Mary McNally

Screening for Frailty in Canada’s Health Care System: A Time for Action

RÉSUMÉ: Avec le vieillissement de la population canadienne, la fragilité–avec son risque accru du déclin fonctionnel, la détérioration de la santé, et le décès–devient de plus en plus répandue. La physiologie de la fragilité reflète son origine parmi organes et systèmes multiples. Environ un quart des Canadiens qui sont âgés de plus de 65 sont fragiles, augmentant à plus de la moitié de ceux âgés de plus de 85. Notre système de soins de santé est organisé pour gérer les systèmes mono-organes, ce qui nuit à notre capacité à traiter efficacement les personnes atteintes de troubles multiples et des limitations fonctionnelles. Pour faire face à la fragilité, il faut reconnaître quand elle se produit, accroître la sensibilisation à son importance, développer des modèles holistiques pour ses soins, et générer des meilleures preuves pour son traitement. La reconnaissance de la façon dont la fragilité impacte la durée de vie permettrait l’intégration des objectifs en matière de soins dans les options de traitement. Les différents organisations de soins responsables variées dans le système de soins de santé canadien nécessiteront des stratégies et outils différentes pour évaluer la fragilité. Les changements dans la politique sera essentiels, étant donné la portée et la complexité des défis que pose la fragilité au système de soins de santé comme cela est organisé actuellement. ABSTRACT: As Canada’s population ages, frailty–with its increased risk of functional decline, deterioration in health status, and death–will become increasingly common. The physiology of frailty reflects its multisystem, multi-organ origins. About a quarter of Canadians over age 65 are frail, increasing to over half in those older than 85. Our health care system is organized around single-organ systems, impairing our ability to effectively treat people having multiple disorders and functional limitations. To address frailty, we must recognize when it occurs, increase awareness of its significance, develop holistic models of care, and generate better evidence for its treatment. Recognizing how frailty impacts lifespan will allow for integration of care goals into treatment options. Different settings in the Canadian health care system will require different strategies and tools to assess frailty. Given the magnitude of challenges frailty poses for the health care system as currently organized, policy changes will be essential.

The oral health of ageing baby boomers: a comparison of adults aged 45-64 and those 65 years and older

OBJECTIVES To compare the oral health status of adults aged 45-64 (baby boomers) and those aged 65 and older. METHODS An observational, cross-sectional survey of adults living independently in rural and urban settings in Nova Scotia, Canada was conducted. Using random digit dialing, calibrated interviewers completed a telephone survey, and clinicians calibrated to WHO standards conducted clinical examinations. Weighting was used to correct for sampling bias. RESULTS 747 community dwelling adults completed both the clinical exam and the questionnaire (n=411, age 45-64; n=336, age 65 or older). Rates of edentulism were low (2.6% aged 45-64; 15.7% aged 65+; p<0.001). Untreated root caries was greater in the older dentate group (19.7 vs. 10.1%; p<0.001). Being 65 years of age or older was identified as a predictor of increased decayed, missing, filled teeth, presence of decayed and/or filled roots and presence of attachment loss≥4 mm, but was not a significant predictor of presence of untreated coronal caries. CONCLUSIONS A falling rate of edentulism and a higher risk for root caries with increasing age may predict the need for more complex dental care as our population ages.

Action planning for daily mouth care in long-term care: the brushing up on mouth care project.

Research focusing on the introduction of daily mouth care programs for dependent older adults in long-term care has met with limited success. There is a need for greater awareness about the importance of oral health, more education for those providing oral care, and organizational structures that provide policy and administrative support for daily mouth care. The purpose of this paper is to describe the establishment of an oral care action plan for long-term care using an interdisciplinary collaborative approach. Methods. Elements of a program planning cycle that includes assessment, planning, implementation, and evaluation guided this work and are described in this paper. Findings associated with assessment and planning are detailed. Assessment involved exploration of internal and external factors influencing oral care in long-term care and included document review, focus groups and one-on-one interviews with end-users. The planning phase brought care providers, stakeholders, and researchers together to design a set of actions to integrate oral care into the organizational policy and practice of the research settings. Findings. The establishment of a meaningful and productive collaboration was beneficial for developing realistic goals, understanding context and institutional culture, creating actions suitable and applicable for end-users, and laying a foundation for broader networking with relevant stakeholders and health policy makers.

