View
0
Download
0
Category
Preview:
Citation preview
10/21/2018
1
Maximizing Mobility and Oral Health:New Approaches
to Common Challenges in Post Acute and Long-Term Care
Philip D. Sloane, MD, MPHElizabeth and Oscar Goodwin Distinguished Professor
of Family Medicine and GeriatricsUniversity 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
10/21/2018
2
How common is lower extremity impairmentin the USA?
Mobility Device Use in Community-Dwelling US Elderly- by Age and Sex -
Overall, 26% of adults aged 65 and older use one or more mobility devices in the prior month
J Am Geriatr Soc 63:853–859, 2015
Mobility Device Use in USA by Setting
Sources: a 2016 National Health and Aging Trends Study; aged 65+ only. b Khatusky, et al. Residential care communities and their residents 2010. c MDS Frequency Report, Fourth Quarter 2017; all residents.
Do mobility devices prevent falls?
10/21/2018
3
62% of older persons who fell owned a cane or walker.75% of the fallers were not using the device at the time.
Gerontologist, 2017, Vol. 57, No. 2, 211–218
How does the impact of lower extremity disability compare with that of dementia?
Mobility Impairment vs Cognitive Impairment
Sources: d Dementia statistics: Sloane, et al. The Public Health Impact of Alzheimer’s disease. Annu Rev Pub Health; 2002.MCI statistics: Estimated based on US Census Current Population Reports and Katz, et al, Alzheimer Dis Assoc Disord.
2012 Oct; 26(4): 335–343..
How Do Service Needs of Mobility Impairment Compare with Those of Cognitive Impairment?
Virginia Nursing Home Reimbursement Rates (2018)RUG4
ClassificationReimbursement
Per DayCategory End Splits ADL
BB2 $230.09 Behav & Cogn Lowest ADLBB1 $220.18 Behav & Cogn w/o Rest Nsg Lowest ADLBA2 $191.86 Behav & Cogn Lowest ADLBA1 $183.37 Behav & Cogn w/o Rest Nsg Lowest ADLPE2 $305.14 Phys Function Highest ADLPE1 $290.98 Phys Function w/o Rest Nsg Highest ADLPD2 $288.14 Phys FunctionPD1 $273.98 Phys Function w/o Rest NsgPC2 $248.50 Phys FunctionPC1 $237.17 Phys Function w/o Rest NsgPB2 $211.68 Phys Function Lowest ADLPB1 $203.19 Phys Function w/o Rest Nsg Lowest ADLPA2 $176.28 Phys Function Lowest ADLPA1 $169.21 Phys Function w/o Rest Nsg Lowest ADL
Source: https://www.ahcancal.org/research_data/funding/Pages/MedicareRateCalculator.aspx
Does mobility impairment add risk over and above other morbidities?
10/21/2018
4
J Am Geriatr Soc 1987 May;35(5):465-6
Immobility Independently Affects Hospitalization Rate
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:10.1093/gerona/glx128
How much does development ofmobility impairment affect
a person’s perceptionof quality of life?
Source: Br J Gen Pract. 2015 Nov;65(640):e716‐23.
Longitudinal Study of Factors Associated with Changes in Self-Rated Quality of Life: Variables Considered
• 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
Factors Associated with Change in Self‐Rating of Quality of Life among
1,968 Persons Aged 78 and
Older
Source: Br J Gen Pract. 2015 Nov;65(640):e716‐23.
How often does disability develop suddenly (from a catastrophic event)
or more gradually (from accumulating chronic illnesses)?
10/21/2018
5
Proportion of New or Worsening Disability that is Progressive vs Catastrophic, by Age and Sex
J Am Geriatr Soc 49:1643‐70, 2001
Among older persons *are there identifiable risk factors for
developing lower extremity impairment?
* i.e. persons at highest high risk of developinggradual onset lower extremity impairment
Reduced Ambulatory Function in Persons Aged 70+
• 568 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
Source: Ann Intern Med. 2012;156:131‐140.
By providing mobility aids we presume that we have addressed the issue.
But have we?
The Rule of 4’s in Geriatric Medicine
Disease
Dis‐Use
Mis‐Use
NormalAging
Preventable?Treatable?
What are the common disease causes of legs no longer working effectively?
10/21/2018
6
Vascular DiseaseSpinal Disease
CervicalStenosis
Lumbar SpinalStenosis
Cognitive and Motor Disorders
• 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
Hip Fracture
Osteoarthritis
What are the commondis-use and mis-use causes
of legs no longer working effectively?
10/21/2018
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
10/21/2018
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)
Sources: Reg Anesth Pain Med. 2015 Sep‐Oct;40(5):443‐54.; Acta Orthop. 2013 Apr;84(2):159‐64.
Physiological Aging:How Much Does It Contribute
to Lower Extremity Dysfunction?
Changes in Equilibrium with Age
Disease, dis-use, mis-use, and physiological aging often
combine to lead to lower extremity impairment
Frequency of Dizziness as a Chief Complaint, by Patient AgeDizziness and Imbalance Dizziness/ Imbalance: Multiple Factors
DEEP WHITE MATTER
10/21/2018
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 ADLKansas: 540 residents in 20 NHs
• 30% had “substantial oral debris” on two-thirds of their teeth
• more than one-third had untreated decayWisconsin: 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
• 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
Why Isn’t Care Better?
Not Recognized as a Health Care Priority
Molly_dontlookinmouths
10/21/2018
10
Mouth Care is More than Unsightly
Typical Nursing Home ResidentPlaque and Gingivitis
Mouth Care and 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
Mouth Care to Prevent Pneumonia
Up to 50% of pneumonias might be avoided by providing mouth care
• Three nursing homes
• Two CNAs in each trained as
oral care aides
• Total of 97 residents
Field Test 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%
10/21/2018
11
Beforetraining
After training
Upper teeth 0% 88%
Lower teeth 0% 91%
Results: Interdental Cleaning Before Mouth Care Program
After Mouth Care Program Before Mouth Care Program
After Mouth Care Program
• 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
System-Level Cluster Randomized Quality Improvement Trial
10/21/2018
12
Preliminary Results:Pneumonia Rate
One Year
Control homes 0.331
Intervention homes 0.251
p value 0.054a
a Intervention was 24% less
Components of a Comprehensive
Mouth Care Program
1. Remove Plaque
Plaque removal reduces the risk of developing gingivitis and promotes gum health
Mechanical action -- jiggle, sweep -- is most important to remove plaque; clean between teeth
2. Treat Gingivitis
Inflammation of the gums largely due to bacteria-filled plaques on 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
Daily fluoride use can reduce tooth decay
Scratched dentures harbor bacteria
Remove dentures; soft brushes and water resist scratches
4. Clean Dentures and Gums
10/21/2018
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
You are encouraging oral health, but staff say patient won’t open mouth
Case Presentation:Refusal to Open Mouth for Care
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
10/21/2018
14
Arguments in Favor Arguments Against 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
Counter to the universal worker philosophy
Supervisory nurses will pull them to fill staff shortages
Cost
System-Level Change:Dedicated Oral Care Aide
Mouth Care Without a Battle
www.mouthcarewithoutabattle.org
MyfathersAtivan
Recommended