Development and validation of a nursing home mortality index to identify nursing home residents nearing the end of life in dental clinics

BACKGROUND

Nursing home (NH) residents seek care at dental offices, yet many of them are at the end of life. The uncertain life expectancy further complicates the care of NH residents. This study aimed to develop and validate a Nursing Home Mortality Index (NHMI) to identify NH residents in the last year of life.

METHODS

Logistic modeling was used to develop predictive models for death within 1 year after initial appointment by utilizing the new patient examination data and mortality data of 903 Minnesota NH residents. The final model was selected based on areas under the curve (AUC) and then validated using data from 586 Iowa NH residents. Based on the final model, the NHMI was developed with the estimated 1-year mortality for the low, medium and high risk group.

RESULTS

One-year mortalities were 21% and 26% in the development and validation cohorts, respectively. Predictors included age, gender, communication capacity, physical mobility, congestive heart failure, peripheral vascular disease, cancer, cerebrovascular disease, chronic renal disease and liver disease. AUCs for the development and validation models were 0.73 and 0.68, respectively. For the validation cohort, the sensitivity and specificity were 0.79 and 0.53, respectively. The estimated 1-year mortality risks for three risk groups were 0%-10%, 11%-19%, and ≥20%, respectively CONCLUSION: The high mortality rate of NH residents following a dental exam highlighted a need to incorporate patients' prognoses in treatment planning along with normative needs and patients' preferences. The NHMI provides a practical way to guide treatment decisions for end-of-life NH residents.

INTEREST GROUP SESSION—ORAL HEALTH: COGNITIVE FUNCTION, SOCIAL SUPPORT, AND ORAL HEALTH STATUS AMONG OLDER ADULTS IN THE U.S. AND ABROAD

There is an increasing awareness of the importance of oral health and its associated risk factors among older adults. This symposium includes four papers that address cognitive function, social support and oral health problems and symptoms among older adults in the U.S. and China. Lu and his colleagues examined the reciprocal relationship between cognitive function and complete tooth loss Chinese adults age 50+ using the China Health and Retirement Longitudinal study. The results show that there is a reciprocal relationship between these two indicators. The second paper used the Population Study of Chinese Elderly in Chicago (PINE) and examined the associations between tooth/gums symptoms and changes in cognitive function in Chinese older immigrants. The results reveal that having teeth symptoms was associated with a decline in cognitive function. Using the same PINE data, the third paper examined the association between different characteristics of social relationships and the number of oral health problems among U.S. older Chinese adults. Wu and her colleagues conducted a partner-assisted pilot intervention to improve oral health for community-dwelling older adults with either mild cognitive impairment or mild dementia. The results of this 6-month intervention show that persons in the treatment group had more improvement in oral hygiene than those in the control group. Findings from these four papers illustrate that cognitive function, social support, and oral health are interrelated. This symposium highlights the importance of improving cognitive health, social support, and oral health for middle-aged and older adults.

Dental caries in older adults in the last year of life

OBJECTIVES

To examine dental caries severity (measured by number of carious teeth) in older adults in the last year of life.

DESIGN

Cross-sectional study based on dental records.

SETTING

Community-based geriatric dental clinic.

PARTICIPANTS

One thousand two hundred sixteen individuals aged 65 and older, including 168 individuals in the last year of life (e.g., individuals died within 1 year after their new-patient examinations).

MEASUREMENTS

Information on socioeconomic, medical history, medication, functional status, and oral health measures, including number of carious teeth, was abstracted from dental records. End-of-life status was determined using the National Death Index. Propensities of death were calculated using a logistic regression and then adjusted together with mobility and oral care function in the multivariable regression model to examine the effect of end-of-life status on dental caries.

RESULTS

Caries severity differed in end-of-life participants with different oral care function. Of those needing help with oral care, end-of-life participants had only a slightly higher and nonstatistically significant risk (7.5 vs 6.1, adjusted incidence density ratio (IDR) = 1.12, 95% confidence interval (CI) = 0.85-1.48) of having more carious teeth than those not in the last year of life. On the other hand, caries severity was lower in end-of-life participants without impaired oral care function (IDR = 0.53, 95% CI = 0.30-0.92).

