Patients In Long-term Care Hospitals Research Articles

Information technology-supported integrated health service for older adults in long-term care settings

BackgroundTo examine the effectiveness and safety of a data sharing and comprehensive management platform for institutionalized older patients.MethodsWe applied information technology-supported integrated health service platform to patients who live at long-term care hospitals (LTCHs) and nursing homes (NHs) with cluster randomized controlled study. We enrolled 555 patients aged 65 or older (461 from 7 LTCHs, 94 from 5 NHs). For the intervention group, a tablet-based platform comprising comprehensive geriatric assessment, disease management, potentially inappropriate medication (PIM) management, rehabilitation program, and screening for adverse events and warning alarms were provided for physicians or nurses. The control group was managed with usual care. Co-primary outcomes were (1) control rate of hypertension and diabetes, (2) medication adjustment (PIM prescription rate, proportion of polypharmacy), and (3) combination of potential quality-of-care problems (composite quality indicator) from the interRAI assessment system which assessed after 3-month of intervention.ResultsWe screened 1119 patients and included 555 patients (control; 289, intervention; 266) for analysis. Patients allocated to the intervention group had better cognitive function and took less medications and PIMs at baseline. The diabetes control rate (OR = 2.61, 95% CI 1.37–4.99, p = 0.0035), discontinuation of PIM (OR = 4.65, 95% CI 2.41–8.97, p < 0.0001), reduction of medication in patients with polypharmacy (OR = 1.98, 95% CI 1.24–3.16, p = 0.0042), and number of PIMs use (ꞵ = − 0.27, p < 0.0001) improved significantly in the intervention group. There was no significant difference in hypertension control rate (OR = 0.54, 95% CI 0.20–1.43, p = 0.2129), proportion of polypharmacy (OR = 1.40, 95% CI 0.75–2.60, p = 0.2863), and improvement of composite quality indicators (ꞵ = 0.03, p = 0.2094). For secondary outcomes, cognitive and motor function, quality of life, and unplanned hospitalization were not different significantly between groups.ConclusionsThe information technology-supported integrated health service effectively reduced PIM use and controlled diabetes among older patients in LTCH or NH without functional decline or increase of healthcare utilization.Trial registrationClinical Research Information Service, KCT0004360. Registered on 21 October 2019.

Cross-setting Comparison of Risk Factors for Pressure Injuries Acquired in Post-Acute Care.

To provide information on the association between risk factors and the development of new or worsened stage 2 to 4 pressure injuries (PIs) in patients in long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. After participating in this educational activity, the participant will:1. Compare the unadjusted PI incidence in SNF, IRF, and LTCH populations.2. Explain the extent to which the clinical risk factors of functional limitation (bed mobility), bowel incontinence, diabetes/peripheral vascular disease/peripheral arterial disease, and low body mass index are associated with new or worsened stage 2 to 4 PIs across the SNF, IRF, and LTCH populations.3. Compare the incidence of new or worsened stage 2 to 4 PI development in SNF, IRF, and LTCH populations associated with high body mass index, urinary incontinence, dual urinary and bowel incontinence, and advanced age.

Assessment and Coping Bahavior of Nurses to Aggressive Behavior of Dementia Patients in Long-term Care hospital

Assessment and Coping Bahavior of Nurses to Aggressive Behavior of Dementia Patients in Long-term Care hospital

Epidemiology, risk profile, management, and outcome in geriatric patients with atrial fibrillation in two long-term care hospitals

Aim of this study was investigate the prevalence and incidence of atrial fibrillation (AF) and to describe the clinical characteristics, risk profiles, and types of anticoagulant therapy for stroke prevention and the clinical outcomes in persons admitted to a long-term care hospital. We conducted a retrospective cohort study using data from the electronic medical records of patients aged 65 years or older living in two long-term care hospitals between January 1, 2014 and October 31, 2017. Overall data from 1148 patients (mean age 84.1 ± 7.9 years, 74.2% women) were analyzed. At baseline, the median CHA2DS2-VASc score was 4 (IQR 3–5) and the HAS-BLED score 2 (IQR 2–3). We observed patients over a median period of 3.7 years. The point prevalence of AF was 29.6% (95% CI 25.8–33.7) on January 1, 2014. The 1-year cumulative incidence of de novo AF was 4.0% (2.8–5.6). Oral anticoagulants were prescribed in 48% of patients with AF. The cumulative incidence at 1 year for a composite outcome of TIA, stroke, or systemic arterial embolism was 0.6% (0.1–3.1) and 1.7% (0.5–4.6) and for bleeding 2.6% (0.9–6.2) and 1.8% (0.5–4.8) in patients with AF and oral anticoagulants or no oral anticoagulants, respectively. In long-term care hospital patients, we observed a high burden of AF. However, only about half of patients with AF received oral anticoagulation for stroke prevention.

