2018. The statistical evaluation used descriptive statistics and Cohen's kappa (95% CI).

RESULTS

RAI-MDS items K1a, chewing (κ 0.098, 95% CI: 0.004-0.19); K1c, pain (κ 0.039, 95% CI: -0.03 to 0.11); L1a, debris (κ 0.117, 95% CI: 0.02-0.21); L1c, dental status (κ 0.229, 95% CI: 0.12-0.34); L1d, dental disease (κ 0.129, 95% CI: 0.02-0.24); L1e, periodontal diseases (κ -0.005, 95% CI: -0.07 to -0.03); and L1f, daily cleaning (κ -0.031, 95% CI: -0.05 to -0.01) showed weak or no agreement, whereas L1b, denture status (κ 0.634, 95% CI: 0.52-0.75), showed substantial agreement.

CONCLUSION

Oral/dental items in RAI-MDS lack reliability and validity. Recognition of oral health situation/treatment needs by nursing staff does not seem to be possible with the current version of this tool.

How accurate is the assessment of certified nursing assistants on resident's oral self-care function in three North Carolina assisted-living facilities?

AIMS

To examine the association between the assessments of certified nursing assistants (CNAs) on resident's oral self-care function and resident's oral hygiene outcomes in three North Carolina assisted-living (AL) facilities.

METHODS AND RESULTS

Sixty-five dentate AL residents were included in this secondary analysis. CNAs were asked to rate the AL residents' overall oral self-care function using a 6-point Likert scale. Their assessments were then compared with the objective, performance-based Dental Activities Test and the oral hygiene and gingival health measures. The analysis showed that nearly 90% of the participants presented with at least one untreated decayed or broken tooth. On average, nearly two-thirds of the surfaces were covered by soft deposits (Debris Index = 1.83, SD = 0.60). Generalized mild to moderate inflammation (Gingival Index = 1.51, SD = 0.53) commonly presented on residents' gingiva. CNAs were able to accurately identify the residents with substantial impairment in oral self-care function, yet they tended to overestimate the oral self-care function of residents with mild to moderate impairment. CNAs assessments were also not significantly correlated with residents' oral hygiene measures.

CONCLUSION

CNAs failed to identify and provide assistance to AL residents with impaired oral self-care function, contributing to poor oral oral hygiene in these vulnerable individuals.

Oral Health Among Older Adults With Complex Needs Living in the Community and in Aged Residential Care Facilities within New Zealand

OBJECTIVES

To describe the oral health status and dental service use of older adults with complex needs living within the community and aged residential care (ARC) facility settings, and to determine associations between dental service utilization and sociodemographic variables.

DESIGN

Secondary analysis of 2 continuously recruited national cohorts.

SETTING AND PARTICIPANTS

Adults aged ≥65 years having standardized assessments between July 1, 2012, and May 31, 2018, within New Zealand and who provided consent.

METHODS

All community-living older people with complex needs undergo a standardized assessment, using the Home Care International Residential Assessment Instrument (interRAI-HC), whereas all ARC facility residents undergo Long Term Care Facilities assessments (interRAI-LTCF). Anonymized data from consenting participants were extracted. Cross-sectional analyses of oral health status and dental service use variables employed logistic regression models, whereas longitudinal analysis of factors influencing dental service utilization employed binary generalized estimating equation models.

RESULTS

Overall, 144,380 interRAI-HC assessments from 97,229 participants, and 195,549 interRAI-LTCF assessments from 62,798 participants were eligible. At first assessment, their average age was 81.9 years (range: 65-109 years) and 84.4 years (range: 65-110 years), respectively. Approximately 65% of the participants wore dentures; 9% had broken, fragmented, loose, or otherwise nonintact natural teeth; and 10% reported difficulties chewing. Overall, only 25.3% of community-dwelling older adults and 17.5% of ARC residents had a dental examination within the previous year. Stark inequalities were observed with, for example, Māori participants having adjusted odds 3.14 [95% confidence interval (CI): 2.88, 3.42] and 2.08 (95% CI: 1.81, 2.39) of not having a dental examination in community and ARC facility settings compared with their New Zealand European counterparts.