CONCLUSION

Oral care function modifies the association between caries severity and end-of-life status. Individuals who could maintain oral hygiene independently had a low level of caries at the end of life, however, dental caries had increased before functionally dependent individuals entered their last year of life.

Patterns of tooth loss in older adults with and without dementia: a retrospective study based on a Minnesota cohort

OBJECTIVES

To study tooth loss patterns in older adults with dementia.

DESIGN

Retrospective longitudinal study.

SETTING

A community-based geriatric dental clinic in Minnesota.

PARTICIPANTS

Four hundred ninety-one older adults who presented to the study clinic as new patients during the study period, remained dentate after finishing the initial treatment plan, and returned for care at least once thereafter were retrospectively selected. One hundred nineteen elderly people with International Classification of Diseases, Ninth Revision, codes 290.x, 294.1, or 331.2 or a plain-text diagnosis of dementia, Alzheimer's disease, or chronic brain syndrome in the medical history were considered having dementia.

INTERVENTION

All existing dental conditions were treated before enrollment. Dental treatment was continually provided for all participants during follow-up.

MEASUREMENTS

Tooth loss patterns, including time to first tooth loss, number of tooth loss events, and number of teeth lost per patient-year were estimated and compared for participants with and without dementia using Cox, Poisson, and negative-binomial regressions.

RESULTS

Participants with dementia arrived with an average of 18 and those without dementia with an average of 20 teeth; 27% of remaining teeth in the group with dementia were decayed or retained roots, higher than in the group without dementia (P<.001). Patterns of tooth loss did not significantly differ between the two groups; 11% of participants in both groups had lost teeth by 12 months of follow-up. By 48 months, 31% of participants without dementia and 37% of participants with dementia had lost at least one tooth (P=.50). On average, 15% of participants in both groups lost at least one tooth each year. Mean numbers of teeth lost in 5 years were 1.21 for participants with dementia and 1.01 for participants without dementia (P=.89).

CONCLUSION

Based on data available in a community-based geriatric dental clinic, dementia was not associated with tooth loss. Although their oral health was poor at arrival, participants with dementia maintained their dentition as well as participants without dementia when dental treatment was provided.

The application of facial expressions to the assessment of orofacial pain in cognitively impaired older adults

BACKGROUND

The anticipated rapid growth in the number of cognitively impaired older adults, declining edentulism and increasing oral health expectations suggest a greater need for comprehensive dental care and effective ways to evaluate orofacial pain in people with compromised mental function and impaired communication skills. The authors conducted a study to evaluate facial expressions as a means of identifying orofacial pain in cognitively impaired and cognitively intact older adults, compared with other available pain assessment tools.

METHODS

The authors conducted a prospective comparative study using three alternative pain measurement tools in a sample of 22 older adults. They divided subjects into cognitively impaired and cognitively intact groups on the basis of their mental status examination scores. The pain measurement methods evaluated were facial expressions quantified by the Facial Actions Coding System (FACS); self-reported pain via the Verbal Descriptor Scale; and physiological response to pain via changes in heart rate. The pain stimuli were local anesthetic injections in subjects who required them for routine dental procedures.

RESULTS

The average FACS scores during anesthetic injections were significantly higher than those during the preinjection period (prebuccal versus buccal, P = .016; prepalatal versus palatal, P = .0002). The differences between preinjection and injection segments were even higher in cognitively impaired patients than in cognitively intact patients. There were no correlations between the three pain measurements (P > .05).

CONCLUSIONS

Changes in facial expression proved to be the most useful measure overall in identifying pain in both cognitively intact and cognitively impaired older patients. This measure appeared to be more sensitive in cognitively impaired patients because they demonstrated fewer facial movements in anticipation of pain stimuli.

