Integration of Oral Health into General Health Services for Older Adults

There is a growing role for digital technologies in society, but concerns that older adults may be disadvantaged and excluded with the growth of use of these technologies. The COVID-19 pandemic led governments across the world to mandate lockdowns and social restrictions. This was accompanied by rapid implementation of many digitalized services, including to access health and social care. This paper reports on a project to advance our understanding of how health and social care services for older adults (65+) have been digitalized during the COVID-19 pandemic, and to learn what has worked well and what has not, with a specific lens on health inequalities. We report main findings from three workstreams: (i) a mapping review, to identify (a) the types of evidence available on the digitalization of health and social care services for older adults during the COVID-19 pandemic, and (b) the extent to which factors related to health inequalities have been considered in this evidence; (ii) quantitative analysis of health care records to examine the impact of digitalization on access to primary care for older people in England during the COVID-19 pandemic, with a focus on incidence rate of consultation types (face-to-face, telephone and video) examined against age, gender, ethnicity and socioeconomic status; (iii) qualitative work to explore the experiences of UK older adults of South Asian and Black African or Caribbean descent of using digital technologies to access primary care. We consider how digitalization of health and social care services relates to health inequalities for older people.

This project is based on the results of telephone surveys with 52 local, state, and national informed respondents including policymakers, county leaders, planners, and advocates in mental health and aging with a particular focus on the states of California and Florida. This article addresses challenges to access to mental health services for diverse older adults including barriers related to race and ethnicity, socioeconomic status, location, age, gender, immigrant status, language, sexual orientation, and diagnosis. The article also highlights broad themes that emerged including (1) the importance of outreach and transportation tailored to diverse elders, and (2) recruitment of diverse staff and training related to diversity. The article concludes with policy and practice recommendations to reduce these disparities in access to mental health services for diverse populations of older adults.

The aim of this study was to present a concise summary of the oral health policies and oral healthcare schemes for older adult populations in a number of selected countries around the world. In this paper, the current and planned national/regional oral health policies and oral healthcare schemes of nine countries (Australia, Brazil, China including Hong Kong, India, Japan, Switzerland, Thailand, the United Kingdom, and the United States) are reported. Barriers and challenges in oral health promotion in terms of devising oral health policies, implementing oral health schemes, and educating the future dental workforce are discussed. In response to the aging of population, individual countries have initiated or reformed their healthcare systems and developed innovative approaches to deliver oral health services for older adults. There is a global shortage of dentists trained in geriatric dentistry. In many countries, geriatric dentistry is not formally recognized as a specialty. Education and training in geriatric dentistry is needed to produce responsive and competent dental professionals to serve the increasing number of older adults. It is expected that oral health policies and oral healthcare services will be changing and reforming in the coming decades to tackle the enduring oral health challenges of aging societies worldwide.

As an important measure to involve services for older adults, the government procurement practices have become a key link for public health services. However, the information asymmetry between public health service purchasers and public health service undertakers triggers a supervision dilemma. Based on this background, this study uses the evolutionary game theory to analyze the symbiotic evolution between local governments and public health service institutions under different reward and punishment mechanisms, explore game evolution, strategy adjustment, and influencing factors of different game subjects, and analyze the necessity and appropriate intensity of dynamic rewards and punishment mechanisms. The results show that: under the static condition, the penalty can change the strategies of local governments to a certain extent, but it is still difficult to achieve complete self-discipline management of public health service institutions. If local governments implement a dynamic reward or penalty mechanism in the supervision process of public health services for older adults, the equilibrium between them tends to be evolutionary stable. For three dynamic mechanisms, a dynamic reward mechanism is more conducive to adopting a self-discipline behavior of public health service institutions, which is helpful to realize the supervision of public health services for older adults. Also, there is a positive correlation between the proportion of public health service institutions who adopt a “self-discipline behavior” strategy and the maximum punishment intensity, and a negative correlation with the reward intensity. This study provides theoretical and decision-making references for governments to explore the promotion and implementation of public health services in older adults.

Increase in life expectancy in India has resulted in a demographic shift in the population, with decline in the percentage of the child population (0–14) and an increase in the percentage of older adults (above 60 years). With this transition in the population in India, there will be an increasing demand of oral and systemic healthcare needs of older adults. A healthy dentition is important for chewing, speech, aesthetics, nutrition, and systemic health all of which affect the quality of life. Till the time separate departments and centres can be set up for health services for older adults, the existing resources like manpower and infrastructure need to be upgraded for provision of oral health services to the geriatric population. There is a need to sensitize and train all those associated in providing oral healthcare regarding the special needs of older adults. Formal training of dentists, dental nurses, chairside assistants, hygienists, and technicians is essential considering the dimension of care and multispeciality services involved. Since older adults will constitute a higher percentage of the population in the future so planning and implementation of oral health services should be immediate for better health outcomes and to ensure good quality of life for senior citizens of India. Failure to do so will have far reaching adverse consequences on the health resources and health of this section of the population.KeywordsOral healthIndiaOlder adultsGeriatric dentistryPlanningImplementation and geriatric units

