Development and validation of a nursing home mortality index to identify nursing home residents nearing the end of life in dental clinics.

BACKGROUND: Nursing home (NH) residents seek care at dental offices, yet many of them are at the end of life. The uncertain life expectancy further complicates the care of NH residents. This study aimed to develop and validate a Nursing Home Mortality Index (NHMI) to identify NH residents in the last year of life. METHODS: Logistic modeling was used to develop predictive models for death within 1 year after initial appointment by utilizing the new patient examination data and mortality data of 903 Minnesota NH residents. The final model was selected based on areas under the curve (AUC) and then validated using data from 586 Iowa NH residents. Based on the final model, the NHMI was developed with the estimated 1-year mortality for the low, medium and high risk group. RESULTS: One-year mortalities were 21% and 26% in the development and validation cohorts, respectively. Predictors included age, gender, communication capacity, physical mobility, congestive heart failure, peripheral vascular disease, cancer, cerebrovascular disease, chronic renal disease and liver disease. AUCs for the development and validation models were 0.73 and 0.68, respectively. For the validation cohort, the sensitivity and specificity were 0.79 and 0.53, respectively. The estimated 1-year mortality risks for three risk groups were 0%-10%, 11%-19%, and ≥20%, respectively CONCLUSION: The high mortality rate of NH residents following a dental exam highlighted a need to incorporate patients' prognoses in treatment planning along with normative needs and patients' preferences. The NHMI provides a practical way to guide treatment decisions for end-of-life NH residents.

Myths and facts about Minnesota's new safe patient handling statute and your dental practice.

With the passage of a safe patient handling statute in 2009, Minnesota became one of a growing number of states requiring health care providers to become more aware and accountable about providing appropriate assistance during the movement of patients in clinical care settings. The Minnesota Department of Labor and Industry and the Minnesota Dental Association have been working together to ensure that Minnesota's SPH regulations are as practical as possible for dental providers while still achieving the objectives of the statute. A template Safe Patient Handling Program for Clinics has been developed with substantial input from MDA's ESNA Committee and is now available on the DLI website: www.dli.mn.gov/WSC/SPHlegislation.asp. All Minnesota dental practices should use this template to develop their own safe patient handling program as soon as possible. Additional background information and resources related to Minnesota's SPH regulations are also available on the DLI website. MDA and DLI are currently also developing a hazard assessment tool for dental practices to assess their specific risks associated with patient movement. This hazard assessment will, in turn, guide decisions about what type of safe patient handling equipment and staff training will be necessary for total compliance with the new statute. MDA, in cooperation with DLI, will continue to keep dental professionals informed about when these materials will be available. Additionally, MDA is working to ensure appropriate training options will be available for compliance with SPH regulations. The University of Minnesota's School of Dentistry's Oral Health Services for Older Adults Program and Department of Continuing Dental Education have been regularly providing such training in conjunction with the school's "Miniresidency in Nursing Home and Long-term Care for the Dental Team," and efforts are now underway at the dental school to create stand-alone training options for Minnesota's dental professionals. Further information about SPH training may also be found on the DLI website (www.dli.mn.gov/WSC/SPHlegislation.asp). MDA members can also contact MDA's Elderly and Special Needs Adults Committee via the MDA central office.

The application of facial expressions to the assessment of orofacial pain in cognitively impaired older adults.

BACKGROUND: The anticipated rapid growth in the number of cognitively impaired older adults, declining edentulism and increasing oral health expectations suggest a greater need for comprehensive dental care and effective ways to evaluate orofacial pain in people with compromised mental function and impaired communication skills. The authors conducted a study to evaluate facial expressions as a means of identifying orofacial pain in cognitively impaired and cognitively intact older adults, compared with other available pain assessment tools. METHODS: The authors conducted a prospective comparative study using three alternative pain measurement tools in a sample of 22 older adults. They divided subjects into cognitively impaired and cognitively intact groups on the basis of their mental status examination scores. The pain measurement methods evaluated were facial expressions quantified by the Facial Actions Coding System (FACS); self-reported pain via the Verbal Descriptor Scale; and physiological response to pain via changes in heart rate. The pain stimuli were local anesthetic injections in subjects who required them for routine dental procedures. RESULTS: The average FACS scores during anesthetic injections were significantly higher than those during the preinjection period (prebuccal versus buccal, P = .016; prepalatal versus palatal, P = .0002). The differences between preinjection and injection segments were even higher in cognitively impaired patients than in cognitively intact patients. There were no correlations between the three pain measurements (P > .05). CONCLUSIONS: Changes in facial expression proved to be the most useful measure overall in identifying pain in both cognitively intact and cognitively impaired older patients. This measure appeared to be more sensitive in cognitively impaired patients because they demonstrated fewer facial movements in anticipation of pain stimuli.

Dental treatment intensity in frail older adults in the last year of life.

