Collaborative Health Care for Older Adults: Uniting Medicine and Dentistry

Web Sites

The American Geriatrics Society
A not-for-profit organization of health professionals devoted to improving the health, independence and quality of life of all older people. See their collections of professional education and public education for providers, as well as their comprehensive set of links to additional online information.

National Institute on Aging
Health and research information from the NIH's leading agency on aging issues. A summary of the report Retooling for an Aging America: Building the Health Care Workforce is available, along with information on grants and training.

Oral Health America
A nonprofit organization working to improve the overall oral health of the American public through access, education, and advocacy.

Portal of Geriatric Online Education
A free public repository of geriatric educational materials in various e-learning formats, including lectures, exercises, virtual patients, case-based discussions, simulations, as well as links to other resources.

Medical Issues of Interest to Dentists

American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. 2009. Pharmacological management of persistent pain in older persons. Pain Med. 10: 1062-1083.

Beissner K, Henderson CR Jr, Papaleontiou M, et al. 2009. Physical therapists' use of cognitive-behavioral therapy for older adults with chronic pain: a nationwide survey. Phys. Ther. 89: 456-469. Full Text

Bruckenthal P, Reid MC, Reisner L. 2009. Special issues in the management of chronic pain in older adults. Pain Med. 10 Suppl 2: S67-78.

Lee JH, Cheng R, Graff-Radford N, et al. 2008. Analyses of the National Institute on Aging Late-Onset Alzheimer's Disease Family Study: implication of additional loci. Arch. Neurol. 65: 1518-1526. Full Text

Mayeux R. 2008. Alzheimer's disease: epidemiology. Handb. Clin. Neurol. 89: 195-205.

Willey JZ. 2009. Prestroke physical activity is associated with severity and long-term outcome from first-ever stroke. Neurology 73: 572-573.

Willey JZ, Williams O, Boden-Albala B. 2009. Stroke literacy in Central Harlem. A high-risk stroke population. Neurology [Epub ahead of print]

Dental Issues of Interest to Medical Doctors

Ambatipudi KS, Lu BW, Hagen FK, et al. 2009. Quantitative analysis of age specific variation in the abundance of human female parotid salivary proteins. J. Proteome Res. 8: 5093–5102. Full Text

Chen Z, Mauk MG, Wang J, et al. 2007. A microfluidic system for saliva-based detection of infectious diseases. Ann. NY Acad. Sci. 1098: 429-436.

Denny P, Hagen FK, Hardt M, et al. 2008. Proteome of the human carotid and submandibular/sublingual gland salivas collected as the ductal secretions. J. Proteome Res. 7: 1994–2006.

Liu C, Qiu X, Ongagna S, et al. 2009. A timer-actuated immunoassay cassette for detecting molecular markers in oral fluids. Lab Chip 9: 768-776.

Mao JJ. 2008. Stem cells and the future of dental care. NY State Dent. J. 74: 20-24.

Woo VL, Kelsch RD, Su L, et al. 2009. Gingival squamous cell carcinoma in adolescence. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 107: 92-99.

Woo VL, Manchanda-Gera A, Park DS, et al. 2007. Juvenile oral lichen planus: a report of 2 cases. Pediatr. Dent. 29: 525-530.

Building Medical/Dental Partnerships

Berkey D, Berg R. 2001. Geriatric oral health issues in the United States. Int. Dent. J. 51 (3 Suppl): 254-256.

Bernard MA, Blanchette PL, Brummel-Smith K. 2009. Strength and influence of geriatrics departments in academic health centers. Acad. Med. 84: 627-632.

Boult C, Reider L, Frey K, et al. 2008. Early effects of "Guided Care" on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J. Gerontol. A Biol. Sci. Med. Sci. 63: 321-327.

Boyd CM, Darer JD, Boult C, et al. 2005. Clinical practice guidelines and quality of care for older patients with multiple chronic diseases. JAMA 294: 716-724.