BackgroundIn India, the absence of formal training in geriatric dentistry and the lack of recognition of it as a speciality contributes to the deterioration of oral health in the older adults. India lacks specific oral healthcare policies for older adults. Additionally, caregivers’ perspective in old age homes regarding oral healthcare services remains underexplored, necessitating further studies in this context.MethodsA mixed method study was conducted, and the quantitative component focused on assessing the oral health status of institutionalized older adults and caregivers’ perceptions using a questionnaire. The qualitative part evaluates caregivers’ perceptions of providing oral healthcare services for older adults through in-depth interviews.ResultsMean DMFT among institutionalized older adults was 15.52±8.23. More than 50% of caregivers perceived that the oral health status of institutionalized older adults was fair. Barriers to oral health services include autonomy, difficulty in traveling, lack of financial support, lack of knowledge and time. Approaches to enhancing oral health services for institutionalized older adults include oral health education for older adults and their caregivers, monthly dental visits to the institution, utilization of portable dental chair services, collaboration with dental colleges/dental clinics, distribution of oral health education materials, and provision of oral hygiene aids.ConclusionFindings from our study indicate the need to collaborate with dental institutions to provide oral health services in old age homes, to improve the oral health status of older adults and caregivers' knowledge.

Background: The majority of the cost of oral health care in Australia is borne by individuals, hence many miss out on early, cost-effective care. 63,000 Australians are hospitalised annually for preventable oral conditions. Current approaches separate the provision of oral from general health care. Australia’s National Oral Health Plan recognises oral health as everyone’s business and a role for health care workers and carers to intervene early in oral disease.Objectives: To present an innovative approach to primary oral health care focussed on patient centred care, workforce reorientation, health promotion and prevention and the integration of oral and general health.Methods: North Richmond Community Health (NRCH), an inner urban community health service, in Victoria, Australia, through developing an innovative oral health program, has also developed a conference series Where the Mind Meets the Mouth WMMM (www.wheremindmeetsmouth.com.au) to inform the integration of oral health and general health. In 2015 the inaugural conference explored significant social determinants in oral and general health, such as substance use, mental illness and family violence. In 2016, the second conference, Putting the Mouth back into the Body, examined common risk factors for oral and general diseases, and working with other health professionals (eg. doctors, pharmacists, nurses).Results: WMMM has raised awareness amongst health professionals of the impact of oral health on general health and vice versa. A national research network committed to integration of oral and general health has been established, and a model of diabetes management that includes oral health has been proposed for trial. Conversations about Care, 2018, places the consumer at the centre of informing integrated health care provision.Conclusion: By responding to community needs, encouraging dialogue and sharing between consumers, health professionals and carers, we can truly collaborate in the delivery of primary preventive integrated health care, bringing the mind, body and mouth together.

Frailty has a profound negative impact on the abilities to perform daily oral hygiene and to regularly attend a dental professional. To inform effective oral care and oral health services for older adults, this research aimed to explore frail, home-dwelling older adults' experiences, needs, and barriers to daily oral hygiene and professional care. Semi-structured interviews were conducted with twenty-seven home-dwelling frail older adults in Belgium. Interviews were analysed using a reflexive thematic approach. Three themes were identified: 'importance of oral healthcare'; 'performing daily oral hygiene'; and 'seeking professional care'. All participants confirmed the importance of maintaining good oral health. Nevertheless, daily oral hygiene was often not performed as the latest guidelines recommend. Functional independence was considered an important issue, and participants expressed reluctance to ask home care nurses for help. Opinions on the usefulness of preventive dental visits were mixed. The findings highlight a gap between older adults' oral health knowledge or practices and the awareness of its importance. Consequently, efforts are needed to enhance older adults' self-efficacy in oral care. Non-oral healthcare providers could play a key role in encouraging and referring older adults to oral health professionals.

Researchers conducted a cross-cultural study using qualitative methods (based on a phenomenological approach) to explore the availability of mental health services (MHS) for older adults in the United States and Turkey. Using purposive sampling, semi-structured in-depth interviews were conducted with administrators (n = 24) from a wide-range of sites (nursing homes, hospice, senior centers) in a rural area of North Central Florida, United States and Ankara, Turkey. Interview questions focused on types of staff employed; integration of MHS with other services provided; community promotion of services; coordination, cooperation and communication with other service providers; and administrators’ perceptions of barriers in the provision of MHS for older adults. Interestingly, employing on-site mental health staff was a much more popular practice in Turkey compared to the United States with three times as many Turkish sites having on-site mental health professionals. As anticipated, administrators in both countries cited inadequate funding as the most common barrier to MHS provision. Potential solutions to MHS barriers in both countries are discussed.

