Oral Health Care for Homebound and Institutional Elderly

The provision of oral health care to homebound and institutionalized patients presents enormous challenges as well as several advantages for the dental professional. This article discusses the rapid growth of this segment of the population, the barriers to their receiving dental care, and the objectives for provision of that care.

To gain insight into the challenges associated with the delivery of oral health care to homebound and nursing home residents, one must have an understanding of the complex issues and problems associated with these unique aging populations. The most rapid population growth is occurring among the oldest age cohort, older than 75. It is expected that by the turn of the century more than 50 percent of the elderly will fall within that age group.¹ Berk and colleagues have reported nearly 30 percent of this age group have chronic health problems that limit daily activities.²

As these physical, cognitive, and functional limitations accumulate with age, an increasing number of adults becomes either homebound or institutionalized. The extent of the cognitive or functional limitations are measured by level of assistance needed with activities of daily living (ADL) or instrumental activities of daily living (IADL). ADL are bathing, eating, dressing, toileting, and transferring. IADL are the ability to use the phone, shop, prepare food, clean house, wash laundry, access transportation, take medications, and handle personal finances. It is estimated that nearly 10 percent of community-dwelling elderly experience at least one ADL or IADL limitation. The extent of functional dependency is based on the level of assistance needed to perform these activities and the number of activities for which assistance is needed. The community-dwelling elderly often described as the functional dependent are older, dependent in physical function, cognitively impaired, incontinent, economically disadvantaged, users of home services, and less likely to be living along. For the purpose of this discussion, these functionally dependent elderly who never or almost never get out of their houses or buildings except for emergencies due to limitations in their ADLs will be defined as the homebound.³

Within the noninstitutionalized adult population older than 65, 11 percent have difficulty with at least one ADL, another 4 percent have two to three ADL difficulties and more than 2 percent have four or more ADL difficulties.⁴ The proportions of individuals requiring assistance with ADLs changes dramatically among individuals who perceive themselves as homebound. In a population of self-reported homebound individuals, 45 percent reported needing assistance with one to two ADLs with another 38 percent needing assistance with three to five ADLs.⁵

Not surprisingly, these ADL limitations in the homebound are comparable to the ADL limitations experienced by 90 percent of nursing home residents. Among this institutionalized population, 33 percent need assistance with three or more ADLs, another 33 percent need assistance with four or more ADLs, and nearly one in 10 needs assistance with all five ADLs.⁶

Long-term care, whether in the home or institution, is big business. Non-institutionalized long-term care and services, or home health care, has increased by 20 percent per year since 1991.^7,8 Home health care accounted for 14 percent of all Medicare Part A expenditures in 1994.⁹ Nursing home care is a $70 billion industry in the United States, representing 12 percent of U.S. chronic health care dollars, with more than 60 percent paid by Medicare/Medicaid and 33 percent paid out of pocket.¹⁰ In 1995, 1.4 million individuals in the United States older than 65 (4 percent) were in nursing homes.¹¹

As previously discussed, there are similarities between the homebound and the nursing home populations in terms of functional dependency. However, the attitudes of caregivers and patients distinguish the homebound from the institutionalized patient. The homebound adults and their caregivers prefer noninstitutionalized approaches to care that utilize home-based services.¹² To avoid institutionalization, the homebound make more frequent use of home-based services -- which can include home health aides, homemaker services, visiting nurses, physical therapy, and home-delivered meals. These services are viewed as the preferred and low-cost alternative to nursing home care.¹³ The average home health client is a woman age 70 with 1.7 ADL impairments.^7,8 The average nursing home resident is an 82-year-old woman, requiring assistance with more than four ADLs and experiencing some degree of cognitive impairment.¹⁴

Differences in Oral Health Status

The increased emphasis on preventive dentistry toward the end of World War II has resulted in older adults retaining natural dentition into old age and experiencing increasing rates of dental disease.^15-17 With more elderly choosing to remain in their own homes with the assistance of home-based services, little is known about the oral health needs of these homebound elderly or their access to oral health care. In nursing home populations, this increased retention of natural teeth has led to a well-documented increase in the prevalence of caries and periodontal disease.^18-20

