Treating Elderly Patients The new aged

Summer 2006 Liability Lifeline

The May 2003 issue of the Journal of Dental Education stated, “The elderly population (65 years or older) is the fastest growing segment of the U.S. population. The over-65 age group now constitutes approximately 14 percent of the total U.S. population.” The impact of an increased elderly population has now reached the dental office. Unlike their parents, this generation has a full complement of teeth with expectations of keeping them and is willing to spend money on dental treatment. Treating these patients presents many challenges for dentists in terms of oral disease, dental procedures, complex medical histories, and patient management.

Dentists should be better educated about common medications taken by this generation. According to the Journal of Dental Education, Volume 67, Number 5, November 2003, “Eighty-six percent of people aged 65 years or more have at least one major chronic disorder such as arthritis, osteoporosis, respiratory disease, cardiovascular disease, cancer, neurological disorders, etc. Many suffer from physical disabilities such as hearing loss, poor vision, and taste disorders, which may impact their ability to comply with a dentist’s instructions. Many of the elderly utilize polypharmacy (taking five or more medications concurrently), with oral side effects such as xerostomia.”

Dr. Janet Yellowitz, past president of the American Society for Geriatric Dentistry, points out that dentists have to be more aware of these conditions that are more common with elderly patients. For example, since many patients in this age group suffer from xerostomia, which contributes to root caries, it is essential to do a thorough evaluation of tissue dryness during the oral exam. A number of saliva-substitute products can be used to increase the salivary flow and thereby assist to decrease caries and lubricate periodontal tissues

Because of the variables that could impact dental treatment, extra time should be allowed to discuss thoroughly an elderly patient’s health history. The health history form will likely be the
most important instrument when treating an elderly patient. According to the February 2006 survey conducted by Dental Product Report (DPR), “only 6 percent of dentists surveyed stated that they had a medical history form specific to older patients.” Keeping this in mind, it is recommended that the dentist set aside additional time to review the completed form with the patient or develop a form exclusively for elderly patients. Also, new medications and treatments are regularly being introduced to and used by patients, and they can cause side effects or complications in response to dental treatment. (See the Questions and Answers on bisphosphonates.)

While the dentist is responsible ultimately for reviewing and discussing the completed health history form with the patient, consider designating a staff person to assist the patient in completing the form. The patient may need assistance in writing or interpreting questions. It is also advisable to have elderly patients bring either a list of the medications they are taking or to bring in the actual medications to ensure that nothing is overlooked. Many patients, including the elderly, don’t realize that the medications they are taking may have contraindications to proposed dental treatment. Also, it is good risk management to talk to a patient’s physician prior to performing invasive dental treatment when you have concerns or questions about the patient’s medications. Be sure to document in the patient’s chart all discussions with other practitioners.

Treating elderly patients can be time consuming, especially when having an informed consent discussion about the recommended treatment. Be sure they comprehend and understand all risks, benefits, and alternatives to the treatment proposed. Since patients will sometimes be reluctant or embarrassed to admit they do not understand, prompt them occasionally by saying in a respectful manner:

  • I want to be sure that I’m communicating clearly, so please stop me at any time if I say something you do not understand.

OR

  • To help me be sure that I’ve explained myself clearly, please tell me what your understanding is regarding treatment options.

If it appears a patient is having a difficult time comprehending, answering questions, or making a decision, consider asking the patient if he or she would like to have someone else involved in the discussion, such as a spouse, an adult child, or a caregiver. Offering all recommended options and cost estimates in writing and allowing the patient the opportunity to review the information at home may also prevent misinterpretation. Again, document the informed consent discussion thoroughly and include who was present during the discussion and any questions asked as well as the responses.

When offering treatment options to elderly patients, be sure the treatment is age appropriate. Even though they may have the means to pay for almost any proposed procedure, patient selection is key to offering the best treatment option. For example, offering a 75-year-old, poorly-controlled diabetic patient the option of an implant supported restoration instead of a removable partial denture may not be in the patient’s best interest. As with all patients, dentists must place the patient’s health and wellbeing before finances.

According to the May 2003 issue of Journal of Dental Education, “Ninety-eight percent of dental schools had a section of their curriculum devoted to geriatric dentistry. However, the survey conducted by DPR in 2006 indicated that only 55 percent of dentists have taken any training or CE courses directly related to treating elderly patients.” Simply knowing that there are issues associated with geriatric patients isn’t enough. Dentists should continue to educate themselves through continuing education courses to be prepared to treat this generation’s unique needs.

Handling this aging patient base will require understanding of medical conditions and all aspects related to aging. Through patient education, careful treatment planning, and a little extra patience, dentists will rise to the challenges of treating the growing population of America’s elderly patients.

Case Study

An 85-year-old female patient presents to the general dentist for a consultation to discuss her bite problems. She arrives by the bus provided by the retirement community where she lives. The front office person requests that she complete a health history form before seeing the dentist. The patient is upset about having to fill out this form because she just wants to talk to the dentist about her bite. After the front office person explains the office policy regarding health history, the patient completes the form. She indicates that she has no health issues, is not taking any medications, and does not include a treating physician’s name.

