Engage at Any Age: Providing Safe Care for the Aging Population in the Dental Office Setting

This article about providing dental care to seniors is by Deanna Mirro Altmann, a Risk Management Consultant with MLMIC Insurance Company. It was originally printed in our Second Quarter 2023 issue of The Scope: Dental Edition. Read more from the publication here.

By 2030, one in six people in the world will be over the age of 60, and the demand for healthcare services in this population is increasing exponentially, as the elderly population experiences more chronic conditions and comorbidities when compared to the rest of the population. According to the National Council on Aging (NCOA), approximately 95% have at least one chronic condition and 80% have at least two chronic conditions. How can dental providers be prepared amidst the lingering effects of the pandemic coupled with the increased demand for care?

Older adults are interested in choosing therapies that will help keep their teeth. There is an emphasis on not only feeling good but also looking good as you age. Elderly patients, especially those with chronic health conditions, require extra precautions when receiving their care. There is increasing demand on dentists to have knowledge of oral manifestations of a chronic systemic disease process. One way to be prepared is by improving access to comprehensive and safe care. This is an important first step toward quality and safety outcomes in this growing patient population.

Providing a safe environment and remaining sensitive to the needs of this patient population will enhance patient care, improve patient satisfaction and minimize exposure to claims of negligence and professional liability. Starting with the physical aspects of the dental office setting, it is important to assess all the following areas where care is to be provided:

• Provide adequate comfortable seating for the elderly.
• Office waiting rooms and examination rooms should be clean, welcoming and comfortable.
• Adequate space needs to be provided in waiting rooms to accommodate persons in wheelchairs.
• Sufficient lighting should be maintained throughout the office.
• Floors and carpeted areas must be in good condition.
• Hallways and waiting rooms should be free of obstacles and trip hazards and allow space for those with walkers to ambulate.
• Consider installing hallway safety rails and inspect required bathroom grab bars regularly.
• Evaluate the building/office for handicap accessibility and ensure sufficient parking is available.
• Have wheelchairs readily available for patients.

Perform a comprehensive geriatric assessment including:

• A thorough and complete client/family interview.
• A full dental examination, including a cancer screening.
• A health literacy assessment for the patient and/or caregiver.
• A review of the patient’s medication history and usage and the patient’s understanding of their medications.
• A comprehensive medication education program, including written materials utilizing a clear, large font.

Additionally, consider a review of the patient’s cognition, support systems and finances, as well as the patient’s willingness to accept help. As part of that engagement, you should provide resources when English is the second language. Use everyday language and avoid technical terms. Also, be sure to document all materials given to the patient and caregiver. Written or typed materials should be a 12-point font or larger.

Care Models to Consider for Effective Patient Engagement

In 2017, the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) partnered with the American Hospital Association and Catholic Health Association of the United States to develop a social movement so that all older adult care is age friendly. The 4Ms, an age-friendly health system, utilizes a patient-centered approach to make care of older adults more manageable.

The 4Ms identify issues that can drive decision making in the care of older adults. The 4Ms framework includes:

• What Matters — Know and align care with each older adult’s specific goals and preferences.
• Medications — If a medication is necessary, use one that is age-friendly and won’t interfere with what matters, mentation and mobility.
• Mentation — Prevent, identify and manage dementia, depression and delirium.
• Mobility — Ensure older adults move safely every day and do what matters.

A 4Ms approach to care can transcend disciplines, specialties and disease states and can have equal importance with providers in all settings.

Additionally, IHI’s Ask Me 3 educational program encourages patients and their caregivers to ask these three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy:

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

Designed by health literacy experts, Ask Me 3 is intended to help patients become more active members of their healthcare team and to improve communications between patients, families and healthcare professionals. Consider placing signage about Ask Me 3 in exam rooms, as this will empower patients and family members to begin the conversation with their provider.

Consider the OSCAR approach to evaluate the geriatric patient:

• Oral and dental needs
• Systemic factors
• Capability
• Autonomy
• Reality

This approach, according to the Clinical Practice of the Dental Hygienist (10th edition), outlines the dental, medical/pharmacological, functional, ethical and fiscal factors that dentists should analyze when planning treatment for older individuals or those with disabilities. Treating aging patients in the dental office is a team effort. The dentist, hygienist, dental assistant and office staff all play a role in providing safe care.