CONCLUSIONS AND IMPLICATIONS

Heavy and unequal oral health burdens were observed among older adults with complex needs, together with low dental service uptake. New Zealand needs an oral health policy for older adults.

Assessment of oral health conditions presented in photographs - is there a difference between dentists and non-dental professional caregivers?

Background

Photographs can help non-dental professional caregivers to identify problems when inspecting the mouth of care-dependent older individuals. This study evaluated whether the assessment of oral health-related conditions presented in photographs differed between dentists and non-dental professional caregivers.

Materials and methods

One-hundred-and-seventy-nine photographs were taken from long-term care facility residents and from patients at the Department of Dentistry of a University Hospital. The following oral health aspects were depicted: denture hygiene, oral hygiene, teeth, gums, tongue and palate/lips/cheeks. Collection continued until for each oral health aspect a pool of photographs was available that showed conditions from perfect health and hygiene to severe problems. A segmented Visual Analogue Scale was applied to assess the conditions presented in the photographs. Each photograph was assessed by each participant of this study. The benchmark was established by three dentists with academic-clinical expertise in gerodontology, special needs dentistry and periodontology. For each photograph, they provided a collective score after reaching consensus. Photographs were assessed individually by 32 general dentists and by 164 non-dental professional caregivers. Linear mixed effects models and generalized linear mixed effects models were fitted and mean squared errors were computed to quantify differences between both groups.

Results

For the different oral health aspects, absolute distances from the benchmark scores were 1.13 (95%CI:1.03–1.23) to 1.51 (95%CI:1.39–1.65) times higher for the caregivers than for the dentists. The odds to overestimate the condition were higher for the caregivers than the dentists for oral hygiene (OR = 0.72, 95%CI = 0.62–0.84) and teeth (OR = 0.74; 95%CI = 0.61–0.88). The odds to underestimate the condition were higher for the caregivers than the dentists for gums (OR = 1.39; 95%CI:1.22–1.59) and palate/lips/cheeks (OR = 1.22; 95%CI = 1.07–1.40). Over all assessments, the variance in caregiver scores was 1.9 (95%CI:1.62–2.23) times higher than that for the dentists.

Conclusion

Small but significant differences were found between dentists and non-dental professional caregivers assessing oral health-related conditions presented in photographs. When photographs are used to aid non-dental professional caregivers with the oral health assessment, these visualizations should be complemented with comments to facilitate accurate interpretation.

Testing the ability for autonomous oral hygiene in hospitalized geriatric patients-clinical validation study

OBJECTIVES

This study aimed to evaluate if the Timed Test for Money Counting (TTMC) complemented with testing the range of shoulder motion by griping the backside of the neck (NG) predicts the ability of geriatric inpatients to perform effective plaque reduction by autonomously conducted oral hygiene.

MATERIAL AND METHODS

This clinical validation study involved 74 hospitalized geriatric inpatients, 48 (64.9%) females, aged between 66 and 98 years (mean age 84.1 years). Oral health status was examined. Dental plaque was assessed with the Turesky modified Quigley-Hein Index (TI) on teeth and the Denture Hygiene Index (DHI) on removable dentures. The performance and duration of TTMC and NG were recorded. After autonomous tooth brushing and denture cleaning by the patient, dental plaque was scored again with the TI and DHI. Geriatric assessment data were collected from medical records.

RESULTS

Forty-nine (66.2%) geriatric inpatients completed the TTMC&NG successfully. Passing the TTMC&NG was significantly associated with better plaque removal on teeth and dentures by autonomously conducted oral hygiene. The sensitivity of the TTMC&NG for above average plaque reduction was 86.4% on teeth and 77.8% on dentures. The test revealed a negative predictive value of 75.0% to detect below average plaque reduction on teeth and 72.7% on dentures.