BACKGROUND: Palliative care focusing on pain and infection is recommended for patients who are terminally ill. It is difficult to implement this strategy in practice because of the lack of clear guidelines. The authors conducted a study to examine dental treatment provided to a group of long-term care (LTC) residents in the last year of life. METHODS: The authors retrospectively followed 197 LTC residents (60 years or older) in the last year of life to death. On the basis of the dental services patients received between the new patient examination and death, the authors categorized the patients into three groups: no care (NC), limited care (LC) and usual care (UC). The authors developed a multivariable continuation ratio logit model with shared regression coefficients across two logits to identify the factors associated with the end-of-life dental care pattern. RESULTS: The authors found that 50.8 percent of the patients received NC before death. Among those who received treatment, 62.9 percent received UC, and 60.7 percent of the patients in the UC group had completed their treatment in the last three months of life. A three-month increment in survival and having dental insurance resulted in 1.74 (95 percent confidence interval [CI], 1.32-2.30) and 2.59 (95 percent CI, 1.03-6.52) times greater odds, respectively, of receiving some dental treatment before death. Neither survival nor dental insurance, however, was associated with dental care intensity in the last year of life (that is, UC versus LC). CONCLUSIONS: While most of the patients who were in the last year of life received insufficient dental care, comprehensive treatment was provided commonly to frail patients at the end of life, raising questions about quality of care. PRACTICAL IMPLICATIONS: Palliative oral health management needs to be revisited to improve quality of care for frail older adults at the end of life.

Dental caries in older adults in the last year of life.

OBJECTIVES: To examine dental caries severity (measured by number of carious teeth) in older adults in the last year of life. DESIGN: Cross-sectional study based on dental records. SETTING: Community-based geriatric dental clinic. PARTICIPANTS: One thousand two hundred sixteen individuals aged 65 and older, including 168 individuals in the last year of life (e.g., individuals died within 1 year after their new-patient examinations). MEASUREMENTS: Information on socioeconomic, medical history, medication, functional status, and oral health measures, including number of carious teeth, was abstracted from dental records. End-of-life status was determined using the National Death Index. Propensities of death were calculated using a logistic regression and then adjusted together with mobility and oral care function in the multivariable regression model to examine the effect of end-of-life status on dental caries. RESULTS: Caries severity differed in end-of-life participants with different oral care function. Of those needing help with oral care, end-of-life participants had only a slightly higher and nonstatistically significant risk (7.5 vs 6.1, adjusted incidence density ratio (IDR) = 1.12, 95% confidence interval (CI) = 0.85-1.48) of having more carious teeth than those not in the last year of life. On the other hand, caries severity was lower in end-of-life participants without impaired oral care function (IDR = 0.53, 95% CI = 0.30-0.92). CONCLUSION: Oral care function modifies the association between caries severity and end-of-life status. Individuals who could maintain oral hygiene independently had a low level of caries at the end of life, however, dental caries had increased before functionally dependent individuals entered their last year of life.

Patterns of tooth loss in older adults with and without dementia: a retrospective study based on a Minnesota cohort.

OBJECTIVES: To study tooth loss patterns in older adults with dementia. DESIGN: Retrospective longitudinal study. SETTING: A community-based geriatric dental clinic in Minnesota. PARTICIPANTS: Four hundred ninety-one older adults who presented to the study clinic as new patients during the study period, remained dentate after finishing the initial treatment plan, and returned for care at least once thereafter were retrospectively selected. One hundred nineteen elderly people with International Classification of Diseases, Ninth Revision, codes 290.x, 294.1, or 331.2 or a plain-text diagnosis of dementia, Alzheimer's disease, or chronic brain syndrome in the medical history were considered having dementia. INTERVENTION: All existing dental conditions were treated before enrollment. Dental treatment was continually provided for all participants during follow-up. MEASUREMENTS: Tooth loss patterns, including time to first tooth loss, number of tooth loss events, and number of teeth lost per patient-year were estimated and compared for participants with and without dementia using Cox, Poisson, and negative-binomial regressions. RESULTS: Participants with dementia arrived with an average of 18 and those without dementia with an average of 20 teeth; 27% of remaining teeth in the group with dementia were decayed or retained roots, higher than in the group without dementia (P<.001). Patterns of tooth loss did not significantly differ between the two groups; 11% of participants in both groups had lost teeth by 12 months of follow-up. By 48 months, 31% of participants without dementia and 37% of participants with dementia had lost at least one tooth (P=.50). On average, 15% of participants in both groups lost at least one tooth each year. Mean numbers of teeth lost in 5 years were 1.21 for participants with dementia and 1.01 for participants without dementia (P=.89). CONCLUSION: Based on data available in a community-based geriatric dental clinic, dementia was not associated with tooth loss. Although their oral health was poor at arrival, participants with dementia maintained their dentition as well as participants without dementia when dental treatment was provided.

Predicting tooth loss for older adults with special needs.

OBJECTIVES: Older Adults with Special Needs (OASN) have more oral health needs compared with healthy, independent elders. Currently, little is known about tooth loss, a key indicator of oral function loss, among OASN. Risk assessment is primarily based on clinical experience rather than scientific evidence, raising concerns for quality of care. The study's objective was to develop an evidence-based model to quantitatively predict tooth loss for OASN. METHODS: Four hundred ninety-one dentate older adults, including 235 from long-term care facilities, were retrospectively recruited. Subjects were treated and brought to a state of oral health before enrollment. Medical and dental assessments were abstracted from dental records and used to predict risk of tooth loss. Tooth loss events were recorded for subjects during follow-up. Multivariate negative-binomial regression was used, starting with 27 risk factors and removing variables using Akaike's Information Criterion. Pearson's correlation was then conducted to evaluate the overall fit of the final fitted model. RESULTS: The final fitted model included eight predictors. Among them, age, number of decayed/broken teeth at arrival, anticholinergic burden of medications and physical mobility were associated with risk of tooth loss in OASN (P ≤ 0.05). Internal validation indicated satisfactory fit of the final fitted model. CONCLUSION: An evidence-based model with eight predictors was developed to quantitatively predict risk of tooth loss for OASN at the individual level.