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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

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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?

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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?

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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)?

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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?

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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?

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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

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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 

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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

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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%

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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

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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

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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

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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