CONCLUSIONS

The TTMC&NG served as a suitable predictor for the ability of geriatric inpatients to perform autonomously effective tooth brushing and denture cleaning.

CLINICAL RELEVANCE

This simple and short test might help the medical staff to identify geriatric inpatients unable to perform effective oral hygiene by themselves.

Aspects of oral health and dementia among Swiss nursing home residents

BACKGROUND

Little empirical evidence of high levels of oral diseases of people in need of care and the impact of dementia is available. The resident assessment instrument minimum data set (RAI-MDS) is an evaluation tool for caregivers.

OBJECTIVE

The aim of this study was to show oral health of nursing home residents through RAI-MDS 2.0 data as a function of the cognitive impairment.

METHODS

A retrospective analysis of RAI-MDS (general, cognitive, oral health variables) of 357 long-term care facilities in Switzerland (data of 105,835 residents) was carried out. The final sample size was 7922 residents after applying the inclusion/exclusion criteria in four evaluation groups (no dementia, moderate, severe and incident dementia).

RESULTS

As dementia developed and severity increased over time, subjects often had fewer or no teeth and did not wear removable dentures. Chewing problems increased over time regardless of the dementia severity. Oral complaints increased over time in subjects with severe dementia, which in turn led to low body mass index (BMI) values (<23 kg/m²) and was associated with an higher risk of mortality.

CONCLUSION

This dataset provides an overview on dental aspects in patients with dementia in nursing homes. The accuracy of the assessment of a given dental situation by nursing staff is to be questioned. The results indicated an underdetection of oral illnesses by nurses.

Oral care practices of long-term care home residents and caregivers: Secondary analysis of observational video recordings

AIMS AND OBJECTIVES

To describe the proportion of toothbrushing task steps, long-term care residents had an opportunity to complete; the duration and quality of toothbrushing by both residents and caregivers; and the feedback caregivers provided.

BACKGROUND

Poor oral health is widespread among older adults in long-term care homes; however, little is known about their actual oral health practices.

DESIGN

Secondary analysis of video recordings.

METHODS

A total of 58 video-recorded sessions were analysed from two long-term care homes in Canada. Eligible residents had at least one natural tooth, required oral care assistance, had Alzheimer's disease and understood English. Eligible caregivers spoke English and had worked for at least 1 year with people with dementia. Toothbrushing success was identified by the resident's participation in, and completion of, nine toothbrushing steps. Total time spent brushing teeth was calculated by summing the duration of time spent brushing teeth. Quality was described by time spent brushing the facial versus the lingual or occlusal surfaces. Caregiver verbal feedback was pulled from transcripts and analysed using content analysis. STROBE guidelines were used in reporting this study.

RESULTS

The two step residents most frequently completed or attempted were brushing their teeth (77% complete, 7% attempt) and rinsing their mouth (86% complete, 2% attempt). The average time spent brushing teeth was 60.33 s (SD = 35.15). In 66% of observed videos, toothbrushing occurred only on the facial tooth surfaces, with no time spent brushing the lingual or occlusal surfaces.

CONCLUSION

Caregivers are supporting residents to independently complete toothbrushing; however, the duration and quality of toothbrushing are not sufficient to ensure optimal oral health.

RELEVANCE TO CLINICAL PRACTICE

Clear, detailed guidelines are required to ensure adequate oral care for long-term care residents. Staff need to be aware that all surfaces should be brushed to ensure proper oral health.

If we cannot measure it, we cannot improve it: Understanding measurement problems in routine oral/dental assessments in Canadian nursing homes-Part I

OBJECTIVE

To compare Resident Assessment Instrument-Minimum Data Set 2.0 (RAI) oral/dental items collected by nursing home (NH) care staff to (a) assessments collected by trained research assistants (RAs) and (b) "gold standard" clinical assessments by dental hygienists (DHs).

BACKGROUND

Routine collection of RAI oral/dental items is mandatory in most Canadian NHs. However, the performance of these items is less than optimal and oral/dental problems are severely under-reported. Accurate assessment is a prerequisite for preventing, detecting and treating oral health problems. Not knowing the reasons for performance problems is a barrier to improving performance of the RAI oral/dental items.

