Kalpa Patel reviews the specific challenges of older patients.
The Office of National Statistics indicates that the fastest increase has been in the population aged 85 years and over. ‘The oldest old’ numbered 1.3m in 2008 and is predicted to be 3.2m in 2033. In the United States, the age group showing the greatest increase in numbers is the centenarians. With increasing age we have increasing frailty, disability and impairment. This can have an impact on an older person’s ability to self-care, access health services, cognitive ability and reliance on others. It is estimated that 20 per cent of people aged 84 years, and 84 per cent of those aged 95 and over live in care homes.
It is predicted that there will be a shift in restorative treatment provision from those in middle age to older people. The ‘newer old’ (70-85) have heavily restored dentitions which require continuing maintenance, and their expectations of retaining natural teeth are high. There will be an increase in teeth with exposed roots plus risk factors for decay such as dry mouth due to medication, wearing partial dentures, poor oral health with increasing frailty and disability with a reliance on carers for oral hygiene measures and poor diet containing sugars. The British National Diet and Nutrition Survey reported that 39 per cent of frail older people living a care homes with exposed root surfaces had signs of decay.
Article 14 of European Convention of Human Rights “prohibits discrimination on non-exhaustive list of grounds of people and could include discrimination on the grounds of age or disability”.Age discrimination has a dramatic and detrimental effect on older people and is often not acknowledged. Sadly, health professionals are not immune from ageism. They may exclude an older patient from decisions about treatment planning, or believe that older patients will not live long enough to make them worth treating. Negative attitudes may affect the way the dental practice provides treatment, and the types of treatment which are offered and recommended to the patient.
Much dental treatment in older people is achieved without any special modifications of the dentist’s technique. However, certain age-related changes in oral tissues (for example increased brittleness of dentine) can influence operative procedures, as can iatrogenic factors (such as medication-induced xerostomia). Oral and denture hygiene may become a problem where the patient is apathetic about personal care, or if his or her manual dexterity and/or eyesight are impaired. Treatment planning decisions must take these factors into account.
The World Oral Health Report 2003 emphasises that oral diseases are age related, that the risk factors for chronic disease are common to most oral diseases, and that oral heath is an integral part of general health and an important component of quality of life. Chronic diseases are more prevalent in the older population, whose age-associated physiological changes deprive them of their mobility and independence. Links between oral and general health in the elderly are summarised in Table 1.
Mental capacity
The Mental Capacity Act provides a framework for decision making for adults who lack capacity to make decisions of their own.
The Mental Capacity Act has five key principles:
- A presumption of capacity unless it is proven otherwise.
- Support individuals to make decisions.
- Respect an individual’s right to make unwise decisions.
- Act in the patient’s best interests.
- The least restrictive intervention of an individual’s fundamental rights and freedoms.
The decision making process for clinical treatment can be complex. It may be necessary to assess capacity for each intervention at each appointment. Some individuals may have the capacity to consent to simpler forms of treatment but may not be able to weigh up the risks and benefits of having a general anaesthetic for treatment for example. When assessing capacity to consent the following must be considered:
- Understand the information relevant to the decision.
- Retain the information relevant to the decision.
- Use or weigh the information.
- Communicate the decision by any means.
When deciding on who should be involved in the decision process for an older person who lacks capacity, the Mental Capacity Act states that appropriate individuals have a right to be consulted prior to a decision:
- Anyone named by the incapacitated person.
- Anyone engaged in caring for the person or interested in his welfare.
- Lasting Powers of Attorney (will extend to health and welfare decisions).
- Court Appointed Deputies (will make healthcare and welfare decisions).
- Independent Mental Capacity Advocate - provided by NHS or local authority.
Abuse
Over 500 000 older people suffer elder abuse in the UK. O’ Keefe et al (2007) states abuse increases with failing health, increased disability, depression and loneliness. Over half the abusers were spouses followed by family members. Thirteen per cent of the cases of abuse were reported to be committed by health care workers.
In the context of dentistry it is now mandatory to ensure that the whole dental team are regularly updated on the protection of vulnerable adults. The dental team must be able to recognise signs of abuse and be able to refer accordingly. If abuse is suspected try to speak to the older person about your concerns. Be open and honest and never promise not to disclose what the individual has told you as it may be affecting more individuals (in a care home for example). Once an individual has disclosed information that is of concern then the dental team has an obligation to ensure that this information is passed on.
The provision of care for our older patients can be challenging, however with consideration a dental practice can provide effective dental care for its elderly patients.
References available on request.