However, as all persons involved in the field of geriatrics know, the sheer number of older adults is on the rise. Therefore, 27% of this growing number is truly an issue to be addressed. As a dental professional, my ultimate goal has always been to keep patients chewing, speaking and smiling with natural teeth as far into life as possible. While dentures are a good answer to the problem of having no teeth, they are not a substitute for natural teeth.

Cavities and periodontal disease are the culprits often cited as the reason to remove natural teeth. And in truth, these two diagnoses are the ones that account for most extractions of natural teeth. However, other issues underlie the decision to extract a tooth versus save it as well as a person’s decision to attend or disregard their oral health in the first place.  Two studies published in 2010 looked at cultural biases that may contribute to choosing removal of all teeth and the reason for tooth loss at various times in life by some but not all people.

Sussex et al, looked at a large cohort of older persons in New Zealand who were edentulous and reasons behind the initial decision.² Several interesting factors were highlighted. They found that while most of the group stated they valued natural teeth over dentures, when faced with diseases such as caries and periodontal disease, they noted that many of their peers and elders had dentures, and did not see this as a burden or a lesser outcome. Once a few teeth were compromised, it was easier to remove the rest.  Those in rural settings were more likely to choose removal of teeth versus saving them. Finally, if they had experienced past toothaches or loose teeth due to periodontal disease, their thought was that from an overall health standpoint they were better off without their teeth.

Thorstensson et al looked at reasons for tooth loss at varying ages.³ Interestingly, these changed as the age groups changed.  The study found that becoming edentulous early in life was closely related to social class. Loss of all teeth during mid-life was more closely associated with achieving a lower educational level. Finally, only in late life, was becoming edentulous significantly linked with self-reported poor life style choices.

As a provider, this information is a key to how I approach my discussions with patients. Obviously, some groups of patients still require education on the benefits of good oral health, with the cornerstone being healthy natural teeth. Prevention can prevent, stop or delay both caries and periodontal disease, but if a patient believes that dentures are as good as natural teeth, there is no motivation for a life style change.

Although far from true, many of our older patients still believe that extraction of teeth is just part of normal aging. While tooth extraction is at times necessary when the oral infectious burden becomes too high, this should not be the norm. Thorstensson et al state that “improved understanding of the underlying causes of tooth loss are still needed to improve interventions and especially to improve prevention,” a primary goal in the practice of dentistry.

References:

1. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in oral health status: United States, 1988–1994 and 1999–2004. National Center for Health Statistics. Vital Health Stat 11(248). 2007.
2. Sussex PV, Thomson WM, et al. Understanding the epidemic of complete tooth loss among older New Zealanders. Gerodontology. 2010;27:85-95.
3. Thorstensson H, Johansson B. Why do some people lose teeth across their lifespan whereas others retain a functional dentition into very old age?Gerodontology. 2010;27:19-25.

The field dedicated to the study of the confluence of aging, health and ethnicity is called ethnogeriatrics. Researchers in this field are focusing on the differences between and within racial and ethnic groups, the health risks and disparities of ethnic minority groups, the influence of family support and participation and the influence of cultural norms on the patient/caregiver relationship. Caregivers are encouraged to understand cultural norms related to greetings, physical distance, eye contact, and other verbal and non-verbal methods of communication on the impact of their relationship with older adults. By using a patient assessment that includes a detailed review ethonogeriatric issues, the patients’ patterns of decision making, the role of religion and spirituality in their lives and their preferred language for communication can be determined and provide vital pieces of information for excellence in healthcare delivery.

ASU offers an online undergraduate course titled “Cultural Competence in the Health Professions.” The course, which incorporates ethnogeriatric principles, demonstrates to students the pivotal role that cultural competence plays in providing quality healthcare. Students have reported high satisfaction with this offering, and currently, enrollment demands exceed available space. This desire to acquire cultural competence bodes well for the future care of older patients from all cultural groups.

At OSA, we have been studying stress in employed caregivers by comparing salivary cortisol profiles, a highly sensitive and at times unpredictable measure, with other indicators of perceived and actual health. Because of the profound impact of stress on physical and mental health, we have been attempting to pin down which of many measures best capture the stress caregivers experience as they move through the workday, home in the evening and on weekends. Our goal in this work is to find a way to identify caregivers at greater risk for health breakdown. The premise is that some combination of paper-and-pencil, physical, and cortisol measures can target those in greater or more immediate need of preventive interventions.