Who receives post-acute care? Characteristics of national population and field test sample.

Each year millions of Medicare beneficiaries in the United States receive post-acute care (PAC) in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), and home health agencies (HHA). We describe, overall and by PAC setting, the national population of facilities and patients, evaluate the representativeness of a national field test sample, and describe patient characteristics in the national field test sample. We analyzed the 2016 Provider of Service file, 2016 patient assessment data reported by PAC providers to Centers for Medicare & Medicaid, and data collected from PAC providers participating in a national field test. National data included 27,234 PAC settings and 5,033,820 beneficiaries receiving PAC. The national field test sample consisted of 143 facilities across 14 markets with 25-30 patients sampled from each facility (n=3669). We describe PAC facility and patient characteristics for both the national and field test sample. Nationally, PAC facilities were more likely for-profit versus not for-profit, have an average nurse-to-bed ratio between 1:10 to 1:1 (lowest in SNFs) and be in metropolitan versus other areas. PAC patients were more likely to be white, female, and 75-89 years of age; heart failure as a primary medical condition tended to be more common than stroke or sepsis. There was limited variability across setting types. In the national field test, patients in LTCHs demonstrated a greater likelihood of cognitive impairment, positive depression screening, bowel and bladder appliance use, higher rates of medication drug classes taken, and use of therapeutic diets and IV medications. The national field test facility and patient samples were fairly representative of the national population overall and across settings with a few exceptions. Moreover, differences according to PAC setting on patient characteristics in the national field test aligned with general differences in patient populations.

Analysis of blood pressure and blood pressure variability pattern among older patients in long-term care hospitals: an observational study analysing the Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) dataset.

There are limited data regarding blood pressure (BP) variability among older adults living in long-term care hospitals (LTCHs). We aimed to collect data from LTCH and analyse BP characteristics and its variability among these patients using a novel platform. The Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) platform was used to construct a daily BP dataset using data of 394 older patients from 6 LTCHs. BP variability was expressed as coefficient of variation (CV = standard deviation/mean of BP × 100). Physical frailty and cognitive function were evaluated using the K-FRAIL questionnaire and the Cognitive Performance Scale of the interRAI Long-Term Care Facilities tool, respectively. From September 2019 to September 2020, 151,092 BP measurements, 346.5 (IQR 290.8-486.3) measurements per patient, were included. The mean BP was 123.4 ± 10.8/71.3 ± 6.5mmHg. BP was significantly lower in frail patients (122.2 ± 11.3/70.4 ± 6.8mmHg) than in pre-frail/robust patients (124.4 ± 10.4/72.1 ± 6.1mmHg, P < 0.05). However, CV of systolic (10.7 ± 2.3% versus 11.3 ± 2.3%, P = 0.005) and diastolic (11.6 ± 2.3% versus 12.4 ± 2.4%, P < 0.001) BP was higher in frail patients. The mean BP was lower, but BP variability was higher in patients with cognitive impairment. The mean BP, but not BP variability, was higher in treated hypertensive patients, as the number of antihypertensive medications increased. Older patients with physical or cognitive frailty had lower BP but higher BP variability. Relationship among frailty, increased BP variability and adverse clinical outcomes should be investigated.

Factors associated with anticholinergic burden among older patients in long-term care hospitals in Korea.