Doing the right thing: resolving ethical issues in geriatric dental care

This article reviews key ethical concerns facing dental professionals caring for older adults and offers guidelines for resolving them. Approaches to securing informed consent for treatment and assessing decision making capacity are discussed. Next, the question of deciding among several treatment options when patient preferences are unknown is considered. Finally, guidelines are offered on restraint use for older adults with behavioral problems.

Fitting the pieces together: treatment planning in the geriatric dental patient

Treatment planning older patients often becomes a complex process as dental professionals, patients, family, and caregivers attempt to prioritize and balance the influences of multiple age-associated dental, systemic, and psychosocial factors. To assist clinicians in identifying and weighing numerous factors that can influence planning dental care for older patients, clinicians should be wary of relying on chronological age as a factor, but should focus on the issues of biologic age and life expectancy, which may be greater than many older adults believe. The longevity of dental interventions is another factor that is helpful to consider in determining the most appropriate treatment plan for older adults. Among many issues influencing the treatment planning process, the quality of communication between clinicians and older patients is critical, along with the influence of third parties, including families and professional caregivers. Due to the lack of objective information on the outcomes of dental care in the older population, clinicians inevitably face many situations in which there is uncertainty about the best course of therapy. Practitioners can adopt specific strategies to help minimize difficulties that may be associated with the provision of care under such circumstances.

Nurses' dental assessments and subsequent care in Minnesota nursing homes

Concerns about the quality of care in US nursing homes led to 1987 federal regulations mandating a national standardized resident assessment. This assessment, or Minimum Data Set (MDS), is performed by nurses on all residents and includes items to detect oral health problems. As yet, however, there are few data on the utility of these MDS oral health evaluations. In this study, we analyzed data from Minnesota nursing homes to determine the prevalence of oral health problems ("triggers") requiring dental referral from the MDS, version 1 (Items L and M). We also analyzed the relationship between these MDS assessments and subsequent dental care. Data came from a 1994 Minnesota nursing home dental utilization study containing information on 466 residents (dental users and non-users) sampled from 21 nursing homes. Nurses identified 3.2% of residents as having oral debris, 3.0% with broken, loose, or carious teeth, and only four (0.9%) residents with gum inflammation/soft tissue problems. Only one resident (0.2%) was identified with mouth pain. Regression analyses of data from 135 residents admitted since 1992 revealed no relationship between the presence of MDS "triggers" and subsequent utilization measured in visits/year and gross charges/year. Nurses' MDS assessments identified few oral health problems, and those problems identified did not translate into dental treatment, raising questions about the utility of the current approach.

Ethical issues in nursing home care: practice guidelines for difficult situations

Dental professionals encounter a number of challenging ethical and legal dilemmas when caring for nursing home residents. Questions may arise in determining a patient's capacity to make decisions, securing consent for treatment, choosing the most appropriate from among several treatment options, and when and how to use restraints. When securing consent for treatment, practitioners must consider both the patient's legal competence and his/her decision-making capacity, and adopt roles appropriate to the patient's circumstances. If legal competence has been retained but decision-making seems impaired, practitioners must involve others in the process of determining appropriate care. The capacity to consent to treatment can be assessed by questions designed to evaluate the patient's ability to understand relevant information, appreciate the situation and consequences, manipulate information rationally, and communicate choices. When faced with a choice of several treatment options and patient preferences are unclear or unknown, the principle of substituted judgment should be used to attempt to provide care in keeping with the patient's values. To maximize patient safety and dignity, ten guidelines are presented for the use of restraints to provide dental care for individuals with behavior problems.