Results from our pilot research (N=31) are tantalizing. They show that:

• Cortisol profiles (within and across days) are specific to each individual and need to be interpreted only within the context of that individual’s experiences pattern of responses.
• Employed caregivers had much greater variability in cortisol responses than did non-caregivers – on all days and on all measures.
• Few relationships existed between psychosocial and cortisol measures for the employed non-caregivers.
• Intriguing relationships were observed for the employed caregivers.  For example;
  • As the work week progressed for the caregivers, the higher the sense of mastery experienced at work, the lower the overall cortisol levels.
  • Caregivers’s SF36 scores were highly negatively correlated with total cortisol produced on Sundays, presumably a pivot day between caregiving and work focus.
  • Caregivers with higher scores on Purpose in Life on the Psychological Well Being Scale had lower overall cortisol values.

Clearly we have only scratched the surface with this pilot work. However, we believe salivary cortisol is a biomarker that holds promise for better understanding the needs and risk status of the increasing numbers of informal caregivers to older persons.

Barbara B. Shadden, Office for Studies on Aging, University of Arkansas
Ro DiBrezzo, Office for Studies on Aging, University of Arkansas
Jean Henry, University of Arkansas

The Arkansas Chronic Illness Collaborative (ACIC) is dedicated to partnering with health care professionals in order to find ways to improve the management of chronic disease. The target audience for this collaborative includes family physicians, pharmacist, nursing specialties, physician assistants, other healthcare professionals and administrative staff. Approximately $100,000 in scholarship funding is available to fund 8 to 10 clinics. To participate, clinics need a diabetes (DM) or cardiovascular (CVD) patient registry of 100 patients or more and are required to report on certain key measures.

The Collaborative’s systems change approach addresses quality of care challenges for all segments of the population, including disparate and aging persons, and supports the Essential Public Health Services framework. The long-range goal of this collaborative is to maximize the length and quality of life for patients with Diabetes Mellitus (DM) and/or Cardiovascular Disease (CVD), to satisfy patient and caregiver needs and maintain or decrease the cost of care.

The ACIC provides a forum where clinic health care teams learn about the delivery of patient care using the National Health Disparities Collaborative Planned Care Model for people with DM and/or CVD. The Collaborative aims to attain this goal by:

• Sharing ideas and knowledge
• Learning and applying new methodologies for organizational change
• Implementing the Planned Care Model in an effort to align medical practices with evidence-based clinical guidelines
• Utilizing evidence based practice

To meet these goals within a 13-month time frame, the Collaborative offers three, two-day Learning Sessions and a one-day Congress to conclude the program, by sharing and celebrating the success of each team. Clinics receive education on the implementation of the Planned Care Model, learn and practice PDSA Cycles (Plan Do Study Act), and share successes and challenges faced during implementation. Teams also receive professional education as it relates to tobacco cessation, aging, diabetes and heart disease. Participating clinic team members earn a minimum of twenty-five hours of CME.

AGEC will provide speakers to address geriatrics issues in treatment of DM and DVD. Through this partnership, the ACIC clinics will focus on diabetic for the geriatric population, and will monitor and report data about such measures as eye exams, foot exams, maintaining Average HbA1c and blood pressure control. At the end of the Collaborative sessions, the desired outcome is for clinic teams to utilize with the entire patient population the evidence based practice interventions taught to them.

Arkansas Department of Health
Chronic Disease Division Staff

http://www.cdc.gov/od/ocphp/nphpsp/essentialphservices.htm

To recruit subjects for the study, instructors teaching courses within the CHBS were asked to invite students to participate. Some instructors provided extra credit to students for attending the seminar. Although 92 students were recruited, only 73 were tracked because they completed the three components of the study: pre- and post-test and attendance at the stroke seminar. These were students majoring in such disciplines as occupational therapy, psychology, and nursing. Among the 73 were 58 (79.5%) females and 15 (20.5%) males, 18 to 40 years of age and an average age of 21.9 years (SD = 4.2). Their educational classification was 20 freshmen and sophomores (27.4%) 20 juniors (27.4%), 23 seniors (31.5%), and 10 (13.7%) graduate students.

A week before the seminar, these 73 students accessed an Internet link to complete a 20-item test developed by CHBS faculty to measure their knowledge of stroke. Questions in the test identified knowledge of proper response to a suspected stroke; risk factors, symptoms and causes of stroke; as well as the long-term consequences of stroke. Answers to this pre-test were collected through Survey Monkey as were those to the post-test, which was accessible after attendance to the stroke seminar. Results from the paired-samples test (t) show statistically significant improvement in students’ knowledge test scores from pre-test (M = 16.20, SD = 2.20) to post-test (M = 18.00, SD = 2.07), t (72) = -7.02, p < .0001 (two-tailed). The mean difference in pre and post- test scores was -1.8 with a 95% confidence interval ranging from -2.12 to -1.23. The eta squared statistic (0.49) indicated a large effect size.

