Kenneth Shay

Infectious Complications of Dental and Periodontal Diseases in the Elderly Population

Retention of teeth into advanced age makes caries and periodontitis lifelong concerns. Dental caries occurs when acidic metabolites of oral streptococci dissolve enamel and dentin. Dissolution progresses to cavitation and, if untreated, to bacterial invasion of dental pulp, whereby oral bacteria access the bloodstream. Oral organisms have been linked to infections of the endocardium, meninges, mediastinum, vertebrae, hepatobiliary system, and prosthetic joints. Periodontitis is a pathogen-specific, lytic inflammatory reaction to dental plaque that degrades the tooth attachment. Periodontal disease is more severe and less readily controlled in people with diabetes; impaired glycemic control may exacerbate host response. Aspiration of oropharyngeal (including periodontal) pathogens is the dominant cause of nursing home-acquired pneumonia; factors reflecting poor oral health strongly correlate with increased risk of developing aspiration pneumonia. Bloodborne periodontopathic organisms may play a role in atherosclerosis. Daily oral hygiene practice and receipt of regular dental care are cost-effective means for minimizing morbidity of oral infections and their nonoral sequelae.

The importance of oral health in the older patient

Oral health is important to general health because stomatologic disease affects more than the mouth. Increasing preservation of teeth among present and future cohorts of older people has increased their risk for serious disease from oral pathogens. The intent of this paper is twofold: first, to alert non-dental health personnel to the significance of oral health and oral disease in the older adult; and second, to recruit the assistance of non-dental professionals in helping patients to achieve and maintain an optimal oral condition. Normative aging processes alone have little effect on the oral cavity, but common disease processes affecting oral health include tooth loss, dental caries, periodontal diseases, and oral mucosal diseases (including candidiasis and squamous cell carcinoma). Systemic diseases and their treatments frequently affect salivary, oral motor, and oral sensory functions. As a result of bacteremia or aspiration of oral contents, organisms of oral origin can be responsible for serious nonstomatological infections. Clinicians caring for older people need to recognize the importance of stomatological health, include an oral component in the multidisciplinary geriatric assessment, support the education of patients on aspects of dental health, and advocate the expansion of personal and public oral health benefits for older adults.

Oropharyngeal Candidosis in the Older Patient

Colonization of the oral and pharyngeal regions by Candida spp., particularly C. albicans, is extremely common in humans, particularly in early and late life. A variety of local and systemic conditions predispose the transformation of the benign colonization to a pathological state, which may have severe local or serious systemic consequences. The finding of oropharyngeal candidosis in an older patient, therefore, merits investigation of the likely host factors responsible for the organism adopting its pathogenic behavior. This paper provides non‐dental clinicians managing older patients a review of the clinical characteristics, risk factors, diagnosis, and management of oropharyngeal candidosis in older adults.

Oral Health Disparities in Older Adults: Oral Bacteria, Inflammation, and Aspiration Pneumonia

Poor oral hygiene has been suggested to be a risk factor for aspiration pneumonia in the institutionalized and disabled elderly. Control of oral biofilm formation in these populations reduces the numbers of potential respiratory pathogens in the oral secretions, which in turn reduces the risk for pneumonia. Together with other preventive measures, improved oral hygiene helps to control lower respiratory infections in frail elderly hospital and nursing home patients.

Validation of a medical record-based delirium risk assessment

To improve identification of patients at high risk for delirium, this study developed a chart abstraction tool for delirium risk and validated the tool against clinical expert diagnosis of delirium.

Delirium: a strategic plan to bring an ancient disease into the 21st century.

Hippocrates described delirium in the fourth century BC and Marcus Aurelius Antoninus in the second century AD. Since then (and probably beforehand), delirium has continued to plague ill and vulnerable people with morbidity and mortality. In the past 20 years, the science of delirium has greatly expanded, with better methods for diagnosis, risk identification, and prevention, but important areas such as risk modification, early recognition and treatment strategies, pathophysiology, and neuropsychology remain underdeveloped, underfunded, and understudied. Most importantly, clinical implementation of delirium programs is trailing scientific understanding, so delirium continues to affect more older adults than need be. As the country and world face the impending “age wave,” the prevalence of age-related diseases is likely to increase. For example, the Alzheimer’s Association predicts that the number of cases of Alzheimer’s disease will nearly double by 2050. Because delirium is more likely to occur in hospitalized older adults with cognitive impairment, it is safe to assume that delirium incidence and prevalence will increase in the future as well. The Centers for Medicare and Medicaid Services predicts that expenditures for hospitalization will nearly double over the next 10 years, exceeding

Quality improvement toward decreasing high-risk medications for older veteran outpatients.

1.3 trillion annually, in part because of the aging of the population. The cost of delirium to the healthcare system is estimated to be between

Strategic plan for geriatrics and extended care in the veterans health administration: background, plan, and progress to date.

38 billion and

Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: Translating Aging Research into Clinical Geriatrics

152 billion annually, in addition to patient costs in terms of compromised functional and cognitive performance. Advances in prevention and treatment and improved care for individuals with delirium are needed to minimize the morbidity, mortality, and healthcare costs associated with delirium. Delirium is a geriatric syndrome characterized by an acute change in mental status. As a geriatric syndrome, delirium does not have a single causal pathway, but instead has many predisposing and precipitating factors and therefore multiple presentations, treatments, and prevention strategies. Thus, many individuals who are focused on the patient (e.g., patients, caregivers, nurses, nursing assistants, social workers, rehabilitation staff, providers, and physicians) working together as a healthcare team can best provide optimal care for individuals who are vulnerable to delirium. The growing paradigm shift to patient-focused models of care suggests new possibilities for more effectively using current knowledge of delirium risk and presentation to modify the healthcare delivery environment with the goal of decreasing the incidence of this highly prevalent and costly syndrome. The purpose of this article is to offer a framework for improving the care of individuals with delirium. Even as we recognize progress in delirium science, the field is early in its development, and much more work is required to minimize the effect of delirium on individuals and the healthcare system. Our framework therefore begins by outlining the goals for delirium progress in education, research, quality improvement, policy, and implementation science necessary to bring delirium care into this century. Following the goals are examples of steps that may be required to achieve the goals. The critical underlying principle is that the individual (and caregiver) bears the burdens of delirium and the consequences thereafter. Therefore, the focus of this framework is to put the individual at the forefront of all recommendations by focusing on improving the delivery of clinical care. From the Geriatric Research, Education, and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Regenstrief Institute, Indiana University Center for Aging Research, Indianapolis, Indiana; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina; Geriatric Research, Education, and Clinical Center, Veterans Affairs Baltimore Medical Center, Baltimore, Maryland; and Office of Geriatrics and Extended Care, Veterans Health Administration, Washington, District of Columbia.

Who Is Responsible for a Nursing Home Resident's Daily Oral Care?

OBJECTIVES: To examine the effectiveness of a quality improvement program to decrease prescribing of high‐risk medications.