Background/AimsDrugs with anticholinergic properties (DAPs) are associated with adverse health outcomes in older patients. The objective of this study was to evaluate the factors that determine the prescribing of more DAPs in long-term care hospitals (LTCHs) in Korea. In addition, the current patterns of DAP prescription were explored using a novel platform, which can collect data from LTCHs.MethodsThis was a Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) sub-study, which is a pragmatic, cluster-randomized, controlled trial. The Health-RESPECT platform was used to collect prescribed medication data of 466 patients (aged ≥ 65 years) from seven LTCHs. DAPs were identified using the Korean Anticholinergic Burden Scale (KABS). Physical frailty, cognitive function, functional status, and quality of life were evaluated.ResultsAmong 466 LTCH patients, 88.8% (n = 414) were prescribed DAPs, and the prevalence of high KABS (≥ 3) was 70.4% (n = 328). The drugs that contributed most to the total KABS were quetiapine (20.7%), chlorpheniramine (19.5%), tramadol (9.8%), cimetidine (5.8%), and furosemide (3.6%). Polypharmacy, higher body mass index, less dependence, better communication and cognitive functions, and poorer quality of life were associated with high KABS.ConclusionsAlthough the patients with a high burden of DAPs were less dependent and had better cognitive and communication functions, they had poorer quality of life. DAP use in LTCH patients should be monitored carefully, and the risk/benefit relationship for their use should be considered.

요양병원 요양보호사의 감염 환자 돌봄 경험

초록·키워드 목차 오류제보하기 Purpose: The purpose of this study is to explore nursing care worker"s experience of care services for infected patients in long-term care hospital. Methods: For this study, the researcher used the convenience sampling method to recruit 9 nursing care workers in long-term care hospitals. Data were collected through in-depth interview with them. The data collected were analyzed using the thematic analysis method. Results: 24 codes were extracted, and through the process of organizing the meanings, 8 sub-themes and 4 themes were deduced. The themes deduced were ‘Diversely coexisting psychological responses’, ‘Caring for an infected patient at a given position’, ‘Obstacles to implementation of principled infection control guidelines’, ‘Needs for customized education of caregiver for infected patients’. Conclusion: This study would be deemed significant in that it has provided for some basic data to the education of the nursing care workers and the development of an intervention program. #Long-term care hospital #Nursing care workers #Infected patient #Qualitative research #요양병원 #요양보호사 #감염관리 #질적연구 서론연구방법연구결과논의결론 및 제언REFERENCES

Nurses’ Experiences on End-of-Life Care for Older Patients in Long-Term Care Hospitals: Focusing on the Process of Practice and Barriers

Purpose: The purpose of this study was to investigate the practical process and barriers of end-of-life nursing practice for older patients in long-term care hospitals by exploring nursing experts’ actual experiences.Methods: Qualitative data were collected through focus group interviews with 9 nurses in 3 different long-term care hospitals from April to May, 2019. All interviews were recorded and transcribed verbatim and analyzed using the content analysis method.Results: Five themes and 14 sub-themes emerged for nurses’ perception regarding end-of-life nursing practice in long-term care hospitals, whereas three themes and 10 sub-themes emerged for the barriers of end-of-life nursing practices. The results show that the end-of-life nursing practice is currently considered an additional area beyond nurses’ existing work in long-term care hospitals and the area of performance is focused almost exclusively on physical care. The care is especially lacking in psychological and spiritual areas. Moreover, aspects of practice vary by institutions, day or night shifts and individuals. Various factors that hinder nurses’ performances of end-of-life care are identified in the areas such as ignoring patients’ dignity, an underdeveloped system and lack of supportive environment.Conclusion: Findings of this study suggest the need to establish standardized protocols for end-of-life nursing care in long-term care hospitals and develop educational programs based on those protocols.

걷기명상이 요양병원에 입원한 암환자의 우울과 삶의 질에 미치는 효과

Purpose: This study aimed to evaluate the effects of walking meditation on cancer patients suffering from depression and their quality of life (QoL) in a long-term care hospital. Methods: This was a quasi-experimental study with a non-equivalent control group and a pretest-posttest design. Forty-nine cancer patients living in a long-term care hospital participated in the study. The experimental group (n=24) received the 2-week walking meditation program while the control group (n=25) received no such treatment. They all answered questionnaires on depression and QoL. The data collected was analyzed using SPSS PC+ 26.0 through paired t-tests, independent t-tests, and ANCOVA. Results: There were significant differences in depression (paired t= &amp;#8722;3.944, p =.001) and QoL (paired t=2.443, p =.023) in the experimental group on pretest-posttest. Also, there were significant differences in both depression (F=8.302, p =.001) and QoL (t=2.360, p =.024) between the two groups. Conclusion: These results suggest that the walking meditation program has positive effects on the depression suffered by cancer patients as well as on their QoL in a long-term care hospital. Thus, this program can be utilized as an effective nursing intervention for cancer patients in long-term care hospitals.