The main areas of knowledge improvement were in defining a stroke and names given to it. At post-test, about 79% of responders, as compared to 60% at pretest, identified stroke as the interruption of blood flow to the brain or bursting of a blood vessel in it. At pretest, only 27% associated a stroke with the term brain attack, but the percentage increased significantly to 90% at post-test. At post-test 92% of the students were able to correctly identify the risk factors and potential causes of stroke. Additional areas of improvement were in the identification of TIAs, whose warning signs may last as long as 24 hours.

With regard to student perception of the educational value of the information provided, the answers from participants show the seminar: 1) increased their knowledge about stroke(91%); 2) fulfilled their need for stroke information (83%); 3) met their expectations (92%). The information received was regarded as an asset for their chosen careers by 81% of participants. In conclusion, students expressed a high degree of satisfaction with their increased knowledge about stroke and the interdisciplinary approach to stroke treatment that the seminar promoted.

Dong Xie, PhD
Jacquie Rainey, DrPH, CHES
Kim McCullough, PhD

A nested case-control study was conducted using the General Practice Research Database (1987-2003). The study cohort consisted of 1.8 million patients over 50 years old who were users and non-users of PPI therapy or acid suppression drugs. Cases consisted of all patients with an incident of hip fracture. The main outcome measure was the risk of hip fracture associated with PPI use.

There were 13,556 hip fracture cases (10,834 among acid suppression non-users and 2,722 among PPI users) and 135,386 controls. The adjusted odds ratio (AOR) for hip fracture associated with more than 1 year of PPI therapy was 1.44 (95% confidence interval (CI) , 1.30-1.59). The risk of hip fracture was significantly increased among patients prescribed high-dose PPIs for more than one year (AOR, 2.65; 95% CI, 1.8-3.9). These patients received at least 75% of their PPI prescriptions for twice daily doses. The strength of the association was statistically significant and increased with increasing duration of PPI therapy with the AOR rising from 1.22 at 1 year to 1.59 at 4 years of therapy. These results show that long-term PPI therapy, particularly at high doses, is associated with an increased risk of hip fracture.

Osteoporotic fractures are common among the elderly and lead to increased morbidity and mortality. Among the various forms of low-trauma fractures, hip fractures lead to the most devastating consequences. They usually require an emergency department visit, hospitalization, surgery, and rehabilitation. During the first year after a hip fracture, the mortality rate is as high as 20%. Among those who survive this period, 1 in 5 will need nursing home care.

PPI therapy, which is widespread, may have an exaggerated effect on bone health among those at risk for osteoporosis. Many patients continue to be on PPIs long past the time for indicated use. For example, stress ulcer prophylaxis during hospitalization and treatment of H. pylori and ulcer disease should be considered time-limited indications. The new information regarding risk for osteoporotic fractures is another good reason to review a patient’s medication list periodically so as to identify and discontinue any unnecessary medications, including PPIs.

At this time, the FDA requires information about the possible risk of fractures (hip, wrist, and spine) be provided on all prescription and over-the-counter proton pump inhibitors. The FDA recommends that healthcare providers consider whether a lower dose or shorter duration of therapy would adequately treat the patient’s condition. All healthcare providers should recommend to patients who continue to receive PPIs and who are at risk for osteoporosis to receive vitamin D and calcium supplementation.

References:

1. Tauseef A, Roberts D, et al. Long-term Safety Concerns with Proton Pump Inhibitors. The American Journal of Medicine. 2009; 122:896-903.
2. Yang YX, Lewis JD, et al. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. 2006; 296:2947-53
3. Cumming RG, Nevitt MC, Cummings SR. Epidemiology of hip fractures. Epidemiol Rev. 1997;19:244-257.
4. Leibson CL, Tosteson AN, Gabriel SE, Ransom JE, Melton LJ. Mortality, disability, and nursing home use for persons with and without hip fracture: a population based study. J Am Geriatr Soc. 2002;50:1644-1650.

Both our AR-GEMS program for health practitioners and the Summer Institute (SI) for faculty in the health professions are accepting applicants. SI will be held May 9-13. To apply, please contactjasinsoledadhd [at] uams [dot] edu or www.arkansasgeriatrics.com/programs/summerinstitute.

This June 8-9, in conjunction with the Central Arkansas Veterans Healthcare System, VISN 16 Palliative Care, the UAMS Winthrop Rockefeller Cancer Institute, and the Arkansas Cancer Coalition, AGEC will be sponsoring the First Annual Hospice and Palliative Care Conference. Up to 8.25 hours of continuing medical education will be available for a variety of health disciplines. Online Registration for this educational event is available at www.uams.edu/cmeregister.