Ethical and legal issues in special patient care

Dental professionals encounter a number of challenging ethical and legal dilemmas when caring for special patients. Questions may arise in securing consent for treatment; using restraints; overcoming economic, social, and physical barriers to care; and dealing with patient abuse. These concerns generally stem from underlying conflicts between any of the fundamental ethical principles of autonomy, nonmaleficence, beneficence, justice, veracity, and fidelity. When securing consent for treatment, practitioners must consider both legal competence and decision-making capacity. If decision-making is impaired, input should be solicited from others to arrive at treatment decisions in keeping with the patient's values concerning dental care. To guard against the inappropriate use of restraints, 10 guidelines are presented for consideration. Providers should strive not to allow economic considerations to influence their care unduly either by failing to offer a full range of options or by providing care that is below usual standards. Services must be made available to disabled individuals on the same basis that they are available to others without disability. This principle forms the basis of the Americans with Disabilities Act, which stipulates what accommodations must be made to ensure that physical and social barriers do not impede access to dental care. Finally, special patients, particularly the frail elderly, are at increased risk to become victims of abuse. Dental professionals should be familiar with the warning signs and symptoms of such abuse and their obligation to take actions to end it.

Patient age, service mix and dental practice productivity

To further explore economic relationships between patient age and dental practice productivity detected in previous studies, this study investigated the effects of variations in the mix of services used by different age groups on time and dollar-based dental practice outputs. Production function models for dental services were estimated using data from 31 Minnesota general dental practices reporting increased visits by older adults between June, 1980 and December, 1984. Analysis suggested that standardised time-based measures of productivity were not greatly affected by differences in the types of services used by different age groups. In contrast, differences in service mix between age groups exerted a substantial influence on dollar-based productivity that was independent of patient age. Overall, dental practices were less productive with older patients, but the decline in monetary productivity was not evident until patient age was disaggregated from differences in service use by different age groups.

Productivity in Minnesota dental practices with increased visits by older patients

There is little scientific information on the economic impact of treating increased numbers of older adults, despite the current growth in this population. To assess the impact of patient age on dental practice productivity, we evaluated an economic production function that included the proportions of patient visits in two older age groups (61-69 years, 70+ years) as factors that might affect the dental service production process. We used data from 12,818 patient visits to 31 Minnesota dental practices enrolled in the Minnesota Dental Practice Analysis System (DPAS) between 1980 and 1984. Ordinary least squares multiple linear regression was used to detect potential associations between practice productivity, measured in standardized time and monetary outputs, and the proportions of visits by older patients. We found that increases in the proportion of visits by patients aged 70 years and older were associated with decreases in productivity when we controlled for differences in the mix of services used. Our results support the notion that dental practices may be less productive when providing services to older patients compared to younger patients. These findings may have implications for personnel and policy planning. Further investigation of this issue is warranted because of the limited number of practices included in the study.

Enhancing infection control for elderly and medically compromised patients

Some patients may be at risk for complications from relatively common infectious diseases. Influenza, tuberculosis and methicillin-resistant Staphylococcus aureus infection can lead to illness and even death in elderly, medically compromised and institutionalized individuals. Dental personnel caring for these individuals should adopt preventive strategies that are simple and inexpensive in addition to standard infection control guidelines.

Are dental practices less productive with older patients? Comparison of alternative output measures

This study assessed the effects of increased visits by older dental patients on alternative measures of time- and dollar-based practice productivity. The Minnesota Dental Practice Analysis System was used for analysis of data from 31 practices (12,818 patients visits) reporting increased visits by older adults between June, 1980, and December, 1984. Results suggested that the productivity effects associated with older patient visits were highly dependent on the practice output measure selected. While increased visits by patients aged 70 and over were associated with increased monetary productivity per patient visit, time and monetary productivity per practice day were found to decline. An association between increased proportions of older patients visits and increased dentist minutes per visit appeared to account for this. This econometric analysis tends to support the notion that dental practices are less productive with older patients.

A physician's guide to coordinating oral health and primary care

Knowledge of specific issues of mutual concern and clear communication between primary care physicians and dentists are of special importance for the safe dental treatment of elderly patients. This article reviews the medical-dental management of patients at risk for infective endocarditis, late prosthetic joint infection, excessive bleeding due to anticoagulants, and complications from ischemic heart disease. Behavior management of mentally impaired individuals who are resistant or combative during dental treatment is also discussed.