Develop Effective Engagement Strategies

When documenting, remember the importance of face-to-face time. Keep external noises, such as suction units, turned off while speaking to the patient. Dental care providers should speak slowly, clearly and loudly when talking with older patients to enhance hearing and understanding, without sounding condescending. Repeating words and phrases verbatim can particularly help those older adults with dementia. If current infection control protocols allow, consider removing your mask when communicating instructions to your elderly patients.

Encouraging patients to set goals and actively participate in their plan of care can increase compliance. Effective communication can help build a rapport with older patients to appropriately manage their care, and strengthening the provider-patient relationship can lead to improved health outcomes and make the most of limited interaction time.

Educate Your Staff

The office staff should be aware of mobility issues and be trained in safely assisting, contact guarding and transferring elderly patients. Consider older adult sensitivity training as part of annual staff competencies.

Additionally, staff should be aware of any vision, hearing and transportation limitations when scheduling office visits or telehealth consultations.

Educating your staff about the needs of elderly patients will enhance their ability to demonstrate understanding, patience, respect and compassion. Interactions between older adults and healthcare professionals are influenced by the expectations and stereotypes that each party brings to the encounter. 

Medication Management in Eldercare

A high liability area in this population revolves around medication. It is important to educate patients and caregivers about each medication, including its name, appearance, purpose and effect. Include any potential side effects and/or interactions associated with the medication regimen. To ensure the patient understands, ask them to repeat what the medication is and what they are taking it for. Be sure to stress the importance of contacting a healthcare provider should any reactions, questions or concerns arise.

Some other points to keep in mind:

1. Query patients regarding any underlying issues with medication selection to resolve any concerns.
2. The importance of using only one pharmacy to obtain all medications should be emphasized to patients and/or their representatives. Collaborative team efforts may be necessary to address the need for the consistency of one pharmacy. Suggest to family members that they request pharmacy history printouts to cross reference what meds are being refilled and when. Emphasize to patients how compliance with the prescribed medication regimen will help keep them at home and limit admissions to the hospital.
3. Patients should also be advised to:
   • Keep an accurate list of all medications, dosages, dosing frequency and the reasons for taking the medication. This list should include generic and brand names, over-the-counter medications and herbal supplements.
   • Bring a list of all medications that they are taking to each and every appointment
   • Maintain a complete list of medical providers and their contact information.
   • Post the name and telephone number of their physician and their local pharmacy in a prominent location in their home. These should be posted near the patient’s POC (plan of care) and Medical Orders for Life-Sustaining Treatment (MOLST) form so that they are readily available in case of a hospital transfer.
   • Establish a daily routine when taking their medications.
4. Make patients aware of the various medication adherence aids and devices available, such as dosing reminders, pill boxes and refill reminder programs.
5. Provide useful written information, in plain language with a large font, that clearly explains how patients can correctly manage their medications.

Taking numerous medications can predispose older adults to oral conditions that dentists should be aware of, such as xerostomia, root caries and periodontal disease. Some older adults are not aware that oral health affects their overall systemic health. Getting the big picture can help minimize risks in treating these patients.

Social Determinants of Health

As part of good patient engagement, it is vital to address the social determinants of health (SDOH). These are factors that play a key role in better health outcomes and overall well-being. Factors to discuss with this patient population include accessibility of housing, food and transportation. Research shows that a lack of understanding about cultural practices, along with an unwillingness to acquire such information from the patient, can result in inaccurate patient evaluation and diagnosis. It may also increase the possibility that the recommended treatment plan will not be followed due to the patient’s dissatisfaction with the healthcare provider.

A State of Decay reports that older patients who have lower income and are less educated are most likely to misunderstand the connection between oral health and overall health. This population is also less likely to understand how medication can affect the health of their mouth.

It is estimated that in the next several decades, the elder patient population will triple. Dental providers must be aware of the unique needs of the elderly to be able to provide safe and effective care. Knowing their everyday physical and social environments will help providers better address this population’s health concerns, lead to better outcomes and minimize exposure to claims of negligence and professional liability

Got questions about providing dental care to older adults? Policyholders can contact our team of risk management professionals 24/7 at no additional cost by calling (844) 667-5291 or emailing hotline@tmglawny.com. For more resources for dentists, visit the MLMIC Dental blog, The Scope: Dental Edition, Dental Impressions and our Twitter and LinkedIn pages.

Photo by Jixiao Huang on Unsplash.