10/21/2018. Maximizing Mobility and Oral Health: New Approaches to Common Challenges in Post Acute and Long-Term Care PART 1:

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1 Maximizing Mobility and Oral Health: New Approaches to Common Challenges in Post Acute and Long-Term Care Philip D. Sloane, MD, MPH Elizabeth and Oscar Goodwin Distinguished Professor of Family Medicine and Geriatrics University of North Carolina at Chapel Hill Co-Editor-in-Chief, JAMDA PART 1: Improving Lower Extremity Function What s with All Those Wheelchairs and Walkers? Philip D. Sloane, MD, MPH University of North Carolina at Chapel Hill Speaker Disclosures Dr. Sloane has no financial relationships to disclose. Learning Objectives By the end of the session, participants will be able to: Understand better the extent, causes and impact of lower extremity impairment Understand better the issues around prevention and treatment of lower extremity impairment Consider the advantages and downsides of mobility aids 1

2 Mobility Device Use in Community-Dwelling US Elderly - by Age and Sex - How common is lower extremity impairment in the USA? Overall, 26% of adults aged 65 and older use one or more mobility devices in the prior month J Am Geriatr Soc 63: , 2015 Mobility Device Use in USA by Setting Do mobility devices prevent falls? Sources: a 2016 National Health and Aging Trends Study; aged 65+ only. b Khatusky, et al. Residential care communities and their residents c MDS Frequency Report, Fourth Quarter 2017; all residents. 2

3 62% of older persons who fell owned a cane or walker. 75% of the fallers were not using the device at the time. How does the impact of lower extremity disability compare with that of dementia? Gerontologist, 2017, Vol. 57, No. 2, Mobility Impairment vs Cognitive Impairment How Do Service Needs of Mobility Impairment Compare with Those of Cognitive Impairment? Sources: d Dementia statistics: Sloane, et al. The Public Health Impact of Alzheimer s disease. Annu Rev Pub Health; MCI statistics: Estimated based on US Census Current Population Reports and Katz, et al, Alzheimer Dis Assoc Disord Oct; 26(4): Virginia Nursing Home Reimbursement Rates (2018) RUG4 Reimbursement Classification Per Day Category End Splits ADL BB2 $ Behav & Cogn Lowest ADL BB1 $ Behav & Cogn w/o Rest Nsg Lowest ADL BA2 $ Behav & Cogn Lowest ADL BA1 $ Behav & Cogn w/o Rest Nsg Lowest ADL PE2 $ Phys Function Highest ADL PE1 $ Phys Function w/o Rest Nsg Highest ADL PD2 $ Phys Function PD1 $ Phys Function w/o Rest Nsg PC2 $ Phys Function PC1 $ Phys Function w/o Rest Nsg PB2 $ Phys Function Lowest ADL PB1 $ Phys Function w/o Rest Nsg Lowest ADL PA2 $ Phys Function Lowest ADL PA1 $ Phys Function w/o Rest Nsg Lowest ADL Source: Does mobility impairment add risk over and above other morbidities? 3

4 Immobility Independently Affects Hospitalization Rate J Am Geriatr Soc 1987 May;35(5):465-6 Number of Disability Days per Year by Morbidity and Mobility Status Mean (95% Confidence Interval) J Gerontol A Biol Sci Med Sci, 2017, Vol. 00, No. 00, 1 7. doi: /gerona/glx128 Longitudinal Study of Factors Associated with Changes in Self-Rated Quality of Life: Variables Considered How much does development of mobility impairment affect a person s perception of quality of life? Age Sex Increasing subjective memory impairment Increasing physical activity / exercise Increasing cognitive activities Placement in institution Change in marital status (married to widowed) Change in ability to walk Change in ability to see Change in ability to hear New visual impairment Change in overall activities of daily living Source: Br J Gen Pract Nov;65(640):e Factors Associated with Change in Self Rating of Quality of Life among 1,968 Persons Aged 78 and Older How often does disability develop suddenly (from a catastrophic event) or more gradually (from accumulating chronic illnesses)? Source: Br J Gen Pract Nov;65(640):e

5 Proportion of New or Worsening Disability that is Progressive vs Catastrophic, by Age and Sex Among older persons * are there identifiable risk factors for developing lower extremity impairment? * i.e. persons at highest high risk of developing gradual onset lower extremity impairment J Am Geriatr Soc 49: , 2001 Reduced Ambulatory Function in Persons Aged community-dwelling persons aged 70+ (mean age 77) who could walk a quarter mile at baseline In 4 years follow-up, 56% lost ability to walk a quarter mile 7 factors were predictive of that functional loss: Age Female sex Cognitive impairment # chronic conditions Low physical activity low functional self-efficacy Low scores on a physical performance battery By providing mobility aids we presume that we have addressed the issue. But have we? Source: Ann Intern Med. 2012;156: The Rule of 4 s in Geriatric Medicine Disease Dis Use Mis Use Normal Aging Preventable? Treatable? What are the common disease causes of legs no longer working effectively? 5

6 Vascular Disease Spinal Disease Cervical Stenosis Lumbar Spinal Stenosis Cognitive and Motor Disorders Hip Fracture Dementia Parkinson s disease Estimated 471,000 hip fractures occurred in persons 65 and older in 2016 Only 40% will have regained full pre-fracture function at 1- year post injury checkup Osteoarthritis What are the common dis-use and mis-use causes of legs no longer working effectively? 6