Boyd CM, Ritchie CS, Tipton EF, et al. 2008. From bedside to bench: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Comorbidity and Multiple Morbidity in Older Adults. Aging Clin. Exp. Res. 20: 181-188.

Butler RN, Miller RA, Perry D, et al. 2008. New model of health promotion and disease prevention for the 21st century. BMJ 337: a399.

Eleazer GP, Brummel-Smith K. 2009. Aging America: meeting the needs of older Americans and the crisis in geriatrics. Acad. Med. 84: 542-544.

Institute of Medicine. 2008. Retooling for an Aging America: Building the Health Care Workforce.

Raphael C. 2008. A sense of urgency is needed. Solutions on long-term care demand action now. Mod. Healthc. 38: 24-25.

Weiss CO, Boyd CM, Wolff J, et al. 2007. Patterns of prevalent major chronic disease among older adults in the United States. JAMA 298: 1160-1162.

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At the conclusion of each session of this conference, attendees were asked a set of questions using an electronic audience response system (ARS). These surveys collected real-time data on participants' opinions about a range of topics important to the event. The results are compiled below.

Medical Considerations for Dentists

Dental Considerations for Medical Doctors

Building Medical / Dental Partnerships

Audience Demographics

Speakers:
Richard Mayeux, Columbia University Medical Center
M. Carrington Reid, Weill Cornell Medical College
Joshua Willey, Columbia University Medical Center

Highlights

• Recent research has implicated periodontal disease as a potential cause of vascular disease; however, it would be premature to recommend periodontal treatment to help prevent heart disease or stroke.
• Individuals with cardiovascular risks such as hypertension or diabetes have a significantly greater chance of developing Alzheimer's disease.
• Chronic pain is poorly managed in older adults, contributing to activity restriction, disability, and loss of function.

Stroke and periodontal disease

"The emergence of periodontal infections as a potential risk factor for CVD is leading to a convergence in oral and medical care," said Joshua Willey of Columbia University Medical Center. Although researchers don't yet know whether the link is causative or if periodontal infections are simply a marker of overall ill health, it is yet another reason for interdisciplinary collaboration in the interest of public health.

"Worldwide, cerebrovascular disease is, by far, the most important cause of death from a neurological disease—more so than Alzheimer's disease or infections that may occur in the developing world," Willey said. In the United States, there are about 700,000–750,000 strokes annually. Stroke is the leading cause of serious disability, and the costs of caring for survivors are "staggering."

Stroke is mainly a disease of older individuals, he stressed. Unlike heart disease, which tends to peak in the 50s and 60s, stroke rises in incidence and prevalence when people are in their 70s and 80s. Stroke tends to be more severe in women, who also have longer hospital stays, the highest hospital mortality rates, increased prevalence of dementia after stroke and, as a result, a higher chance of being placed in a nursing home.

U.S. stroke deaths tend to aggregate in the buckle of the "stroke belt"—primarily North and South Carolina. However, a comparable number of deaths is seen in northern Manhattan—particularly central Harlem. Most of that mortality is likely related to untreated hypertension and socioeconomic status, Willey said, although dietary factors may also play a role.

Chronic infection and inflammation associated with periodontal disease may predispose an individual to vascular disease or accelerate its progression.

Beyond established modifiable risk factors such as smoking, excess alcohol use, physical inactivity, obesity, waist-to-hip ratio, and diet, recent research has implicated periodontal disease as a potential cause of vascular disease. The hypothesis is that the chronic infection and inflammation associated with periodontal disease predisposes an individual to vascular disease or accelerates its progression, Willey explained. Some recently discovered markers for cardiovascular disease—infectious burden, levels of c-reactive protein, and elevated white blood count—reflect the connection.