MATERIALS AND METHODS

We included 103 NH residents from 4 NHs in Edmonton, Alberta, Canada. Using Kappa statistics, we compared the agreement of residents' last (no older than 90 days) RAI assessment with RAI assessments completed by trained RAs and "gold standard" clinical assessments by DHs. We also assessed the inter-rater reliability (IRR) of RA and DH assessments.

RESULTS

Care staff assessments had poor agreement with RA and DH assessments (Kappa < 0.2 for most items). RAs and DHs identified more oral/dental problems than care staff. However, IRR of RA assessments was low (Kappa < 0.7 for 7/9 items). IRR of DH assessments was acceptable (Kappa > 0.7) for most items.

CONCLUSIONS

The quality of RAI oral/dental assessments can be improved by better training care staff and ensuring appropriate time to do the assessments. However, remaining problems-even with trained RAs-suggest that rewording some of the items or supplementing them by more robust tools may be required.

Oral Health Status and Need for Oral Care in an Aging Population: A Systematic Review

Background. The world population is aging. This phenomenon is accompanied by an increase in the number of elderly with dementia, whose oral hygiene care is a challenge. Objective. This paper presents a literature review of oral health status and the need for oral care in people with dementia, as compared to people without dementia and also of the relationship between periodontal disease and cognitive impairment. Methods. A systematic review was conducted in PubMed, CINAHL, and the Cochrane Library. Fifty-six articles met the inclusion criteria and were consequently included for quality assessment and data extraction. Results. No significant differences were found between both groups with regard to the number of present teeth, DMFT Index, edentulousness/use of denture, and orofacial pain. Coronal/root caries and retained roots were more common in people with dementia than in those without dementia. Most of the participants with dementia presented gingival bleeding or inflammation and they suffered from the periodontal disease more than people without dementia. Conclusions. Poor oral health is a common condition among the elderly with dementia. The education process of caregivers might improve the oral health status of people with dementia. Finally, periodontal disease might contribute to the onset or progression of dementia.

The oral health-related section of the interRAI: Evaluation of test content validity by expert rating and assessment of potential reasons for inaccurate assessments based on focus group discussions with caregivers

OBJECTIVES

To explore the failure of the oral health-related section of the interRAI (ohr-interRAI), this study investigated test content validity (A.) and reasons for inaccurate assessments (B.).

BACKGROUND

Poor oral health negatively affects quality of life and is associated with a number of systemic diseases. The interRAI instruments, internationally used for geriatric assessment, should accurately detect oral conditions that require care. Previous research showed that the ohr-interRAI and related precursor versions do not achieve this goal.

MATERIALS AND METHODS

(A.) A group of 12 experts rated completeness, relevance, clarity of wording and feasibility of the ohr-interRAI. Content validity indices were calculated per item (threshold 0.78). (B.) Focus group discussions with 23 caregivers were organized. A semi-structured question guide made sure that all topics of interest were covered. Qualitative content structuring analysis was applied after transcription.

RESULTS

(A.) Experts agreed on the relevance of the items on chewing, pain, gingival inflammation and damaged teeth. They regarded none of the items as worded clearly and only prosthesis use and pain were considered to be assessable by untrained caregivers. All experts agreed that the ohr-interRAI was incomplete. (B.) Focus group discussions revealed that in the care environment oral health had low priority. Aspects related to the ohr-interRAI itself and aspects related to the assessment situation impeded the oral health assessment. The approach of the caregivers to complete the ohr-interRAI was inappropriate to accurately detect oral care needs.

CONCLUSIONS

Findings challenge test content validity of the ohr-interRAI and reveal reasons for inaccurate assessments.

