Oral Health Considerations for Older Adults During the Pandemic
Acknowledging the impact of COVID-19 on general and mental health among vulnerable populations is key to providing effective oral healthcare.
This course was published in the October 2020 issue and expires October 2023. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Identify the relationship between the COVID-19 pandemic and social isolation, loneliness, and depression.
- Discuss the effects of social isolation, loneliness, and depression on general and mental health.
- Explain oral health considerations related to the global pandemic.
Never have the issues of social isolation, loneliness, and depression been brought to light more poignantly and dramatically than through the COVID-19 pandemic and its ongoing public health sequelae, especially among the most vulnerable populations in the United States.1 Older adults, particularly those in long-term care facilities, have been among the hardest hit, with devastating loss of life, as well as greatly diminished connections with family and friends, leading to further isolation and reduction in quality of life.2,3
Research on the effect of epidemics, especially the consequences of social distancing, is very limited. Nevertheless, the impact on the mental health of the population as a whole and its most vulnerable members can be estimated based on the information gleaned from other large-scale calamities.1,3 Traumatic, natural, and environmental disasters lead to increases in depression, post-traumatic stress disorder, and substance use issues, occurring both in the immediate aftermath and long-term.3 Awareness of the pandemic’s impact on mental, behavioral, and overall health, including oral health, and the negative outcomes on the quality of life of the most at-risk populations will assist oral health professionals in recognizing the signs of various interconnected aspects of health decline and in developing immediate and long-term approaches to providing oral healthcare and promoting disease prevention.
IMPACT ON GENERAL AND MENTAL HEALTH
Obviously, the most devastating negative outcome of SARS-CoV-2 infection is death. Older adults, a significant number of whom have chronic diseases and comorbidities, are at much greater risk, with more than 80% of related fatalities occurring in those age 65 and older.2 A comparison of US fatalities among people younger than 54 (1%) demonstrates a stark increase in those between ages 65 and 84 (3% to 11%), and especially those age 85 and older (10% to 27%).2 In addition to comorbidities such as diabetes, cardiovascular disease (CVD), and chronic kidney disease, one particularly remarkable risk factor for SARS-CoV-2 infection is a commonly prescribed group of medications for hypertension and CVD: angiotensin converting enzyme-2 inhibitors (ACEIs) and angiotensin receptor blockers.2 These medications upregulate the ACE-2 receptors located broadly in the body, including heart, lungs, and gastrointestinal system. The SARS-CoV-2 virus uses the ACE-2 receptors to attach to the cell surface and enter the cells in the lower respiratory tract. This places patients who take these medications at higher risk for COVID-19 infection and possibly a more severe course of disease.2
Other, more indirect effects of the pandemic on systemic health may include postponement or neglect of routine medical maintenance, preventive, or elective visits, such as blood screenings, eye exams, psychotherapy, and dental care. Disturbingly, a trend in refusal of more critical medical care, including organ transplants, joint replacement, cardiovascular procedures, and even cancer care, has occurred with alarming frequency as hospitals, surgical centers, and medical offices resume scheduling postponed procedures.4 Additionally, data from the US Centers for Disease Control and Prevention (CDC) indicate emergency department visits have dropped drastically in the US and other countries compared to the same period last year, with a 42% decrease in US visits over 4 weeks from March to April.5 At the start of the national quarantine, emergency department visits specifically for exposure and symptoms associated with COVID-19 infection increased by four-fold, while presentation at emergency rooms across the nation for other symptoms, such as nonspecific chest pain and acute myocardial infarction, declined. Conversely, emergency department visits for cardiac arrest and ventricular fibrillation showed an increase compared to the previous year, suggesting delays in seeking care until symptoms were more severe and outcomes were more serious.5
Some of the concerns with less urgent, ambulatory care have been mitigated by the use of critical care strategies, telehealth services, and current reopening of nonhospital medical and dental facilties. A “new normal” is evolving in which medical and dental practitioners must follow the CDC infection control protocols to the highest level, but also continue to triage the necessity of and approach to procedures that expose both patients and staff to risk of COVID-19 infection until the virus is truly contained, a process that may take up to 2 years or more.6,7 The lessons learned during the pandemic quarantine may be valuable in treating individuals with medical complexities, cognitive impairment, and phobias.8 In this way, enhanced patient communication skills, such as telehealth and video conferencing, allow oral health professionals to practice forms of behavioral cognitive therapy prior to treatment to address phobias and safety concerns. This is especially true because deferred treatment suggests that more radical procedures may be indicated, and the reassurance provided may aid in cooperation, compliance, and increased dental attendance.8
SOCIAL ISOLATION AND LONELINESS