Researchers in the Oral Infections and Vascular Disease Epidemiology Study (INVEST), a nested study within the Northern Manhattan Stroke study, are investigating further. Findings from a subsample of the cohort—about 700 men and women with an average age of 66 who were free of vascular disease and chronic inflammation at the start of the study—revealed that tooth loss, which is a marker of past periodontal disease, was associated with a greater prevalence of carotid plaque. "If you had zero to nine teeth missing, you had a 45% prevalence of carotid atherosclerosis," Willey said. "With 10 or more missing, prevalence increased to 60%."

Other researchers have found associations between periodontal disease and intima-media thickness (IMT, a marker of atherosclerosis). Periodontal bone loss has also been associated with carotid atherosclerosis, bacterial burden, and a greater IMT.

Yet despite the growing association between periodontal disease and vascular disease, INVEST researchers caution that it would be premature to recommend periodontal treatment to help prevent heart disease or stroke. Rather, periodontal treatment should be recommended because of its oral health benefits, because people are not healthy without oral health.

Alzheimer's disease—a dental connection?

As the U.S. population grows older and people survive longer into old age, the prevalence of Alzheimer's disease is expected to increase from 5 million adults to about 12 million. As Richard Mayeux of Columbia University told attendees, "It's like the U.S. is in a rowboat and there's a tsunami coming across the ocean, and we're totally unprepared to deal with it."

Recent findings have found relationships between oral health and cardiovascular disease. In turn, cardiovascular risk factors have been associated with an increased risk of Alzheimer's disease. If the infection and inflammation associated with periodontal disease indeed predisposes to heart disease, then periodontal disease could be contributing—albeit indirectly—to the increased risk of Alzheimer's as well.

Recent studies have shown that people who survive a heart attack and go on to develop heart failure have an increased risk of developing Alzheimer's disease, Mayeux said. In fact, "if you have hypertension, diabetes, and heart disease, your risk of eventually developing Alzheimer's disease is about threefold greater." A recent study by his group showed that having a stroke increased the risk of developing Alzheimer's disease approximately twofold. That said, "lifestyle factors, cholesterol, and cardiovascular factors are probably secondary factors that don't directly cause the disease but modify one's genetic risk," Mayeux explained. "We're probably all at somewhat different degrees of genetic risk, but environmental factors and age do play a role."

During the question and answer session, an audience member asked whether controlling all cardiovascular risks and inflammatory disease would affect the risk of developing Alzheimer's. "I think there would be a major impact," Mayeux said. Studies in Northern Manhattan have shown that up to half of older adults in those neighborhoods have a history of hypertension, diabetes, and heart disease. Magnetic resonance imaging tests of healthy, symptomless older adults in that area revealed that about one-third of have had strokes. "That means we have an epidemic of silent vascular disease" Mayeux observed. "And one key to controlling both stroke and Alzheimer's disease is to get the cardiovascular and inflammatory risks under control."

Another participant asked whether treating adults who already have risk factors and disease could really lower the risk of Alzheimer's, given that the disease seems to start many years earlier than was originally thought. "The answer appears to be yes," Mayeux said. "If somebody has diabetes and hypertension for 20 years and you can effectively treat their lipids, hypertension, and other risks, then you may be able to reverse whatever process has already been set in motion and significantly reduce the burden of disease. The problem is that in most cases, these conditions are not well controlled. For example, only about 30% of people with hypertension are actually adequately controlled. So even though the goal would probably achieve the results, the goal is not being met on multiple levels," he concluded.

Several symposium participants noted that although it is important to maintain the oral health of people with stroke or Alzheimer's, their physical and/or mental condition often renders such care difficult. Speakers underscored the need for dental training modules addressing patients with special needs and innovative solutions such as mobile dental chairs that can be used in long-term care settings.

The role of chronic pain

"Pain is a highly prevalent symptom across multiple chronic conditions and is a significant and an underrepresented cause of disability and suffering in later life," M. Carrington Reid of Weill Cornell Medical Center told the audience. Chronic pain is also strongly associated with frailty: about 20%–45% of independent older adults report pain, compared with 42%–64% of home care recipients and as many as 82% of nursing home residents.