Assessing the oral health of an ageing population: methods, challenges and predictors of survey participation

Assessing the oral health of an ageing population: methods, challenges and predictors of survey participation Objectives To examine predictors of participation and to describe the methodological considerations of conducting a two-stage population-based oral health survey. Methods An observational, cross-sectional survey (telephone interview and clinical oral examination) of community-dwelling adults aged 45–64 and ≥65 living in Nova Scotia, Canada was conducted. Results The survey response rate was 21% for the interview and 13.5% for the examination. A total of 1141 participants completed one or both components of the survey. Both age groups had higher levels of education than the target population; the age 45–64 sample also had a higher proportion of females and lower levels of employment than the target population. Completers (participants who completed interview and examination) were compared with partial completers (who completed only the interview), and stepwise logistic regression was performed to examine predictors of completion. Identified predictors were as follows: not working, post-secondary education and frequent dental visits. Conclusion Recruitment, communications and logistics present challenges in conducting a province-wide survey. Identification of employment, education and dental visit frequency as predictors of survey participation provide insight into possible non-response bias and suggest potential for underestimation of oral disease prevalence in this and similar surveys. This potential must be considered in analysis and in future recruitment strategies.

Frailty's Place in Ethics and Law: Some Thoughts on Equality and Autonomy and on Limits and Possibilities for Aging Citizens

Consideration of ethical and legal themes relating to frailty must engage with the concern that frailty is a pejorative concept that validates and reinforces the disadvantage and vulnerability of aging adults. In this chapter, we consider whether a greater focus on frailty may indeed be part of the solution to the disadvantages that aging adults face in achieving equality and maintaining their autonomy within systems that have used their frailty to deny them equality and autonomy. First, by examining equality both as an ethical norm and as a requirement for protections against discrimination, we raise questions about the grounds on which health providers and health systems can be required to give equal concern and respect to the needs of frail older persons. Second, we explore autonomy and identify the tension between meaningful self-determination and prevailing ethical and legal norms associated with informed choice. Third, we argue that a proper understanding of frailty is essential within both of these themes; it respects equality by enabling health providers and systems to identify and address the distinct care needs of aging adults and helps to align informed choice theory with appropriate processes for decision-making about those needs.

First Nations, Inuit and Métis health: Considerations for Canadian health leaders in the wake of the Truth and Reconciliation Commission of Canada report

First Nations, Inuit and Métis peoples living in Canada face profound health disparities relative to non-Indigenous Canadians on almost every measure of health and well-being. Advancing health opportunities for Indigenous peoples require responses at all levels of healthcare delivery and policy. Therefore, it is critical for health leaders and providers within Canada’s healthcare institutions, systems, and settings to understand and address the determinants of health unique to Indigenous peoples, including the legacy of colonialism and both long-standing and present-day racism. The Truth and Reconciliation Commission of Canada provides a starting point from which positive responses to injustices can be advanced.

Management of Xerostomia in Older Adults: A Systematic Review

Background: Xerostomia (dry mouth) is a common adverse effect of many medications and can severely diminish quality of life for older adults. Objective: To assess the effectiveness of 3 categories of interventions used to manage drug-induced xerostomia and xerostomia secondary to Sjögren syndrome and radiation treatment for head and neck cancer in older adults: saliva substitutes, saliva stimulants, and topical fluoride. Data Sources: The Cochrane Library, PubMed, EMBASE (to July 2009) and CINAHL (to February 2010) were searched for randomized or quasi-randomized studies involving older adults with drug- or radiation-induced xerostomia or Sjögren syndrome. Study Selection and Data Extraction: An updating search focusing on systematic reviews (to June 2012) was conducted prior to publication. Outcomes included perceived dryness of the mouth, reduced sialometry, or increased root caries. Duplicate study selection and data extraction were conducted. Risk of bias was assessed. A random effects meta-analysis was employed. Data Synthesis: Four studies of saliva substitutes (N = 116), 3 studies of saliva stimulants (N = 361), and 1 of fluoride treatment (N = 334) met selection criteria. Saliva substitutes were more effective than other treatments at improving perceived dryness of the mouth as determined on a 10-point visual analog scale (weighted mean difference [WMD] −1.91 [95% CI −2.54 to −1.29]) but less effective than placebo (WMD 0.26 [95% CI 0.51–1.02]). Parasympathetic stimulants were more effective than placebo in improving oral dryness (OR = 0.37 [95% CI 0.19–0.72]). Due to lack of data, quantitative synthesis of results for topical fluoride was not possible. Conclusions: There is evidence to suggest that saliva substitutes improve symptoms but the clinical significance is minimal. The evidence more strongly supports the effect of saliva stimulants, although the quality of evidence is poor and adverse effects from these medications cannot be overlooked. Evidence demonstrating efficacy of topical fluoride in disease prevention was inconclusive. Addressing underlying causes of xerostomia, including drug choices, may help mitigate the burden of illness and effects on quality of life.