Social isolation necessitated by the COVID pandemic may contribute to the increase of some systemic diseases, including CVD and metabolic syndrome.9 Approximately 24% of community-dwelling American adults age 65 and older were considered to be socially isolated (before the COVID-19 pandemic) and almost half of those age 60 and older reported feeling lonely.10 While these connections and their precise mechanisms are yet to be fully understood, the experiences of loneliness and social isolation can significantly impact older adults, increasing their risk for hypertension, CVD, and stroke; weight gain and decreased physical activity; impaired attention, cognition, and sleep; and harmful habits such as increased alcohol/drug use and smoking.11
While often thought of interchangeably, the terms “social isolation” and “loneliness” are related but quite distinct. Social isolation is an objective measure of the person’s lack of relationships and contacts with others, while loneliness is a subjective negative experience of lack of meaningful or any relationships, even in the company of others. While social isolation can be imagined as a physical barrier, loneliness is the individual’s perception.9,10,12
As nearly one-third of American older adults reported experiencing social isolation before the pandemic-associated restrictions, they may be at an increased risk for neglect and abuse.13,14 Social distancing and increased reliance on caregivers for daily routines, including oral hygiene, may contribute to a “multidimensional state of vulnerability” already experienced by older adults due to high rates of anxiety and depression.14 Sadly, as social isolation has been indicated as the strongest predictor of elder abuse, it may only intensify during the current pandemic.14 While it is estimated that one in 10 Americans older than 60 experience some form of elder abuse, only about one in 14 cases are reported.15 As healthcare providers, oral heath professionals must note, evaluate, and report suspected cases of elder abuse or neglect, even if not mandated by law.
US adults age 65 and older numbered approximately 50 million (15%) in 2016 and are expected to exceed 80 million (> 20%) by 2050.16,17 As only 2 million to 3 million older adults currently reside in assisted living and nursing home facilities, most dependent adults need assistance with activities of daily living (ADLs), relying predominantly on personal healthcare aides and/or informal caregivers, such as family members.17 More than 53 million (20%) of US adults are unpaid caregivers.18
DEPRESSION AND ANXIETY
Depressive disorders affect approximately 15% to 23% of US older adults living in the community, and up to 40% for elders in residential care. There is evidence of underdiagnosis and treatment in both categories.19,20 Depression in this population is expressed as either a medical comorbidity (minor depressive disorder) or a unique diagnosis (major depressive disorder). Strong associations exist with systemic disease and a positive correlation with increased medical burden, risk of death from suicide and CVD, most notably myocardial infarction, for older adults with depression.21 While it is not possible to evaluate the long-term mental health effects of pandemic-related anxiety and depressive symptoms now, the aspects of sustained and enhanced social isolation and perceived loneliness among older adults have a long history of interconnectedness with depression, even though they can be experienced independent of each other. Over time, research has shown the relationship between isolation and loneliness with clinical depression is at least reciprocal, if not directly causative.10 The extended separation of many older adults from the social connections in their communities and families underscores the need for outreach strategies even before social and healthcare systems are fully operational. The American Psychological Association issued COVID-19 practice guidelines to assist in treating existing patients and those who will need care in the aftermath of the crisis.22 There is much support for adding mental health services to Medicare-funded home healthcare, and this can encompass both screening for depressive disorders as well as treatment.23 Mental health practitioners are being more innovative in light of waivers of some regulatory barriers, and the new model of triage and even treatment using telehealth emerges again as a rational approach moving forward. This model of care meshes perfectly with the CDC recommendations prior to dental office visits for prescreening for COVID-19 symptoms, triage, and perhaps most important, human-to-human communication and trust-building.7,8
ORAL HEALTH CONCERNS AND CONSIDERATIONS
While isolation, loneliness, and depression are associated with increased risk of systemic disease and mortality among elders, deleterious effects on oral health and oral-health related quality of life have also been found.24 Behavioral and biological factors play a role in oral disease among older adults, and reduced access to oral care, physical limitations, systemic disease, cognitive decline, and dependence on caregivers also contribute to its prevalence. Additionally, commonly prescribed medications in this population, especially in combination with each other (polypharmacy), also contribute to increased risk of oral disease.25
Research demonstrates an association between depressive disorders and caries, tooth loss, and edentulism, and longitudinal studies show a correlation between periodontal diseases and risk of depressive symptoms among elders.24 When used alongside clinical examination, poor oral health, including existing pain and dysfunction, is strongly correlated with reduced oral health-related quality of life, and the ability to perform oral self-care and other ADLs, leading to further disease and dependence on others.