Characteristics and Death Risk Factors of Patients in Long-Term Care Hospital Connected to Special Hospital

Characteristics and Death Risk Factors of Patients in Long-Term Care Hospital Connected to Special Hospital

Nurses' Experiences of End-of-life Care for Elderly Patients in Long-term Care Hospitals

Purpose: The purpose of this qualitative study was to describe the essence and the meaning of nurses’ experiences of end-of-life care (EOLC) for elderly patients in the long-term care hospitals (LTCHs). Methods: Data were gathered from 12 nurses who had been working at LTCHs in Korea through one-on-one interviews and the data were analyzed by Colaizzi''s phenomenological method. Results: The emergent 5 themes were ‘Doing the best for protecting patients’ life’, ‘Providing a comfortable dying process for patients’, ‘Supporting a family’s keeping on patient’s death’, ‘Reflecting on life’ and ‘Desiring for the establishment of a humanity end-of-life care environment’. Conclusion: The end-of-life care for the elderly patients includes supporting elderly patients’ comfortable dying process and helping the family keep the death of the elderly. The results indicated that physical facilities and end-of-life nursing capacity should be established in LTCHs for improving the quality of EOLC.

Improving Preparedness for and Response to Coronavirus Disease 19 (COVID-19) in Long-Term Care Hospitals in Korea.

Clusters of coronavirus disease 2019 (COVID-19) in long-term care facilities (LTCFs) have been widely reported in Korea and around the world. COVID-19 has a high mortality rate, and older patients and those with underlying diseases are at particularly high risk of being infected. Outbreaks in LTCFs, where many high-risk patients reside, result in the occupation of beds meant for severely ill patients and even death in many patients. Long-term care hospitals (LTCH) are major LTCFs in Korea. Therefore, it is very important to protect patients in LTCHs from COVID-19. The reality is that preparedness for COVID-19 in LTCHs is inadequate, and there are barriers to improvements in preparedness. Through institutional improvement and policy support, the government should help healthcare personnel and LTCHs improve installation and raise the level of knowledge of infection prevention and control. With these improvement, prevention, surveillance, and screening for COVID-19 should be done and a response system to the COVID-19 outbreak should be established. There are many challenges that must be overcome to meet the goals proposed in this article. This may be possible only with a spirit of solidarity and cooperation of government, public and private healthcare facilities.

Paired Interviews to Evaluate Patient and Proxy Responses on Patient Experience of Care Surveys (PECS)

Paired interviews are used to evaluate whether a questionnaire functions properly for both the target respondent and an alternate respondent (proxy). We developed a new application of this tool to evaluate whether a Patient Experience of Care Survey (PECS) for long-term care hospitals (LTCHs) and inpatient rehabilitation facilities (IRFs) functioned acceptably for patients and their family members. Frequently, patients in LTCHs and IRFs cannot fully recall their care experience and are often unable to complete surveys because of cognitive or physical limitations. For this project, researchers conducted interviews with 20 paired respondents: a patient and a proxy. Results revealed that the patient and their proxy went through similar response strategies and answered questions similarly to each other a majority of the time. We concluded that the questionnaires function acceptably for patients and proxies.

Good Death Awareness, Attitudes toward Advance Directives and Preferences for Care Near the End of Life among Hospitalized Elders in Long-term Care Hospitals