Recent studies showed that in a cohort of 18,000 older adults, one in four said they had moderate or severe pain, which correlated with increased difficulty in doing activities of daily living. Moreover, "people ages 50–59 with moderate or severe pain seemed to look like people who were two decades older," Reid said, meaning that pain itself—which could include pain from oral infections—may be playing a role in the disability process.

Prospective studies by Reid and his colleagues documented a reduction in gait speed as a result of pain, showing that the effect was not due to activity restriction alone. Investigations of 19 other causes of activity restriction—for example, dizziness, problems with balance, infection—showed that the time needed to walk 20 feet declined by about .3 seconds due to these causes. But gait reduction secondary to pain is twice that, indicating that there is "something special about pain" and its effects on activity restriction.

Clinicians should document the functional impact of pain, and assess how the patient is coping.

Speaking as a clinician, Reid speculated that pain leads to activity restriction and other mediators—specifically depression, social isolation, and less commonly, falls and substance abuse— "cascade into a problem of disability." Other studies have shown that severe pain is a cause of death due to suicide. To help counteract pain, clinicians should be "getting patients involved in activity programs, identifying and treating depression, and finding ways for patients to become engaged socially."

In addition, clinicians should be doing a physical exam that includes a documentation of painful areas, maintain records detailing the functional impact of pain, and assess how the patient is coping, Reid said. And they should be aware of recently updated guidelines for the management of pain in older adults, published in the August 2009 issue of the Journal of the American Geriatrics Society. Included are details on age-associated changes related to drug therapy; for example, fat-soluble drugs will have an extended half life, renal clearance declines with age, and older adults have increased sensitivity to CNS effects such as somnolence, confusion, and dizziness.

In contrast to the 1998 pain-management recommendations, the 2009 guidelines call for the avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), meaning that patients will move from acetaminophen to opioids. Abuse rates for opioids seem to be very low, on the order of about 1%. "This is important because clinicians are concerned about precipitating or fostering abuse if I give they prescribe opioids," he said.

Exercise and other non-pharmacologic strategies such as mindfulness therapies, cognitive behavior therapy, distraction, and relaxation should be recommended for all older patients with pain, Reid stressed. Engaging patients in such strategies requires overcoming barriers such as fear of harm from exercise, and ageism—the idea that being older means a person will, a priori, be in pain. One patient told Reid that when he complains of pain, "my doctor tells me, 'well you're just getting older.'" Another remarked, "I showed my family doctor where I hurt and she said, 'it's only going to get worse, get used to it.'"

Two initiatives underway in New York City aim to turn those perceptions around and put effective pain-management programs into practice: The New York City Persistent Pain Working Group, and the Roybal Center/Cornell Columbia Translational Research Institute on Pain in Later Life, funded by the National Institute of Aging. The new center aims to promote the translation of behavioral, medical, social science research findings into treatments, intervention programs, and policies that can benefit older adults with or at risk of pain, and disseminate study findings and resources on the Web and elsewhere to researchers, practitioners, and policy makers, Reid concluded.

Speakers:
Daniel Malamud, New York University College of Dentistry and New York University College of Medicine
Jeremy Mao, Columbia University College of Dental Medicine
David Zegarelli, Columbia University College of Dental Medicine

Highlights

• Salivary diagnostics could help detect systemic infections and diseases in older adults, although challenges must be overcome before such tools become mainstream.
• Candidiasis, a common oral infection among the elderly, may be a symptom of systemic disease or a reaction to xerostomic medication.
• Extracted or exfoliating teeth—now considered medical waste—contain dental stem cells that one day could be used to treat, and potentially cure, myriad diseases.

Salivary diagnostics hold promise

Many molecules present in blood can also be detected by sampling the oral cavity. Is there, then, a potential role for "oral diagnostics"—the use of salivary markers to detect and/or monitor systemic diseases—in older adults?