MEDICATIONS AND ORAL HEALTH
More than 94% of adults age 65 and older use at least one prescription medication, with an average of 8.2 drugs for community-dwelling adults. This number increases to 12.7 medications in those newly admitted to nursing homes.25–27 An estimated one in four older adults takes psychoactive medications such as antidepressants, anxiolytics, and sedative-hypnotics, which can have anticholinergic properties. Adverse effects include blurred vision, confusion, and xerostomia or salivary gland hypofunction.25 A longitudinal study of medication exposure and salivary function revealed that almost two-thirds of participants were taking antihypertensive and other cardiac medications (predominantly diuretics, calcium channel blockers, and ACEIs).27 Although this 11-year-long observation did not address the effect of polypharmacy on the incidence/prevalence and severity of xerostomia, it did demonstrate a strong association of medication exposure with both prevalence and severity of the condition.27 Medication-induced salivary gland hypofunction is associated with dental caries, dysgeusia, oral mucosal soreness, and oral candidiasis, and chronic dry mouth affects speech, digestion, and enjoyment of food, denture wearing, and overall quality of life.27,28 A recent systematic review compiled a comprehensive list of medications with documented effects on salivary gland function and identified 56 medications with strong evidence of interference with salivary gland function. Of these, 36 belonged to the group of nervous system drugs including analgesics, anti-Parkinson drugs, anxiolytics, sedatives/hypnotics, and antidepressants.28 A careful review of all prescription and over-the-counter medications will help patients avoid adverse effects and possibly dangerous drug interactions, especially common in older adults due to polypharmacy and age-related physiological changes in drug metabolism.25,26
SARS-COV-2-RELATED ORAL LESIONS
Dermatologic manifestations of SARS-CoV-2 infection have been widely reported. Several cases of oral-mucosal and oropharyngeal lesions, mostly in the form of herpetic-like ulcerations and erythema multiforme, affecting keratinized and nonkeratinized tissue have been documented.29 These lesions may be related to immune defense mechanisms, with etiologies in the SARS-CoV-2 infection and/or intense drug therapies, especially those that alter the oral microbiota.30 All lesions were self-limiting or resolved with the use of antimicrobial therapies. Self-report of pain by these patients was associated with the lesions, suggesting oral manifestations may have been underdiagnosed, and intraoral examinations should be performed in suspected or confirmed SARS-CoV-2 cases.30
The direct effects of the COVID-19 crisis on the morbidity and mortality of vulnerable older adults, combined with the psychosocial impact of exacerbating existing health challenges, including oral health, underline the need to address these concerns in a timely fashion. Those elders who have survived COVID-19’s adverse systemic effects and treatments may have lasting symptoms that require continued care.30 Additionally, postponed preventive and operative dental care should be resumed with caution and attention to patient concerns in returning to a safe treatment environment.8
- Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry. 2020;66:317–320.
- Shahid Z, Kalayanamitra R, McClafferty B, et al. COVID-19 and older adults: what we know. J Am Geriatr Soc. 2020;68:926–929.
- Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med. 2020;180:817–818.
- Hafner K. Fear of COVID-19 leads other patients to decline critical treatment. New York Times. May 25, 2020.
- Hartnett KP. Impact of the COVID-19 pandemic on emergency department visits — United States, January 1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69.
- Chigurupati R, Panchal N, Henry AM, et al. Considerations for oral and maxillofacial surgeons in covid-19 era: can we sustain the solutions to keep our patients and healthcare personnel safe? J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg. 2020;78:1241–1256.
- United States Centers for Disease Control and Prevention. Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response. Available at: cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Accessed September 10, 2020.
- Dziedzic A. Special care dentistry and covid-19 outbreak: what lesson should we learn? Dent J. 2020;8:46.