After reviewing the patient’s health history, the dentist asks why she has come to see him. She tells him that her teeth “do not bite together properly.” Sometimes she rests her teeth on the right side and other times on the left. She also tells him that she seems to have a “wild” jaw. The dentist does an oral exam but does not take any radiographs. After checking her temporomandibular joints and bite, the dentist tells her that she is likely grinding her teeth. He tells her that he can fabricate a nightguard for her and explains the treatment process. Since she relies on bus transportation, she requests to have the impressions taken that same day. The dentist complies and takes the impressions and a bite registration. She schedules a follow-up appointment for two weeks later to deliver the nightguard.

On the day of the delivery, the patient has a difficult time putting the nightguard in and taking it out. The dentist sees that she is getting upset and frustrated and gives her some time alone in an operatory. After 30 minutes, the patient comes out of the operatory confident that she can place and remove the nightguard.

One week later, the patient contacts the dentist upset that the nightguard is not helping and her jaw is still not in the proper place. The office schedules a follow-up appointment for later in the week. On the day of the appointment, the dentist notes that the nightguard does not fit properly. The patient informs him she added fingernail acrylic to one side of the nightguard to “even” out her bite. She tells the dentist she is upset because it is not helping her bite problems. The dentist offers another option to correct her bite. He explains that he can place her in braces for 18 months and then remake the nightguard. The patient agrees to this new treatment option. The front office person discusses finances and schedules the appointments. The patient chooses to write one check to cover the entire cost of treatment.

After the dentist places the braces, the patient continues to call the office at least twice a week complaining about her bite. She tells him that she is having a difficult time eating and sleeping because her teeth still won’t fit together. The dentist repeatedly tells her that over the course of 18 months the braces will move her teeth into proper alignment and she will be more comfortable. After each conversation, the patient tells the dentist she understands and will try to be more patient. After four months of explaining the treatment plan time and again, the dentist recommends removing the braces and referring her to see a myofunctional therapist. With the patient’s verbal permission, the dentist removes her braces and has his front office person set an appointment with a therapist. The dentist mails a letter to the myofunctional therapist regarding the issues with the patient’s bite and summarizes the treatment attempted so far. Not wanting to treat the patient any longer, the dentist sends the patient a formal dismissal letter the following week.

One month later the dentist receives a letter of intent to sue from the patient’s daughter on behalf of her mother. The allegations include malpractice, patient abandonment, and fraudulent billing practices.

Learning Points

When the patient filled out her health history form, she indicated the she was not taking any medication and did not provide the name of a treating physician. Statistics indicate that most elderly patients take a multitude of medications and are most likely under the care of a physician. While reviewing the patient’s completed health history form, the dentist should have questioned her about her responses and the missing information. Medications may not have played a role in this particular case, but had the dentist properly questioned the patient about the missing information, he would have learned she was under the care of a physician. Once the dentist became frustrated with repeating the treatment plan and noting her lack of comprehension, he could have contacted the patient’s physician, and learned that she was in the early stages of dementia and her daughter was responsible for making any treatment decisions.

Many elderly patients suffer from hearing loss and have comprehension issues, which can be very frustrating and may lead to problems with treatment. In this case, the patient’s unrealistic expectations about the nightguard, communication issues, and the dentist’s note in the chart that “the patient doesn’t seem to understand treatment outcome” were indicators that the dentist should have involved another person in the discussions before treating the patient.

Often times, the adult children or another legal guardian are involved in the decision making for the overall health and welfare of elderly parents. Many elderly patients have a healthcare power of attorney which appoints a “healthcare agent” to make decisions when they become unable to make or communicate decisions. It should be a red flag to the dentist when elderly patients appear to be having trouble completing their health history, understanding treatment options, and comprehending the proposed treatment.

In this case, asking the patient, “Would you prefer to have someone here with you to discuss the treatment options?” or, “Is there someone you trust to help you with this decision?” may have led the patient to tell the dentist her daughter assists with treatment decision issues. Asking leading questions will often get patients to tell dentists whether someone helps them with treatment decisions. With the patient’s consent, it is good risk management to contact this person, explain the situation, and invite them to the next appointment.

The dentist also did himself a disservice by allowing her to pay the entire amount for the treatment and not refunding money when the orthodontic treatment was discontinued prematurely. In the end, it appeared to the patient’s family that the dentist extorted money from an 85-year-old woman.

When treating elderly patients:

  • Review their health histories thoroughly to identify contraindications or other health concerns.
  • Consider speaking to their physician if there are any concerns regarding invasive treatment, medications, or health issues.
  • Ask whether they would like another adult to be present during discussions about treatment when it appears they have difficulty comprehending.
  • Do not let their financial means influence your treatment recommendations.
  • Customize the treatment plan, taking into consideration their advanced age, medical condition, and practicality of treatment.
  • Be patient and understanding.