Evidence summary: why is access to dental care for frail elderly people worse than for other groups?

Key Points

• Frail elderly: older adults or aged individuals who are lacking in strength and are unusually susceptible to disease or to other infirmity.

• Access: a measure of how much dental care a person has received either in absolute terms or relative to health need.

• Dental care: care provided by a dental professional involving at least formal examination of oral health and possible treatment.

Abstract

In August 2009, members of the newly redeveloped Primary Care Dentistry Research Forum (http://www.dentistryresearch.org) took part in an online vote to identify questions in day-to-day practice that they felt most needed to be answered with conclusive research. The question which received the most votes formed the subject of a critical appraisal of the relevant literature. Each month a new round of voting will take place to decide which further questions will be reviewed. Dental practitioners and dental care professionals are encouraged to take part in the voting and submit their own questions to be included in the vote by joining the website.

This paper details a summary of the findings of the first critical appraisal. In conclusion, the critical appraisal has identified that primary research is needed to look at the subject of access to dental care for frail elderly people. Similar barriers to accessing care for this group of people are still being reported today as they were 20 years ago.

Background

Oral health is a lifetime concept.¹ High quality oral healthcare should be available to all people regardless of their age or circumstances.² By 2043 it is likely that 25% of the population in England will be aged 65 years and over.³ Increasingly dentate, the nature of oral healthcare need is rapidly changing, leading to more complex restorative treatments and more preventive dental services being required.^4,5

People aged over 90 years, and those made frail by stroke or dementia, are more likely to require domiciliary care. Help the Aged⁶ recently stated 'elderly people are suffering because of poor access to dentistry services', with those in care homes or the housebound struggling to see a dentist.

Aim

This review aimed to use research evidence to construct a comprehensive list of the factors believed to cause poor access to dental care by the frail elderly in the UK, and also try to identify research which shows which of these factors are the most important determinants of access for this group.

Review Method

Ovid MEDLINE was searched (1950 to week 4, August 2009) using the key terms as search terms, limited to the UK. Thirty papers were identified and 18 were excluded. Two further papers were sourced from reference lists. One quantitative study was identified in 14 papers reviewed. Locally developed quality criteria applied.

Further searches included CEBD, Cochrane Oral Health Group, CRD, IADR, BSDR, ADA and individual journal websites, eg Gerodontology.

Literature searches were supplemented by contacting Help the Aged and the British Society of Gerodontology.

Findings

The 14 studies included in the analysis reported factors affecting access to dental care by the frail elderly (see Table 1). Half of the studies were conducted before 2000, and nine of the 20 different types of respondent across all studies were care home managers and staff. Three studies^7,12,19 reported the views of GDPs/CDOs, including two since the 2006 introduction of the 'new contract' for dentists. Only three studies^10,13,16 reported the views of the frail elderly, however these were confined to institutionalised persons. Three studies^8,10,13 reported oral health assessments, including of the confused elderly, however direct research specific to this special care group appears to be lacking.

Table 1 Studies reporting suggested factors that lead to poor access

Most studies were descriptive, offering a low quality of evidence and focusing upon the practical, psychological, and information and training challenges of access to dental care. One recent study²⁰ found very low levels of awareness of 2005 'best practice' guidelines, indicating a gap in research upon the strategic, including commissioning, service design and implementation aspects of dental care for the frail elderly.

One study¹⁶ in 1998 provided a moderate quality of evidence, attempting to quantitatively prioritise the barriers to care in frail and functionally dependent older adults as lack of perceived need, cost of treatment (real or apparent), and transport.

Overall, in terms of the practical aspects of care for the frail elderly, it appears that, in the UK, similar barriers to access to dental care for the frail elderly are being reported now as were reported almost 20 years ago. It is unclear, due to a lack of research undertaken/reported, whether recent UK policy developments are having a measurable impact upon access to dental care for the frail elderly. Factors associated with poor access are shown in Figure 1.

Figure 1

Factors associated with poor access to dental care (reference numbers in brackets)