Purpose This study was done to examine good death awareness, attitudes toward advance directives (ADs), and preference for care near the end-of-life (PCEOL) of hospitalized elders in long-term care hospitals. Relevant characteristics were investigated as well as correlation of the variables. Methods This descriptive research study involved 161 hospitalized elderly patients in long-term care hospitals. A self-report questionnaire was used to measure Good Death Scale, ADs Survey, PCEOL Scale, and general characteristics. Collected data were analyzed using descriptive statistics, t-test, ANOVA, and Pearson correlation with SPSS/WIN 23.0. Results In terms of good death awareness, a significant difference was observed; in according to age (F=3.35, p=.037), payer of treatment costs (F=3.98, p=.021), mobility (F=3.97, p=.021), heard discussion about ADs (t=-3.89, p<.001), and willing to complete ADs (t=2.12, p=.036). As far as attitudes toward ADs, the participants presented significant difference depending on religion (t=2.38, p=.018), average monthly income (F=3.91, p=.022), duration of hospital admission (F=5.33, p=.006), person to discuss ADs (t=-2.76, p=.006). On PCEOL, there was a significant difference, depending on religion (t=-3.59, p<.001) and perceived health status (F=3.93, p=.022). Finally, as for how the variables were related to each other, good death awareness and attitudes toward ADs had a weak positive correlation with PCEOL. Conclusion To help seniors staying in nursing homes face a good death and enjoy autonomy, there should be educational and support systems that reflect each individual’s sociodemographic characteristics so that the seniors can choose what kind of care they want to receive near the end-of-life. 주요어: 죽음, ì‚¬ì „ì˜ë£Œì˜í–¥ì„œ, ì‚¬ì „ì˜ë£Œê³„íš, ìž„ì¢ ê°„í˜¸, ë ¸ì¸ Key words: Death, Advance directives, Advance care planning, Terminal care, Aged

Factors Influencing Death Anxiety in Elderly Patients in Long-term Care Hospitals

Factors Influencing Death Anxiety in Elderly Patients in Long-term Care Hospitals

요양병원 입원노인의 간호만족도, 자아존중감 및 우울이 적응에 미치는 영향

본 연구는 요양병원 입원노인의 간호만족도, 자아존중감 및 우울이 적응에 미치는 영향을 규명하기 위한 서술적 조사연구이다. 대상자는 B시와 K시 소재 15개 요양병원 입원노인 116명이며, 자료수집기간은 2015년 2월14일에서 3월31일 까지였다. 수집된 자료는 t-test, ANOVA, Scheff's test, Pearson's correlation coefficients와 multiple regression으로 분석하였다. 연구결과, 대상자의 간호만족도 정도는 평균평점이 <TEX>$3.92{\pm}0.60$</TEX>으로 비교적 높게 나타났다. 자아존중감 정도는 평균평점이 <TEX>$2.83{\pm}0.47$</TEX>로 중간보다 높게 나타났으며, 우울정도는 평균평점이 <TEX>$0.38{\pm}0.25$</TEX>로 비교적 낮게 나타났다. 대상자의 적응정도는 평균평점이 <TEX>$3.45{\pm}0.64$</TEX>로 비교적 높게 나타났다. 대상자의 적응 정도는 제 특성 중종교, 배우자 유무, 지각된 경제상태, 지각된 힘든 문제에 따라 통계적으로 유의한 차이가 있었다. 간호만족도와 적응과의 관계와 자아존중감과 적응과의 관계는 각각 중간정도의 양의 상관관계가 있었고 통계적으로 유의하였다. 우울과 적응과의 관계는 강한 음의 상관관계가 있었고, 통계적으로 유의하였다. 적응을 설명하는 유의한 변수는 우울, 간호만족도, 자아존중감, 종교 순이었으며, 전체 설명력은 53.5%이었다. 따라서 요양병원 입원노인의 적응을 높이기 위해서는 우울을 감소시키고, 간호만족도와 자아존중감을 높일 수 있는 간호중재의 개발을 위한 구체적인 노력이 필요하다. This study was conducted to determine the influence of satisfaction, self-esteem, and depression on adjustment of elderly patients in long-term care hospitals. The subjects were 116 elderly patients in 15 long-term care hospitals in B and K city. Data were collected from February 14 to March 30, 2015, and analyzed by t-rest, ANOVA, Scheff's test, Pearson correlation coefficients, and stepwise multiple regression. According to the results, there were significant differences in adjustment by religion, marital status, economic status, and perceived level of difficult problems. Adjustment was positively related to satisfaction and self-esteem. In addition, a negative correlation was observed between adjustment and depression. Meaningful variables that influenced the adjustment of elderly patients were depression, satisfaction, self-esteem, and religion. These factors accounted for 53.5% of the total variance in adjustment of the elderly patients in long-term care hospitals, and depression was the most influential factor. In conclusion, development and implementation of effective programs and strategies to reduce depression and to increase satisfaction with care and self-esteem is needed in order to enhance the adjustment of elderly patients in long-term care hospitals.

