In 1900, people over 65 accounted for approximately 4% of the United States population, less than one in 25. Today, more than 100 years later, this portion of the population has grown to almost 35 million or just under 13% of the American population.1 By the year 2030, when the Baby Boom generation reaches senior status, more than 70 million Americans will be 65 and over—comprising between 19%-20% of the total population.
The impact of these demographics will certainly affect the future practice of clinical dental hygiene. Recent studies indicate that older adults are seeking dental care at an unprecedented rate and in numbers that outweigh their growing proportion of the population.2 Statistics published by the Center for Disease Control and Prevention’s, National Oral Health Surveillance System (NOHSS) show that in 2002, 64% of those over 65 had a dental visit in the past year and 73% had a dental prophylaxis. These reports also reveal that only 24.4% of this population is completely edentulous, which is a significant change over previous cohorts of older adults.3
Older people are much more likely to suffer from chronic health conditions that are long-term and that may lead to disability. According to the National Center for Chronic Disease Prevention and Health Promotion, approximately 80% of all seniors have at least one chronic condition and 50% have at least two chronic illnesses.4 Chronic conditions include diseases such as asthma, hypertension, diabetes, heart disease, and arthritis. Impairments such as deafness, paralysis, vision problems, and permanent joint stiffness are also considered chronic. For the vast majority of older adults who are already suffering the debilitating effects of chronic illness, most are managed by prescription medications. Medication compliance (taking medications as prescribed) can greatly affect health and quality of life. The dental hygienist’s role as patient educator, clinician, and patient advocate, allows us the unique opportunity to provide a comprehensive assessment that will empower the patient toward improved medication compliance. The indication of medication use in a patient’s assessment should raise a red flag to the dental hygienist that further investigation is needed. You can prevent a medical emergency via thorough investigation.
FOLLOWING A DRUG REGIMEN
Approximately 83% of adults over 65 take at least one prescription drug daily.5 In fact, 30% of those over 65 take eight or more prescription drugs daily.5 Not only are older adults the largest consumer group of prescription medications, they also use a significant amount of over-the-counter and herbal supplements as well. About 40% of older Americans have used some form of dietary supplement within the past year.6
Compliance with a medication regimen is essential for controlling many of these chronic diseases or medical conditions. Noncompliance can cause a drug routine to fail, can increase overall health care costs, and can ultimately result in death. Compliance includes patients’ active participation in their own health care such as: keeping medical appointments, seeking medical advice, following recommendations regarding lifestyle changes, as well as complying with medication regimens. Noncompliance does not simply mean failing to take prescribed medication but can also include:
- Missing doses,
- Stopping therapy too soon,
- Taking more than is prescribed,
- Taking a medication for the wrong reason,
- Improper timing of doses,
- Failure to fill or refill a prescription,
- Failing to attend follow-up appointments,
- Not making recommended changes in daily routine, and
- Sharing medications.
Noncompliance with drug therapy, either underdosing or overdosing, occurs in approximately 1/3 to 1/2 of elderly patients.7 Research conducted at the University of Arkansas indicates 21% of all patients never have their prescriptions refilled.7 In fact, the literature indicates than 20% of older adults do not have their prescriptions filled initially.8 Similarly, a medication management study done in the United States found that between 10% and 25% of older adults take none of their prescription medications.9
FACTORS FOR NONCOMPLIANCE
Although there are varying views about the extent of noncompliance in older people, most research concurs that elderly people are at greater risk for noncompliance than any other segment of the population.8 More important, the consequences of noncompliance in an older patient may be more severe than in younger patients.1
There are many factors that put patients at risk for noncompliance, including: number of medications taken, inadequate information or instruction, cultural background, social isolation, cost of drugs, duration of drug treatment, and limitation of chronic illness and physical and mental impairments.
Taking three or more drugs increases the likelihood of noncompliance. Elderly individuals are at risk for noncompliance because 25% take three or more drugs a day.8 In addition to being unsure about basic information regarding drugs (name, purpose, dosage schedule, side effects), older people frequently hesitate to ask for information. This hesitation, coupled with failure of physicians to provide the necessary information about the drug regimen, increases the likelihood of noncompliance in these patients. In a study conducted by the American Association of Retired Persons, older individuals reported less satisfaction than younger people with the medication information they receive from health professionals.8
Another serious problem is variation in interpretation of directions on prescription labels by the elderly or undocumented changes in prescription instructions. Often, the long and somewhat complicated medical histories of older adults can lead to confusion.8
Cultural background can also significantly influence therapeutic regimens or a person’s health behaviors. For example, illness perceptions can create barriers to treatment recommendations. Prescribed treatment that does not account for a person’s beliefs about the causes of illness or diseases often leads to noncompliance because the person doubts the effectiveness of the prescribed treatment.