The provision of oral health care to homebound and institutionalized patients presents enormous challenges for the dental profession. These challenges range from having adequately trained personnel, availability of appropriate dental equipment, financing of oral health care, and the health status of the patient. Several significant changes are occurring that ensure that this challenge will continue. Each succeeding elderly cohort is living longer in place in the community while those that enter a nursing home have greater levels of functional and cognitive impairment. While preventive dental service utilization has risen significantly for young cohorts during the past two decades, the use by older cohorts has increased only slightly. Older people continue to be the lowest utilizers of oral health care services, with 63 percent not having seen a dentist in the past year and 33 percent not having obtained care in the past five years.^21,22 However, those elderly who do seek regular dental care average more than 3.26 visits per person per year, the highest average number of visits per person of any age group.²³

Differences in oral health status and treatment needs among homebound and nursing home patients have not been well-documented. One study found that the mean age, mean number of teeth present, and gender did not differ significantly between homebound and nursing home patients. However, more than 38 percent of nursing home patients were completely edentulous compared with just 24 percent among the homebound. A significant difference was method of payment, with more than two-thirds of the nursing home patients paying for oral health care services with Medicaid while 78 percent of the homebound paid for services out of pocket. Treatment needs among these populations did not vary greatly. Nearly 60 percent of both groups had operative needs, 25 percent had prosthodontic needs, and 50 percent had surgery needs. The major treatment difference was in the periodontal/preventive category. More than 76 percent of the nursing home patients needed periodontal treatment while fewer than 60 percent of the homebound needed preventive services.²⁴

These treatment differences could be attributed to the nursing home patients’ having gone a longer period with limited access to routine oral health services. However, this argument does not explain the similar trends in the other treatment categories. Additionally, these treatment-need comparisons do not necessarily reflect differences in severity of condition or length of time that these conditions have existed.²⁴

As discussed earlier, measures of functional status can indicate homebound or nursing home status. The extent of functional-status decline is viewed as a barrier to receiving oral health care services. Among elderly living in the community, those described as homebound were receiving a greater number of home services and greater level of assistance with ADLs and transportation.⁵ Among elderly receiving home services, the majority reported their oral health was "fair" or "poor," nearly 80 percent reported a perceived dental need, while 26 percent reported having been to the dentist within the past two years, and 40 percent reporting having not been to the dentist in more than 10 years.²⁵

Barriers to Oral Health Care

There are several barriers to oral health care delivery for homebound and nursing home residents. However, the relationship between subjective oral health needs and barriers to receiving oral health care among the functionally dependent and homebound elderly are not well-documented. Previously identified barriers to receiving oral health care among the elderly include functional status, medical status, transportation difficulties, financing oral health care, previous patterns of dental utilization, knowledge and use of available oral health care services, perceived oral health status, education and attitudes of health care providers, elderly consumer attitudes, caregiver and family attitudes, and availability of necessary dental equipment.^26-30

For elderly consumers, oral health care financing option are limited. Dental insurance associated with employment generally does not extend into retirement. The majority of oral health care services for the elderly is paid out-of-pocket (79 percent) with just 10 percent covered by private insurance.³¹ The current Medicare and Medicaid health care delivery system for the elderly has improved access to care and assisted with the improvement in general health enjoyed by the elderly. However, these two social welfare programs were developed in the 1960s when the edentulous rate in the elderly was significantly higher and fewer elderly sought routine non-emergent dental care. Subsequently, Medicare has no provisions for preventive oral health care services or routine dental procedures. Individual states have the option of including oral health care services in their Medicaid package, but just 2 percent of total Medicaid dollars are directed to oral health care.³¹

Health care providers such as physicians, nurses, and nurses aides are most likely to have regular contact with homebound and nursing home residents. For physicians and nurses, training to recognize oral problems, oral lesions, or oral sequella of chronic systems conditions and the medications to treat these conditions are limited.³² However, these health care practitioners are primarily responsible for completing the minimum data set for each resident in the nursing home facility. Any nursing home accepting Medicare of Medicaid reimbursement is required to complete an MDS assessment upon admission and at least yearly thereafter and develop a plan of care for the resident.³³ Two sections of the MDS specifically deal with oral condition. Section M (oral/dental status) of the MDS is usually completed by a nurse and Section L (oral/nutritional status) is regularly completed by a dietitian.

The use of nondental personnel to complete the MDS or initial nursing home care oral examination can lead to much variability in the identification of oral health problems. The literature indicates that more-experienced nurses were able to identify broken or carious teeth nearly 85 percent of the time among nursing home residents. However, soft tissue lesions were less readily identified regardless of the nurse’s experience level.³⁴ Consequently, there can be a high level of misidentification of oral health problems.

