Study reveals complexity in treating frail older adults

While ensuring that pediatric patients receive excellent oral healthcare remains a priority, few studies focus on the oral healthcare needs of terminally ill patients. Are these patients receiving the care they need? Are dentists getting the communication and education they need to best care for these patients? What should be the focus of treatment in terms of pain management and quality of life?

In a recent study in the Journal of the American Dental Association, Xi Chen, DDS, PhD, and colleagues looked at what treatments were being provided to long-term care residents during the last year of their lives (November 2013, Vol. 144:11, pp. 1234-1242). Their study found that while comprehensive dental treatment, including multiple restorations and tooth extractions, were commonly provided to frail older patients at the terminal stage of life, several concerns regarding the quality of care for these frail end-of-life patients were raised.

The authors retrospectively followed 197 long-term care residents (60 years or older) who were in their last year of life. The authors divided the patients into three groups: those who received no care, those who received limited care, and those who received what was termed usual care, depending on the treatment the patients received.

Their study revealed that more than half of these patients (50.8%) received no care before death. Among the 49% who did receive some treatment, almost 63% received their usual care, and almost 61% of these patients completed their treatment in the last three months of life. The authors found that neither survival nor dental insurance was associated with the level of care (usual or limited) the patient received.

Lack of awareness

In an interview with DrBicuspid.com, Dr. Chen talked about the questions the study raised and the barriers that exist in ensuring these patients have adequate care. Dr. Chen is an assistant professor in the department of dental ecology at the University of North Carolina at Chapel Hill School of Dentistry.

"There is a general lack of awareness of oral health issues in healthcare providers for older adults with terminal illnesses," she said. "Many physicians don't realize the impacts of oral disease on systemic health and quality of life in older adults at the end of life."

Just as important, however, Dr. Chen readily acknowledged the challenges faced in caring for older adults with terminal illnesses.

"These patients usually present with complex medical history," she said. "Many patients also have cognitive and functional impairment, which further complicates the treatment."

On top of the complicated treatment, Dr. Chen also noted the caring for these patients requires interdisciplinary communication and interaction.

"Dental professionals also often lack timely support from their medical colleagues in determining a patient's prognosis, which increases difficulty in clinical treatment planning," she said. "Moreover, many terminally ill patients reside in long-term care facilities. The lower oral health priority in patients and their families, the limited resources available for dental care, the lack of onsite dental treatment accessibility, and the difficulty in coordinating and scheduling care, and in transferring patients between healthcare facility and dental care facility, also make dental management for these patients more complicated and challenging."

For Dr. Chen, the questions raised by the study include the following:

• Were all the treatments provided to these patients appropriate and necessary?
• To what extent did the dental treatment benefit or harm patients, their systemic health, and quality of life?
• How to identify patients at the end of life in dental offices, and how to incorporate their prognoses in clinical treatment planning?
• What are the appropriate treatment approaches and intensity for frail elderly patients?
• When should in-office dental treatment be stopped?
• How do older adults at the end of life and their families perceive the needs of oral health and oral healthcare? How do their perceptions differ from that of dental professionals? How these differences, if any, inform clinical management for these individuals?

Palliative care

The study authors recommended that palliative oral health management be revisited to improve quality of care for these patients. But Dr. Chen said several factors contributed to a lack of clear guidelines for palliative care among this patient group.

"First is the lack of training for dental professionals in caring for these challenging patients," she said. "Then, because of a lack of research on end-of-life oral health and oral healthcare, several important clinical questions remain unknown, such as how oral health changes in individuals with different dying trajectories; how terminally ill patients perceive the needs and value of oral health and oral healthcare; when to start palliative care; and what are the appropriate, safe, and effective treatments for these patients."

When seeing frail older adult patients, Dr. Chen mentioned that the dental treatment plan should focus on preventing pain and infection, maintaining function, preventing systemic complications of oral diseases and conditions, and improving or maintaining quality of life. While not comprehensive, she lists a few items for dentists to consider, including the following:

• Consulting with the patient's physician regarding the patient's prognosis and treatment goal
• Considering the oral healthcare plan as a part of the overall palliative care plan
• Designing dental treatment plans that correspond to patient's prognosis, functional reserve, oral health needs, and caregiver support
• Doing no harm -- evaluating risks/benefits of treatment, avoiding aggressive treatments, and considering noninvasive bedside alternatives (e.g., use of antibiotics and analgesic for dental infection) when needed
• Considering patient and family's preference in treatment planning

Speaking generally, Dr. Chen considers three areas that might need to be studied to improve care for these patients: education, communication, and policy.

"The current medical, nursing, and dental education may need to be improved. Oral disease and its impacts on systemic health and quality of life should be introduced to medical and nursing students, so that oral health management could be included into daily palliative care. End-of-life oral health management should also be enhanced in dental education," she said.

Her second focus is better and more communication.

"A better palliative care model which enables dental professionals to more frequently interact with physicians, nurses, and other palliative care staff, and provides oral health consultations and receive timely feedback from other health professionals should be developed," Dr. Chen said. "This active interprofessional interaction will enable healthcare providers in different disciplines and settings to address patients' oral health needs within the larger context of that individual's dying trajectory, medical needs, and personal values."

Finally, from a policymaker's perspective, she recommended including oral health as a component during the assessment of quality of care in long-term care or hospice care.