Evaluating the Comprehensive Model of Ego-integrity for Senior Patients in Convalescent Hospitals: Influence Factors and Outcome Variables

This study was performed to evaluate the applicability of the ego-integrity model for home residing elderly to elderly patients in long-term care hospitals. In order to identify the predictors of ego-integrity in elderly patients, a regression analysis was conducted. Results showed that higher age, lower pain levels, higher levels of fantasy and perspective taking, and lower personal distress level in the empathy dimension, as well as higher spiritual well-being, were related to higher ego-integrity. These results show that multidimensional factors covering all the physical, psychosocial, and spiritual aspects have to be considered to formulate a comprehensive understanding of ego-integrity in seniors.

A single-day point-prevalence study of faecal carriers in long-term care hospitals in Madrid (Spain) depicts a complex clonal and polyclonal dissemination of carbapenemase-producing Enterobacteriaceae.

The objective of this study was to describe the prevalence and microbiological characteristics of carbapenemase-producing Enterobacteriaceae (CPE) colonizing patients in long-term care hospitals (LTCHs) in Madrid, Spain. Three LTCHs were included in a single-day point-prevalence survey (September 2013). Rectal swabs, collected from all hospitalized patients (137 in LTCH-A, 121 in LTCH-B and 83 in LTCH-C), were plated onto chromogenic media. Population structure (PFGE and MLST), genes encoding carbapenemases and ESBLs and plasmids carrying carbapenemase genes were characterized. The prevalence of CPE carriers was 4.1% (14/341) [2.9% (4/137), LTCH-A; 4.1% (5/121), LTCH-B; and 6.0% (5/83), LTCH-C]. OXA-48 was the most prevalent carbapenemase (nine Klebsiella pneumoniae, two Escherichia coli, one Enterobacter cloacae and one Citrobacter braakii) followed by VIM-1 (one K. pneumoniae and one Raoultella ornithinolytica). One patient (LTCH-C) was co-colonized with OXA-48-producing K. pneumoniae and E. coli. K. pneumoniae and E. coli isolates also coproduced CTX-M-15 (n = 11) or CTX-M-9 (n = 1) enzymes. K. pneumoniae clustered into six PFGE types corresponding to ST11 (n = 1), ST15 (n = 6), ST307 (n = 1) and ST405 (n = 2). E. coli from LTCH-A and LTCH-C exhibited two different PFGE types associated with ST68. OXA-48 and VIM-1 enzymes were found in different clones in LTCH-A and LTCH-C. However, OXA-48 was the only carbapenemase detected in LTCH-B, mainly associated with K. pneumoniae ST15. KPC, IMP and NDM enzymes were not detected. blaOXA-48 was located on an ∼ 60 kb plasmid with a pOXA-48a-IncL/M backbone. We describe the first point-prevalence study of CPE faecal carriers in LTCHs in Spain. OXA-48, the most prevalent carbapenemase, showed a complex dissemination pattern with clonal and polyclonal bacterial populations.

요양병원 노인환자의 구강건강상태와 구강건강관리 요구도

Objectives: The purpose of this study is to identify oral health status and oral health care needs of elderly patients in long-term care hospital. Methods: Oral health examination was carried out by a dentist and questionnaire was completed by direct individual interview by a dental hygienist for 245 elderly patients in seven long-term care hospitals in Daegu from March 12 to April 16, 2011. Results: Those who need dental care were 188(76.7%) and was done by oral health examination by a dentist. 93 patients(38.0%) wanted dental care and 63 patients(25.3%) need dental care. The most important dental service in the elderly patients was denture and prosthetic service. As demand for denture and prosthetic service exceeds the supply, but only 35.9 percent of the elderly received the dental care service by the estimation of the caregivers. Conclusions: It will be necessary to establish the customized dental care service for the elderly patients in long term care hospitals. The oral health education for the caregivers is very important and the continuing education program must be implemented in the future.