La santé des Premières nations, des Inuits et des Métis: les facteurs que doivent envisager les leaders en santé canadiens dans la foulée du rapport de la Commission de vérité et réconciliation du Canada

Les peuples des Premières nations, inuits et métis qui habitent au Canada sont aux prises avec de profondes disparités en matière de santé par rapport aux Canadiens non autochtones, et ce, dans presque toutes les mesures liées à la santé et au bien-être. Pour faire progresser les services de santé auprès des peuples autochtones, il faut passer à l’action dans tous les ordres de prestation des soins et des politiques en santé. Il est donc essentiel que les leaders et les prestataires des établissements, des systèmes et des installations de santé du Canada comprennent et prennent en main les déterminants de la santé propres aux peuples autochtones, y compris l’héritage du colonialisme et le racisme ancien et actuel. La Commission de vérité et réconciliation du Canada est le point de départ pour réagir de manière positive aux injustices.

Ethics of frailty: Some thoughts on equality and autonomy

I have long been interested in the impacts of frailty on oral health— and, conversely, in the effects of poor oral health on advancing frailty. When I first began thinking about these connections, it occurred to me that frequently one of the earliest signs of frailty is poor oral hygiene—a veritable canary in the coalmine of systemic health. It does make sense after all! Effective toothbrushing and flossing are manually quite difficult. They require agility, strength, good eyesight and motivation. What may seem to be a mundane, gradual and nuanced decline in the technicalities of selfcare has the potential to be exceedingly informative about frailty. Why is this important? It is wellknown that the ageing population is among the most significant health challenges today. While an increased lifespan offers enhanced opportunities for some, an accumulation of multiple health and functional deficits moves many individuals along a spectrum from fitness towards increasingly debilitating levels of frailty. Although there are numerous operational definitions, “frailty” is generally understood as the concept of increased vulnerability to adverse outcomes among people of the same chronological age.1,2 It is a construct of ageing and health primarily characterised through either its phenotypic definition as a biological syndrome or as the result of deficit accumulation resulting in a multidimensional risk state.1 Efforts to operationalise frailty for the purpose of screening, diagnosing, clinical decisionmaking and healthcare planning have followed largely from these two approaches accompanied by questions about mechanisms that lead to advancing frailty for some and not others, and to questions about how frailty can be prevented and managed. In response to these and other related questions, much has been done to advance our understanding of ageing and frailty in recent years.3,4 Biophysical changes that accompany frailty, medical innovations to assess and measure frailty as well as innovations to appropriately manage frailty are the subject of much exploration in geriatric medicine and related fields. This ever increasing body of knowledge suggests that the new science of “frailty” is beginning to be appropriately framed in clinical care and within the broader health system and public health context. Largely missing from this scholarship, however, is careful attention to the unique ethical considerations (including bioethical, clinical, organisational, research and health ethics) that should accompany our thinking about frailty. As with many innovations in health care, an understanding of the ethical implications often lags behind their introduction. Of relevance to dentists with a particular interest in geriatrics, the care we provide and the supported personal care that we advocate, often fall outside the healthcare mainstream. Obviously, there are opportunities to improve the health and care experience of our ageing patients through timely identification of frailty at various stages, followed by appropriate discussions and decisions on how to best promote health and provide care. Indeed, dentists may be in the unique position of providing invaluable insights within the circle of care for ageing patients. However, a proper understanding of associated ethical norms is essential to ensure that the provision of oral health care and the decisionmaking that precedes it gives appropriate concern and respect to the needs and autonomy of patients. I have previously argued that at the backdrop to the “ethics of frailty” is the recognition that for many people frailty is a pejorative concept that validates and reinforces the disadvantage and vulnerability of old age.5 At the same time, a diagnosis of “frailty,” understood as an objective and measurable biophysical and medical phenomenon, has the potential to provide the basis for appropriate clinical decisionmaking and overall health care.6 Of particular ethical interest here is the extent to which the mere adoption of the “frailty” label has the potential to be both harmful (ie, predisposing to paternalism and negative stereotypes) and beneficial (ie, identifying the legitimate health needs arising from it). We have a fundamental ethical obligation to identify and mitigate relevant risks for harm on behalf of our patients. Paternalism for example, particularly when coupled with vulnerability associated with frailty, has the potential to disturb both the equality and autonomy of those who are frail. Equality is an ethical norm to protect against discrimination. It refers to a fundamental aim of justice, namely to ensure fair and equitable treatment. Aristotle’s principle of formal justice that “equals must be treated equally, and unequals must be treated unequally” should motivate care to maximise opportunities for equity relating to individual’s needs, circumstances and capacity to benefit. Identifying and