Workplace Satisfaction in a Mental Health Service for Older Adults: An Analysis of the Effects of Setting and Professional Status

BackgroundThe prevalence of oral diseases among Taiwanese prisoners has rarely been investigated. This study aimed to estimate the gender-specific prevalence of oral disease in a sample of Taiwanese prisoners.MethodsWe included 83,048 participants from the National Health Insurance (NHI) Program. Outcomes were measured using the clinical version of the International Classification of Diseases, Ninth Revision (ICD-9-CM). For prevalence, we provide absolute values and percentages. We also performed a χ2 test to assess sex and age group differences in the percentage of disease in the oral cavity, salivary glands, and jaw.ResultsThe prevalence rate of oral diseases was 25.90%, which was higher than that of the general population. The prevalence of oral diseases in female prisoners was higher than that in male prisoners (p < 0.001), and the prevalence of oral diseases in prisoners aged ≤ 40 was higher than that of prisoners aged > 40. Among all cases of diagnosed oral diseases, the top three diseases were dental hard tissue diseases (13.28%), other cellulitis and abscesses (9.79%), and pruritus and related conditions (2.88%), respectively. The prevalence of various oral diseases in female prisoners was significantly higher than that in male prisoners.ConclusionOral disease is common among Taiwanese prisoners. Female prisoners had a higher prevalence of oral, salivary gland, and jaw diseases than male prisoners. Therefore, early prevention and appropriate treatment are required and also a need for gender-specific oral disease products given the differences in the prevalence of oral disease among male and female prisoners.

ObjectivesSocial distancing restrictions in the COVID‐19 pandemic may have had adverse effects on older adults' mental health. Whereby the impact on mood is well‐described, less is known about psychotic symptoms. The aim of this study was to compare characteristics associated with psychotic symptoms during the first UK lockdown and a pre‐pandemic comparison period.MethodsIn this retrospective observational study we analysed anonymised records from patients referred to mental health services for older adults in South London in the 16‐week period of the UK lockdown starting in March 2020, and in the comparable pre‐pandemic period in 2019. We used logistic regression models to compare the associations of different patient characteristics with increased odds of presenting with any psychotic symptom (defined as hallucinations and/or delusion), hallucinations, or delusions, during lockdown and the corresponding pre‐pandemic period.Results1991 referrals were identified. There were fewer referrals during lockdown but a higher proportion of presentations with any psychotic symptom (48.7% vs. 42.8%, p = 0.018), particularly hallucinations (41.0% vs. 27.8%, p < 0.001). Patients of non‐White ethnicity (adjusted odds ratio (OR): 1.83; 95% confidence interval (CI): 1.13–2.99) and patients with dementia (adjusted OR: 3.09; 95% CI: 1.91–4.99) were more likely to be referred with psychotic symptoms during lockdown. While a weaker association between dementia and psychotic symptoms was found in the pre‐COVID period (adjusted OR: 1.55; 95% CI: 1.19–2.03), interaction terms indicated higher odds of patients of non‐White ethnicity or dementia to present with psychosis during the lockdown period.ConclusionsDuring lockdown, referrals to mental health services for adults decreased, but contained a higher proportion with psychotic symptoms. The stronger association with psychotic symptoms in non‐White ethnic groups and patients with dementia during lockdown suggests that barriers in accessing care might have increased during the COVID‐19 pandemic.

After efforts to improve mental health services for older adults, services to older adult minorities in Michigan were compared with services to non-minority counterparts. Although aging specialists perceived substantial growth in services for all older adults, mental health services for ethnic minority adults showed a lower rate of growth. The effects of special funding and technical assistance on services to both groups were examined.

As the number of older adults increases in the world’s population, and as many of these older people retain their natural teeth, oral health promotion becomes more important for maintaining their quality of life. In this chapter we will examine why oral health is an important concern for the older population and their care providers as well as for the health professionals who must treat them when oral conditions become unmanageable at home, and the methods and benefits of health promotion to maintain the older person’s well-being. Throughout this chapter we will use a systems perspective to discuss the interaction of multiple individual and social systems in creating the need for and influencing the success of health promotion efforts. Age-related changes in the older person’s organ systems interact with the individual’s expectations about health and disease in old age; these changes in turn interact with society’s willingness and ability to provide oral health services for older adults. These interactions influence health beliefs, behaviours and subsequently the oral health status of older adults.

Older adults with serious illness are particularly vulnerable to oral disease due to worsened overall health, progressive functional loss and polypharmacy. Meanwhile, inability to communicate oral health needs, increased functional disability and psychological distress also hamper timely oral health care and lead to prolonged suffering and compromised quality of life. While many seriously-ill older adults with poor oral health receive no oral health care prior to death, unnecessary treatment is also common. In response to these issues, a new oral health care model is proposed to better address the oral health needs of older adults with serious illness. This model aims to promote comfort, maintain oral function and improve quality of life. End-of-life oral health trajectories and stage-appropriate oral health care strategies are also introduced to guide the care of these vulnerable individuals.