Of equal concern is the tremendous burden of care placed on nurse’s aides. Nurse’s aides are responsible for up to 90 percent of nursing home resident daily care. It has been reported that the majority of residents require some or complete assistance with oral care. Nearly 75 percent of nurse’s aides indicate that patient behavior and physical difficulties prevented adequate oral hygiene from being provided.³⁵ However, these nurse’s aides receive the least amount of training, are the lowest paid staff, and have the highest rate of turnover in the nursing home.

Dentists, as do many health care workers, hold negative attitudes toward elderly patients. These attitudes are generally based on personal experiences and result from limited knowledge about the aging process and more specifically about oral manifestations of aging.^30,36 While dental education has made strides toward the inclusion of geriatric content in the curriculum and some schools offer extracurricular experiences, relatively few dentists have received the level of training that makes them comfortable in providing oral health care services outside the traditional office situation.³²

Developing ways to incorporate nursing home or homebound dentistry into private practice presents financial, scheduling, and logistical challenges. Development of an alternative dental practice to treat this population could range from providing simple denture adjustments using an electric handpiece to transporting portable dental equipment or developing an on-site dental suite within a nursing home. Portable dental equipment can cost from $5,000 to $20,000, can be transported in a car or van, and can include slow and high speed handpieces, suction, air compressors, and three-way syringes.³⁷

Several advantages have been associated with these alternative or nontraditional practice settings. These advantages include the personal satisfaction derived from providing oral health care to neglected patients with significant physical and cognitive impairments, the potential for patient referrals to a traditional office from patients’ families and facility staff, the professional challenge derived from treating the diverse oral health needs of a medically challenging population, and practice freedom in the form of flexible hours and scheduling.³⁷

The provision of oral health care services to nursing home or homebound patients requires the development of treatment objectives that meet the needs of this population. Several objectives for the delivery of oral health care services in long-term care settings have been developed by the American Society for Geriatric Dentistry. These guidelines are equally applicable to the delivery of oral health care to the homebound as well. The first objective answers the question as to why oral health care should be provided to long-term care patients. This objective states that oral health care should be provided to prevent disease, maintain chewing and speaking ability, and preserve comfort, hygiene and dignity.

The second objective discusses how the oral health care should be provided. This objective states that both the standard of oral health care and access to oral health care should be equal to that in the community. This objective implies that the oral health care must be setting-neutral and should be determined by patient needs and not limited by the training of the provider or technological capabilities or policies of the setting in which these services are provided.

The third objective addresses the question of patient rights in long-term care settings. This objective states that residents or their representatives should have the right to freely choose whether to receive oral health care, who will provide their care, and what specific oral health services will be provided. The final objective deals with the issue of oral neglect found among the functionally dependent chronically ill elderly, regardless of the setting. This objective states that all caregivers should advocate against the neglect of oral health problems suffered by the vulnerable adults who cannot advocate for themselves.³⁸

It is clear that the number of adults needing long-term care, whether provided in institutions or in the home, will continue to grow as the nation’s population ages. The recent growth in the home health care industry has resulted in more than 1.45 million people receiving home care services. However, less than 1.5 percent of these individuals reported having received any oral hygiene services or dental treatment.³⁹ For the institutionalized population, a recent survey noted that 60 percent of nursing homes did not have the services of dentists or had them only on call or available for off-site visits.⁴⁰

Summary

The need for greater accessibility to oral health care services for adults with long-term health care needs has been demonstrated. The role of prevention coupled with greater access to oral health care at earlier ages has resulted in older adults retaining more of their natural teeth. This places the elderly at greater risk for caries and periodontal disease as their functional capability declines and they are less able to maintain good oral hygiene. For these older adults with cognitive and/or functional limitations, prevention goals that focus on limiting further tooth loss and decay are often secondary to coexisting medical conditions and medications consumed.⁴¹

The complex medical, social, and oral health needs of these adults present a tremendous challenge to the dental profession. The ability of the profession to provide access to oral health care for these long-term care patients will ensure a better quality of life, free from pain and infection, with improved function for these deserving patients.

Author/

Michael Strayer, DDS, MS, is an associate professor in the Section of Health Services Research at the Ohio State University College of Dentistry.

References/

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To request a printed copy of this article, please contact/Michael Strayer, DDS, MS, Box 196, Postle Hall, OHU College of Dentistry, 305 W. 12th Ave., Columbus, OH 43210.