Addressing Barriers to Care for Older Adults

The number of older adults in the United States continues to rapidly grow. By 2030, the nation will be home to approximately 72.2 million individuals age 65 and older, constituting 22% of the total population. This demographic shift is attributed to a combination of reduced infant mortality rates, heightened life expectancy, and advancements in healthcare delivery.¹

The prevalence of chronic diseases, disabilities, and limitations escalates with age, particularly among those age 75 and older. More than half of older adults have at least one chronic condition.² An individual’s functional age, however, holds more significance than chronological age when gauging health status. Individualized evaluations, devoid of preconceived notions grounded in stereotypes or bias, are imperative to address the healthcare needs of older adults. Recognizing the fundamental role of oral health in overall health and quality of life underscores the importance of integrating dental care into comprehensive healthcare for older individuals.

Despite the increasing healthcare needs of the aging population, approximately one-third fail to regularly access preventive or restorative dental care.³ Factors, such as perceived lack of value, affordability, and accessibility contribute to this trend.⁴ To address these challenges, healthcare professionals must critically reassess existing policies and practice models, working to dismantle barriers. The implementation of an interprofessional healthcare team is a key strategy to enhance older adult care.

General Healthcare Trends of the Older Population

Health issues observed in old age are typically due to inadequate care and use of the body over time, rather than an inherent consequence of aging itself. Factors, such as poor nutrition, substance abuse, and insufficient physical activity, exhibit a closer correlation with the development of chronic health conditions than chronological age.⁵ Many chronic conditions are cumulative in nature, wherein the repercussions of unhealthy habits or exposures gradually manifest later in life.⁵

Common medical conditions prevalent among older adults include arthritis, diabetes, heart disease, obesity, osteoporosis, and hypertension. Additionally, older adults are more prone to experiencing multiple chronic conditions simultaneously, a phenomenon known as comorbidity.² This contributes to a surge in the demand for healthcare services. Projections indicate a nearly 20% increase in healthcare spending by 2025 due to the expanding older adult population and rising service prices.⁶ Healthcare spending for older adults varies due to such as health status, utilization of healthcare services, insurance coverage, and other individual considerations.

Medicare is a social insurance program designed to offer coverage primarily to individuals age 65 and older. Eligibility for Medicare is typically achieved upon reaching the age of 65, regardless of income or health status.⁷ Unfortunately, about one in five adults with Medicare are considered underinsured and struggle to afford insurance premiums, meaning their out-of-pocket expenses are high relative to their income.⁸

Original Medicare (Part A and Part B) generally does not cover dental care.⁷ However, exceptions exist, and Medicare may cover dental costs if the services are deemed medically necessary for treating or diagnosing a covered medical condition.⁷ For instance, if a dental procedure is essential as a precursor to heart surgery, Medicare may cover the related dental care.

Medicare Advantage plans, offered by private insurance companies sanctioned by Medicare, present an alternative. Some Medicare Advantage plans may include additional dental benefits beyond what original Medicare covers. Despite these options, a substantial number of older adults may face financial constraints that limit their ability to access private insurance plans.⁸ The majority of the public supports expanding Medicare to cover routine hearing, vision, and dental care.⁹

Effective preventive care plays a pivotal role in averting or postponing the onset of diseases, concurrently contributing to a reduction in healthcare costs.¹⁰ Regrettably, the utilization of preventive health services remains relatively low among older age groups.³ A key factor contributing to this trend is the lack of awareness among older adults regarding the availability of preventive health services and the critical role these services play in preserving their well-being. Additionally, some older adults may underestimate their susceptibility to certain health conditions or perceive preventive services as unnecessary due to the absence of noticeable symptoms.¹¹ In essence, there is a tendency to prioritize immediate health concerns over proactive preventive measures. Moreover, negative past experiences with healthcare providers, coupled with issues related to communication, trust, or cultural sensitivity, can instill hesitation among older adults to engage in preventive care.¹² Addressing these cultural factors and fostering positive healthcare experiences are crucial steps in promoting the uptake of preventive health services among older populations.

Oral Health Status of the Older Population

Due to notable progress in preventive care, older adults are experiencing prolonged retention of their natural dentition. This positive shift can be attributed to advancements in epidemiology, robust public health initiatives, and the availability of preventive dental care services.¹³ While this development is encouraging in terms of overall oral health, it introduces a longer timeframe during which oral diseases and issues may manifest. Fostering awareness among older adults about the potential challenges associated with prolonged retention of their natural dentition can empower them to take preemptive steps. In this context, addressing specific concerns related to aging, such as limited dexterity, health literacy concerns, or medication-induced oral health issues, becomes integral to ensuring a holistic and effective approach to dental care.

Many older adults encounter physical and/​or cognitive obstacles that impede their ability to effectively use a manual toothbrush and traditional string floss.¹⁴ To alleviate these issues, power toothbrushes and interdental aids featuring ergonomic handles for enhanced grip and maneuverability can be helpful. Implementing three-dimensional (3D) printed customized handles supports both interproximal brushing and toothbrushing. These handles, known for their durability and water resistance, offer reusability with diverse toothbrush designs, highlighting their efficacy in improving oral plaque control and advancing oral health for individuals with limited dexterity.¹⁵ Common household items, such as bike handles, washcloths, or playdough, can also create an ergonomic handle.