Speaking the same language: Development of a Nutrition Minimum Data Set for healthcare professionals in primary healthcare

Providing the best possible nutritional care requires accurate and precise communication between healthcare professionals. Developing a Nutrition Minimum Data Set will inform professionals in primary healthcare of which core elements should be documented and facilitate a standardized approach to the documentation of nutritional care. A two-step methodological approach was utilized in this study: (1) a systematic scoping review was conducted to map evidence underpinning the development of a Minimum Data Set and (2) the datasources were categorized using the inductive content analysis approach. A total of 32 items were identified in the datasources. Five categories were inductively derived from the data: (1) physiologic measurements, (2) ability to eat, (3) intake, (4) stress factors and (5) factors which indirectly affect intake and needs. Organizing the documentation following the structure presented in this Minimum Data Set will contribute to a standardized terminology, which may lead to increased quality of documentation, increased continuity of care and improved health outcomes.

Oral hygiene and oral health in older people with dementia: a comprehensive review with focus on oral soft tissues

BACKGROUND

The number of older people with dementia and a natural dentition is growing. Recently, a systematic review concerning the oral health of older people with dementia with the focus on diseases of oral hard tissues was published.

OBJECTIVE

To provide a comprehensive literature overview following a systematic approach of the level of oral hygiene and oral health status in older people with dementia with focus on oral soft tissues.

METHODS

A literature search was conducted in the databases PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. A critical appraisal of the included studies was performed with the Newcastle-Ottawa scale (NOS) and Delphi list.

RESULTS

The searches yielded 549 unique articles, of which 36 were included for critical appraisal and data extraction. The included studies suggest that older people with dementia had high scores for gingival bleeding, periodontitis, plaque, and assistance for oral care. In addition, candidiasis, stomatitis, and reduced salivary flow were frequently present in older people with dementia.

CONCLUSIONS

The studies included in the current systematic review suggest that older people with dementia have high levels of plaque and many oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, stomatitis, mucosal lesions, and reduced salivary flow.

SCIENTIFIC RATIONALE FOR STUDY

With the aging of the population, a higher prevalence of dementia and an increase in oral health problems can be expected. It is of interest to have an overview of the prevalence of oral problems in people with dementia.

PRINCIPAL FINDINGS

Older people with dementia have multiple oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, mucosal lesions, and reduced salivary flow.

PRACTICAL IMPLICATIONS

The oral health and hygiene of older people with dementia is not sufficient and could be improved with oral care education of formal and informal caregivers and regular professional dental care to people with dementia.

An Old Challenge with New Promises: A Systematic Review on Comprehensive Geriatric Assessment in Long-Term Care Facilities

Comprehensive geriatric assessment (CGA) is a multidimensional and multidisciplinary diagnostic process focused on determining the clinical profile, pathological risk, residual skills, short- and long-term prognosis, and personalized therapeutic and care plan of the functionally compromised and frail older subjects. Previous evidence suggested that the effectiveness of CGA programs may be influenced by settings where the CGA is performed [i.e., hospital, posthospital discharge/long-term care facilities (LTCFs), or community/home] as well as the specific clinical conditions of older frail individuals. In this scenario, CGA and quality of care in LTCFs have been a challenge for decades. In the present article, we systematically reviewed evidence from the last three decades of clinical research devoted to systematic implementation of CGA programs in LTCFs, that is, nursing homes, care homes, residential homes, and rehabilitation facilities. In the United States, all LTC residents must undergo a CGA on a regular basis on admission to a facility, prompting the development of the Resident Assessment Instrument (RAI) Minimum Data Set, a specific CGA-based assessment tool in this population. In the LTCF setting, the present reviewed evidence suggested that most complex older subjects may benefit from a CGA in terms of improved quality of care and reduced hospitalization events and that CGA must be standardized across healthcare settings to promote greater health system integration and coordination. In the LTCF setting, particularly in nursing homes, other new and promising CGA programs have also been proposed to develop rapid screening CGA-based tools to enhance in the future the ability of primary care physicians to recognize and treat geriatric syndromes in this setting. However, at present, the interRAI suite of instruments represented an integrated health information system that has the potential to provide person-centered information transcending healthcare settings.

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.