- Winterton A, Rødevand L, Westlye LT, Steen NE, Andreassen OA, Quintana DS. Associations of loneliness and social isolation with cardiovascular and metabolic health: a systematic review and meta-analysis protocol. Syst Rev. 2020;9:102.
- The National Academies of Sciences, Engineering, Medicine. Social isolation and loneliness in older adults: opportunities for the health care system. Available at: .nap.edu/catalog/25663/social-isolation-and-loneliness-in-older-adults-opportunities-for-the. Accessed September 10, 2020.
- Berg-Weger M, Morley JE. Loneliness in old age: an unaddressed health problem. J Nutr Health Aging. 2020;24:243–245.
- Ong AD, Uchino BN, Wethington E. Loneliness and health in older adults: a mini-review and synthesis. Gerontology. 2016;62:443449.
- Berg-Weger M, Morley JE. Editorial: loneliness and social isolation in older adults during the COVID-19 pandemic: implications for gerontological social work. J Nutr Health Aging. 2020;24:456–458.
- Han SD, Mosqueda L. Elder abuse in the COVID‐19 era. J Am Geriatr Soc. 2020;68:1386–1387.
- National Council on Aging. What Is Elder Abuse? Available at: ncoa.org/public-policy-action/elder-justice/elder-abuse-facts/. Accessed September 10, 2020.
- Roberts AW, Ogunwole SU, Blakeslee L, Rabe MA. The population 65 years and older in the United States: 2016. Available at: census.gov/content/dam/Census/library/publications/2018/acs/ACS-38.pdf. Accessed September 10, 2020.
- Aging & Health. Health Affairs. 2016;35:1556–1557.
- AARP. Caregiving in the United States 2020. Available at: aarp.org/ppi/info-2020/caregiving-in-the-united-states.html. Accessed September 10, 2020.
- Xiang X, Danilovich MK, Tomasino KN, Jordan N. Depression prevalence and treatment among older home health services users in the United States. Arch Gerontol Geriatr. 2018;75:151–157.
- Levin CA, Wei W, Akincigil A, Lucas JA, Bilder S, Crystal S. Prevalence and treatment of diagnosed depression among elderly nursing home residents in Ohio. J Am Med Dir Assoc. 2007;8:585–594.
- Alexopoulos GS. Depression in the elderly. Lancet Lond Engl. 2005;365:1961–1970.
- Bojdani E, Rajagopalan A, Chen A, et al. COVID-19 pandemic: impact on psychiatric care in the United States. Psychiatry Res. 2020;289:113069.
- Szanton SL, Leff B, Wolff JL, Roberts L, Gitlin LN. Home-based care program reduces disability and promotes aging in place. Health Aff (Millwood). 2016;35:1558–1563.
- Cademartori MG, Gastal MT, Nascimento GG, Demarco FF, Corrêa MB. Is depression associated with oral health outcomes in adults and elders? A systematic review and meta-analysis. Clin Oral Investig. 2018;22:2685–2702.
- Berryman SN, Jennings J, Ragsdale S, Lofton T, Huff DC, Rooker JS. Beers criteria for potentially inappropriate medication use in older adults. MEDSURG Nurs. 2012;21:129–133.
- Skaar DD, O’Connor H. Potentially serious drug-drug interactions among community-dwelling older adult dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112:153–160.
- Thomson WM, Chalmers JM, Spencer AJ, Slade GD, Carter KD. A longitudinal study of medication exposure and xerostomia among older people. Gerodontology. 2006;23:205–213.
- Wolff A, Joshi RK, Ekström J, et al. A guide to medications inducing salivary gland dysfunction, xerostomia, and subjective sialorrhea: a systematic review sponsored by the World Workshop on Oral Medicine VI. Drugs RD. 2017;17:1–28.
- Martín Carreras-Presas C, Amaro Sánchez J, López-Sánchez AF, Jané-Salas E, Somacarrera Pérez ML. Oral vesiculobullous lesions associated with SARS-CoV-2 infection. Oral Dis. 2020:10:1111.
- Dziedzic A, Wojtyczka R. The impact of coronavirus infectious disease 19 (COVID-19) on oral health. Oral Dis. 2020;10:1111.
From Dimensions of Dental Hygiene. October 2020;18(9):32-35.