7 Sarcopenia Progressive decline in muscle mass and low muscle function associated with ageing Increases the risk of adverse outcomes such as physical disability, poor quality of life, and mortality Associated with immobility and lack of physical activity Prevented or improved by regular exercise (including muscle strengthening exercises) and possibly by amino acid supplements Preventable? Preventable? The Escalator Paradox 7

8 Knee Surgery and Ambulation Mobility improves in physically active persons but rarely in largely inactive persons Tourniquet-associated peripheral nerve injury is not unusual, can affect proprioception and gait. Even arthroscopy can frequently lead to nerve injury (see photo) Physiological Aging: How Much Does It Contribute to Lower Extremity Dysfunction? Sources: Reg Anesth Pain Med Sep Oct;40(5): ; Acta Orthop Apr;84(2): Changes in Equilibrium with Age Disease, dis-use, mis-use, and physiological aging often combine to lead to lower extremity impairment Frequency Dizziness of Dizziness and Imbalance as a Chief Complaint, by Patient Age Dizziness/ Imbalance: Multiple Factors DEEP WHITE MATTER 8

9 Targets for Geriatric Care Providers Encourage individual and societal physical activity More physical therapy for pre-habilitation and maintenance of function Less emphasis on if this doesn t work, we can try surgery and more on surgical risks Develop programs on balance If ambulatory aids are needed, provide the ones that most encourage muscle use and encourage regular use Minimize polypharmacy especially of medications that sedate, cause orthostatic hypotension, or affect balance Targets for Society: Prevention in Youth and Middle Age More walking, less driving More weight control Reduce our love affair with contact sports Reduce our love affair with mobility devices Focus on low-impact exercise PART 2: Oral Hygiene Care: The Hidden ADL Philip D. Sloane, MD, MPH University of North Carolina at Chapel Hill Oral Care: The Hidden ADL Kansas: 540 residents in 20 NHs 30% had substantial oral debris on twothirds of their teeth more than one-third had untreated decay Wisconsin: 1,100 residents in 24 NHs 31% had teeth broken to gums 35% had substantial oral debris New York: residents in 5 NHs only 16% received any care at all among those who did, the average time spent brushing teeth was 16 seconds Why Isn t Care Better? Lack of knowledge and skill - Residents who resist care - Products and techniques Lack of time Fear of injury; distaste for task No oversight or accountability Molly_dontlookinmouths Not Recognized as a Health Care Priority 9

10 Mouth Care is More than Unsightly Typical Nursing Home Resident Plaque and Gingivitis Mouth Care and Pneumonia Mouth Care to Prevent Pneumonia Poor oral health bacterial pathogens Bacteria get inhaled aspiration pneumonia Two-thirds of nursing home residents have bacterial pathogens in their dental plaque Pilot Studies Weekly dental hygienist 42% reduction in pneumonia mortality Systematic mouth care after meals 56% reduction in pneumonia Up to 50% of pneumonias might be avoided by providing mouth care Field Test Three nursing homes Two CNAs in each trained as oral care aides Total of 97 residents Results: Tooth Surface Cleaning Before training After training Upper teeth Outer surface 96% 97% Inner surface 44% 95% Lower teeth Outer surface 97% 98% Inner surface 63% 93% 10

11 Results: Interdental Cleaning Before Mouth Care Program Before training After training Upper teeth 0% 88% Lower teeth 0% 91% After Mouth Care Program Before Mouth Care Program After Mouth Care Program System-Level Cluster Randomized Quality Improvement Trial 14 nursing homes involved for two years 7 intervention, 7 control Provided standardized training and ongoing support to oral care aides and all aides Monitored fidelity, assessed pneumonia, hospitalization, costs 11

12 Preliminary Results: Pneumonia Rate One Year Control homes Intervention homes p value a Components of a Comprehensive Mouth Care Program a Intervention was 24% less 1. Remove Plaque Plaque removal reduces the risk of developing gingivitis and promotes gum health 2. Treat Gingivitis Inflammation of the gums largely due to bacteria-filled plaques on teeth Mechanical action -- jiggle, sweep -- is most important to remove plaque; clean between teeth Brushing with antimicrobial agents can restore gum health 3. Prevent Tooth Decay Tooth decay is associated with decreased oral intake and reduced quality of life 4. Clean Dentures and Gums Scratched dentures harbor bacteria Daily fluoride use can reduce tooth decay Remove dentures; soft brushes and water resist scratches 12

13 5. Meet Behavioral Challenges Refusing to open mouth Biting tooth brush Refusing to let denture be removed/inserted Hitting, yelling, grabbing Next 3 slides summarize approaches to common behavioral challenges 6. Assess and Monitor Care Case Presentation: Refusal to Open Mouth for Care You are encouraging oral health, but staff say patient won t open mouth Techniques for Persons who Refuse to Open Mouth for Oral Care Focus on relationship, not task Go slowly at first; allow resident control Give a reason Provide distraction Massage jaw muscles or below chin Sing with person 13

14 System-Level Change: Dedicated Oral Care Aide Arguments in Favor Mouth care of highly impaired people is complex and specialized Results are better Nothing else has worked People receiving care and their families notice the difference Serves as a career ladder for motivated staff Mouth care aide can train and support other staff Arguments Against Counter to the universal worker philosophy Supervisory nurses will pull them to fill staff shortages Cost Mouth Care Without a Battle MyfathersAtivan 14