"I think it's obvious that if someone had a choice between being stuck with a needle [to draw blood] or having their mouth swabbed, they would probably choose the latter," said Daniel Malamud of New York University's College of Dentistry and College of Medicine. Oral/salivary tests are noninvasive, safe, cost-effective, and user friendly, he observed. And they sit at the interface between medicine and dentistry.

Most analytes in blood are also found somewhere in the oral cavity, although it's not always obvious where they are. "Sometimes we'll guess where an analyte is and other times we actually do a study and sample all of the possible locations. Once we know where it's coming from, we know the best way to collect it," Malamud explained. Analytes of interest may be located, for example, in whole saliva, duct saliva, gingival crevicular crevice, mucosal transudate, the inside of the cheek, or in plaque.

Where the analytes are, as well as whether a qualitative or quantitative result is needed, helps determine whether an oral test might be appropriate for home use, point of care, or solely for research purposes. An untrained health professional would likely have difficulty collecting a sample from the parotid or submandibular gland, or from the gingival crevicular fluid, for example, so whereas such a sample might be useful as a laboratory tool, it's unlikely to be useful as a point-of-care test.

Similarly, it's easier to get a "yes" or "no" answer—e.g., does someone have HIV infection—from an oral test than to calculate something like a person's blood glucose level. "It doesn't do much good to know that yes, there's glucose in the oral cavity. You need to know that it's correlated with the blood value—something that's often overlooked," Malamud explained.

A recent study identified all the proteins that can be found in the various salivas—914 in parotid, 917 in submandibular/sublingual, and an overlap of 665 between the two types. This means scientists studying a particular disease can search and find whether it has a marker that is present in saliva, Malamud explained.

But certain characteristics of the geriatric population must be taken into consideration before salivary diagnostic tools can become mainstream. Interestingly, researchers recently discovered that certain proteins are present in younger women (ages 20–30) but not in older women (55–65), and vice versa. These normal differences in protein expression will influence the interpretation of findings, both in research and clinically.

Number of parotid proteins by function at different ages.

A number of salivary gland alterations in older adults may also pose problems, Malamud said. Xerostomia and salivary gland hypofunction are extremely common in the elderly. These conditions may result from systemic diseases and their treatments. It's been estimated about 400 drugs—for example, anticholinergics, antidepressants, antihistamines, and diuretics—cause dry mouth as a side effect. Systemic diseases such as Sjögren's Syndrome—an autoimmune disease that affects secretions of the oral cavity and the eyes, mainly in postmenopausal women—also interfere with salivary analyses.

Nonetheless, a number of oral/salivary tests are in development. These include tests from Malamud's lab for HIV, tuberculosis, and malaria and, from other groups, tests for chronic obstructive pulmonary disease, asthma, oral cancer, and markers of cardiovascular disease. Of particular interest, Malamud said in closing, is new work suggesting that the five specific cytokines—epidermal growth factor, colony-stimulating factor 3, interleukin 1?, interleukin 3, and tumor necrosis factor—are associated with the development of Alzheimer's disease. As markers, the five cytokines had a predictive accuracy of 96%. Although the finding is an association, not causal, "all five are part of the innate immune inflammatory response, and significantly they're all present in saliva," Malamud enthused. "So, in terms of studying the link between inflammation and Alzheimer's, saliva may be a neat place to look."

What is the oral mucosa saying?

Moving from oral diagnostics to disease, David Zegarelli of Columbia University's College of Medicine described two conditions that he has seen most often in his 35-year practice, particularly with older adults, that may also be symptomatic of systemic disease.

"More than any other disease, I am dealing with candidiasis. I cannot emphasize that enough," Dr. Zegarelli said. Lichen planus is a distant second; however, it is potentially more dangerous in that it is sometimes associated with squamous cell carcinoma.

Medications that reduce salivary flow may promote oral disease.