The health literacy status of older adults significantly influences the prevalence of dental diseases and their limited engagement in preventive dental care.¹⁶ A lack of comprehension regarding oral health concepts, proper hygiene practices, and the significance of preventive measures can obstruct the ability of older adults to uphold optimal oral health.

Many older individuals may be unaware of the correlation between oral health and overall well-being. Additionally, intricate treatment terminologies and procedural details can pose challenges for individuals with low oral health literacy, potentially causing delays or incomplete adherence to prescribed oral health regimens.¹⁷ In terms of health literacy skills, the National Assessment of Adult Literacy reveals that 71% of adults age 60 and older encounter difficulties in using print materials, while 80% face challenges with documents such as forms or charts.¹⁸

To accommodate the challenges posed by low literacy levels, dental hygienists can adopt visual aids, interactive demonstrations, and simplified written materials in their oral health education. These approaches enhance comprehension and engagement, bridging the gap for individuals facing difficulties with print materials and documents, ultimately, promoting better oral health outcomes.

Many medications prescribed by primary care providers have oral side effects with xerostomia, or salivary hypofunction, being one of the most prevalent. Individuals experiencing xerostomia face an elevated risk of caries. Other causes of xerostomia in geriatric patients include autoimmune diseases, systemic disease, and head and neck radiation.¹⁹ Xerostomia may also cause difficulty with speaking and swallowing, impair taste, and initiate a burning sensation or soreness in the oral cavity.^19,20

Patients with prostheses and xerostomia encounter additional hurdles, including challenges in wearing dentures and ensuring the proper fit of prostheses. These complications may manifest as stomatitis, candidiasis, and generalized issues with ill-fitting dentures. To address medication-induced oral challenges, dental hygienists can provide tailored information on the specific medications contributing to xerostomia and associated oral issues. Additionally, promoting lifestyle modifications, such as encouraging increased water intake and advising on saliva-stimulating products, can play a crucial role in mitigating the impact of dry mouth.¹⁹

The Importance of Interprofessional Collaboration

Recognizing the heightened vulnerability of older adults to various health conditions, fostering collaboration among diverse healthcare professionals is imperative. Dental hygienists assume an essential role in this collaborative effort, working closely with other professionals to deliver holistic and comprehensive care.²¹

Effective geriatric care planning should involve a multidisciplinary team that includes medical providers, dental professionals, nursing care staff, pharmacists, social workers, and other relevant professionals. Moreover, involving both the caregiver and the patient in treatment plan decisions ensures a more inclusive and patient-centric approach to care.

The integration of interprofessional collaboration through information-sharing platforms, such as electronic health records, or through verbal and written conversations, can substantially reduce adverse drug reactions, prevent emergency hospitalizations, decrease morbidity and mortality rates, and reduce nursing home admissions.²²

Approximately 1.5 million elderly adults reside in nursing homes, with an additional 1 million in assisted living facilities throughout the United States.²³ This population often struggles to find transportation to healthcare appointments. While Original Medicare covers transportation in specific situations, routine trips to and from healthcare facilities are generally not included. Part A may cover emergency transportation services, and Part B may cover medically necessary transportation.⁷ Addressing this barrier necessitates the implementation of outreach services, deploying dental professionals who can collaborate on-site with long-term care providers. Furthermore, proactively and collaboratively informing older adults about available resources, such as transportation services, is essential. Examples of these resources include community-based transportation programs, volunteer driver networks, or partnerships with local transportation services.²⁴ Ensuring that older adults are aware of these options and assisting them in navigating these services can significantly enhance their ability to attend healthcare appointments, including dental visits.

In the context of long-term care facilities, effective communication among the care team members is essential for assessing the needs and establishing mutually agreed upon goals in the best interest of the patient. Collaborating with other professionals to assess a patient’s health literacy before treatment planning ensures comprehensive understanding, facilitating effective communication of appointment details, instructions, and self-care education.²⁵ Consulting the patient’s primary care provider can be a valuable resource for determining mental capacity. Additionally, dental hygienists can integrate health literacy screening tools into the assessment phase of care.²⁶

Interprofessional collaboration stands out as a cornerstone for increasing healthcare utilization of older adults. Collaborative teams can develop tailored educational initiatives and health promotion programs for older adults, addressing crucial topics such as oral health and the interconnection between oral health and overall well-being. Additionally, interprofessional research allows experts from different fields, including dental hygiene, to pool knowledge and skills, leading to the development of holistic and integrated solutions that might not be achievable through single-discipline research. Ultimately, interprofessional collaboration serves as a powerful mechanism to empower older adults with the knowledge and skills needed to make informed decisions about their overall well-being.

Future Directions

As the aging population continues to grow, targeted efforts aimed at raising awareness, improving access, and enhancing health literacy are important. This involves not only providing clear and accessible information but also ensuring the affordability and convenience of preventive services. Additionally, fostering trust and cultural sensitivity in healthcare interactions plays a fundamental role in overcoming these barriers. By dismantling existing barriers and adopting a collaborative approach, oral health professionals can strive toward an era where older adults receive optimal and comprehensive care.

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From Dimensions of Dental Hygiene. August/September 2024; 22(5):36; 42-45