These cultured health beliefs are strongly held by the older portion of ethnic communities and some evidence indicates that these beliefs grow stronger with age.8 About 25% of the elderly population lives alone.8Social isolation is a common phenomenon among older people. Compliance problems become more common when the elderly are socially isolated.8
The available literature on the relationship between noncompliance and drug costs indicates that drugs costs are a factor in noncompliance.8 Because many older people are on fixed incomes and drug costs are high, some may discontinue medication when they feel better, instead of waiting for the physician’s order. Studies have shown that the level of compliance decreases over time.8 For people with chronic illness, this is definitely the case.8
Limited mobility due to arthritis and heart disease, as well as sensory impairments, all contribute to noncompliance in older adults. Chronic illness and limited mobility can inhibit a person’s ability to get prescriptions filled and arthritic hands make it difficult to open and close medication containers.8
Sensory impairments are problems that interfere with an older person’s ability to carry out drug regimens accurately. Vision impairments create a problem when reading labels or differentiating drug tablet colors, especially blue-green or white-yellow. Hearing loss can affect the ability of older people to ask questions.8 Cognitive impairments, like decreases in the ability to process and retrieve drug information, can lead to serious medication misuse.
According to research conducted to evaluate self-medication programs, patient medication knowledge is the best predictor of patient compliance.10 Programs designed to counsel patients on the pharmaceutical profile of medications increases the probability of compliance. The following methods can help improve patient compliance:
- Using devices that aid in taking medication, such as: pill boxes and pill calendars, containers labeled with large type, pill containers that open easily, accurate medication lists, and time doses to meal times.
- Encourage patients to establish partnerships with family, pharmacists, and home health aids to ensure compliance.
THE ROLE OF THE DENTAL HYGIENIST
As dental hygienists, we are in a unique position to identify patients who may be noncompliant with medication regimens. We can assist them by suggesting some of these methods to improve compliance. Determining the level of medication compliance during the assessment phase of treatment is important. When conducting a health history, using close-ended questions such as: “Do you take medication for high blood pressure,”may not be enough. Clinicians need to ask more probing questions regarding medication. We should be aware of the name of the medication, what the medication is prescribed for, and how much and how often the patient is taking each medication. An important additional question is “Do you ever miss a dose?” Health histories should also include questions regarding the use of over-the-counter drugs and herbal supplements, such as why they are taking them, how often they are taken, and whether their physician is aware of their use. Maintaining a positive demeanor when questioning leads to the patient being more forthcoming with information. The patient’s perception of a professional’s high level of interest will empower the patient to maintain more open communication.10
A patient’s level of compliance can pose a risk in the dental office. For example, a patient who is noncompliant with hypertension medication can impede the dental hygienist’s process of care after assessment until the hypertension is controlled. This patient presents a greater risk for heart attack or stroke because of his or her medication irregularity. The patient should be referred back to his or her physician for further medical evaluation and treatment.
Similarly, a patient with diabetes who is noncompliant in a treatment regimen can increase the likelihood of an emergency situation in the dental office. It is important that we carefully question diabetic patients as per compliance with medication and glucose monitoring.
Considering the changing demographics of our population, the future practice of dental hygiene will include an increase in the number of patients over the age of 65. As oral health care providers, we must be aware of the numerous factors that impact patient compliance and strive to support the elderly in maintaining good oral and overall health.
- Cox HG. Later Life, The Realities of Aging. 5th ed. Upper Saddle River, NJ: Prentice Hall; 2001:3-9.
- Shay K. Older Dental Patients: Myths and Realities. Available at: www.dentalcare.com/soap/ce_prot/ce6/pg01.htm. Accessed March 20, 2005.
- Center for Disease Control and Prevention. National Oral Health Surveillance System. Available at: www.cdc.gov/nohss. Accessed March 10, 2005.
- US Department of Health and Human Services. Chronic Diseases Notes and Reports. Atlanta: National Centre for Chronic Disease Prevention and Health Promotion; 1999.
- Substance Abuse and Mental Health Administration. Substance Abuse Among Older Adults. Rockville, Md: US Department of Health and Human Services; 1998:29-26.
- Williams CM. Using Medications Appropriately in Older Adults. American Family Physician. Available at: www.aafp.org/afp/20021115/1917.html . Accessed March 10, 2005.
- Gardner T, Knoll K, Dunn J, Dacus C. Compliance in Elderly Patients. Available at: www.uams.edu/compliance. Accessed March 10, 2005.
- Lewis CB. Aging, The Health Care Challenge. 4th ed. Philadelphia: F.A. Davis Co; 2002:262-264.
- Kelly A. Medication Compliance in the Elderly. Available at: www.sergp.org/Educ2/CommunEduc/Meds%20Compliance.htm .
- Buchmann WF. Adherence: a matter of self-efficacy and power. J Adv Nurs. 1997;26:132-137.
From Dimensions of Dental Hygiene. April 2005;3(4):10, 12-13.