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Little difference in rate of acceptance was found based on resident age. Family and caregiver’s attitudes may be even more powerful in limiting access to care. Dolan and Atchison report that nursing home administrators pointed to lack of interest by the resident and lack of interest by the resident’s family as barriers to care. In addition, consulting dentists to nursing homes identified apathy of nursing home administrators and staff as significant barriers. Gordon, Berkey, and Call found a very substantial discrepancy between Colorado hospice patients and administrators regarding their perceptions of the importance of oral health. Of hospice patients, 86 percent reported that maintaining or improving their oral health status was either “important” or “very important” to them, whereas only 18 percent of administrators believed this to be true. Knowledge about dental health care is, however, increasing over time. Dr. Michael Helgeson, a geriatric dentist, emphasizes that the population of people age 65 and older is a very diverse group with a wide range of needs and expectations:46 “The people born between 1900 and 1910 are dramatically different from the people born between 1920 and 1930 in terms of the health care they have received and their lifetime access to dental services. Each age cohort is very, very different.” As the number of aging Americans continues to rise, dentists will be working with more elderly patients in their everyday practice and will be seeing greater numbers of older patients who bring high expectations for quality dental care. In the last 15 years alone, dentists specializing in care for older individuals have seen shifts in attitudes toward prevention of oral disease. They note that increasing numbers of patients are retaining their natural teeth, and there is a higher level of dental health knowledge emerging among older patients and their families. Helgeson cites his experience working with frail elderly adults living in nursing homes served by Apple Tree Dental in Minneapolis/St. Paul. When the nonprofit mobile dental program opened in 1986, 61 percent of the nursing home residents treated had no teeth. Ten years later, the percentage of residents with no teeth had dropped to only 40 percent. He notes that more and more elderly patients are retaining their natural teeth. Furthermore, patient expectations are changing as well. “When Apple Tree began in 1986, it was very rare to have either a patient or the son or daughter of a patient question a treatment plan that called for extracting teeth. Rarely, if ever, would the patient or the family ask if the teeth could be saved. The prevailing attitude was that teeth were dispensable. During the 15 years since that time, we are dealing with people who have completely different personal histories with dentistry. They are much more familiar with saving and repairing their teeth. The idea of going without any teeth at all is much more unacceptable now than it was 15 or 20 years ago.”
Lack of Effective Patient Self-Care or Caregiver
Assistance with Oral Care
Over half of those persons 75 years and over report limitations caused by chronic conditions.1 Self-care, in general, and oral health care in particular, can be adversely affected by these chronic conditions. Prevalent visual, manual, or shoulder and arm impairments can make effective cleaning of the teeth and mouth difficult. Increasing needs for help in other areas of life may overshadow a declining oral health situation. Either the older adult or their caregivers must become aware that daily oral care is not being done effectively. Problem recognition may be slowed by a number of factors. The older adult may be unable or unwilling to admit that an additional level of self-care (and independence) is being lost. The caregiver, particularly if they are a spouse or other family member, may be so burdened with other needed care that oral concerns are not recognized. If health services are being brought into the home, oral health issues may not be recognized or addressed by the home health worker. In the nursing home, nurse’s aides provide oral hygiene services. These individuals, who are minimally trained (75 hours or less), provide up to 90 percent of hands-on care that residents receive. 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 behavior and physical difficulties prevented adequate oral hygiene from being provided.58 A Connecticut study explored the beliefs, attitudes, and knowledge of nurse’s aides regarding oral health care for nursing home residents compared to other body care services that the aides performed such as bathing, toileting, and dressing. Mouth care was seen as a disliked task both by the aides and, in the aides’ opinion, by the residents despite being perceived as a significant benefit to the residents.59 Kambhu and Levy noted that poor hygiene levels correlated with uncooperative residents (82 percent), nurse’s aides who lacked a perceived need for good oral hygiene care (68 percent), and a perceived lack of time (49 percent). Lacking the ability to provide oral self-care, the frail elderly depend on someone with the necessary willingness and skill to provide or assist with that care on a consistent basis, either daily or every other day at a minimum. Judging by the extensive oral health needs of the homebound and institutionalized elderly, that key component of oral health maintenance is missing.