Candidiasis is more common in older adults. It's said to be ubiquitous—up to 50% of people have candidal microbes in their mouth. The most common subtype is Candida albicans, which has the greatest potential for adherence to the oral mucosa compared with the other more than subtypes of candidal microbes. "It is almost always a secondary invader, and orally more common in women than in men," Dr. Zegarelli said. It's considered a secondary invader because xerostomia (dry mouth) seems to be the most common condition predisposing to candidiasis infection. Xerostomic medications include antibiotics that kill the oral mucosa and anti-inflammatory agents such as prednisone. If the compromising condition is not eliminated—for example, by switching medications—the infection tends to recur, he said.

Lichen planus, while much less common, may also be the result of medications, chemical substances, or the ingestion of spicy flavoring agents. Often exacerbated by stress, the condition appears in six forms: papules, laces, plaques, erosive, ulcerative, and bullous. Treatment with steroids or other medications is effective, but long-term monitoring is warranted, particularly because of the association of lichen planus with squamous cell carcinoma.

Sometimes, the solution is "not to add a medication, but to take one or more chemicals away," Dr. Zegarelli said. For example, in one patient, stopping an anticonvulsant and an antipsychotic were sufficient to remove oral lesions entirely.

Transforming dental stem cells

Also at the intersection of dentistry and medicine, but outside of the realm of clinical treatment for now, is regenerative medicine using dental stem cells. Jeremy Mao of Columbia University College of Dental Medicine believes "the future [of medicine and dentistry] is probably right around the corner, if not already in the present." Whereas contemporary medicine treats disease, "regenerative medicine, if it works the way it's supposed to, cures it."

From the oral health perspective, adult dental stem cells eventually could be used, with tissue engineering techniques, to fix disorders of the craniofacial region, Mao said. Work is also underway in various laboratories to differentiate adult dental stem cells into odontoblasts or osteoblasts in an effort to regenerate teeth and bones.

In parallel, Mao and others have differentiated adult stem cells into chondrocytes to make cartilage; fibroblasts for the regeneration of tendons, ligaments (including the periodontal ligament), and cranial sutures. More recently, Mao's team differentiated dental stem cells into muscle cells and into neuron-like cells, which have the potential to one day help cure muscular dystrophy and neurodegenerative diseases, respectively. They've also used dental pulp to produce pancreatic beta cell-like cells that produce insulin, and implanted the cells into diabetic animals to see if they can reverse diabetes.

Of course, a number of hurdles related both to science and cost must be overcome before such work moves into the clinic. But "despite the potential for failure, it is far worse not to get clinical trials started," Mao stated. "This is a symposium on the connection between dentistry and medicine. The extracted or exfoliating teeth that we [dentists] deal with on a daily basis currently are treated as medical waste—yet they contain stem cells that have potential for use in medical treatment."

Speakers:
Douglas Berkey, University of Colorado, Denver
Kenneth Brummel-Smith, Florida State University College of Medicine
Cynthia M. Boyd, Johns Hopkins University
Carol Raphael, Visiting Nurse Service of New York

Highlights

• There is a tremendous shortfall in the health care workforce, including a dearth of physicians and dentists trained in geriatrics.
• Specialties without specific training in geriatrics include such important fields as ophthalmology, neurology, dermatology, and otolaryngology.
• Dental schools, like medical schools, fall short on geriatrics education, and the clinical care experiences that dental students receive are on well elderly, not those who are functionally impaired or frail.
• Health care teams made up of physicians, dentists, nurses, other providers, and informal caregiver are essential for implementing care plans for older adults with multimorbidity.
• The geriatric competence of the entire workforce must be enhanced.

Workforce issues

What are the chances that medical/dental collaborations will become a reality? Carol Raphael of the Visiting Nurse Service of New York was the first to address some of the obstacles, focusing specifically on the "woefully insufficient" numbers of skilled health care workers of all sorts to meet the needs of a rapidly aging U.S. population. Like Bernard, Raphael participated in the Institute of Medicine task force that grappled with the "retooling" of the health care workforce to better care for aging Americans. She emphasized that one out of five Americans will be over age 65 by 2030; in New York City alone, the population of older adults is projected to grow by 44% to 1.35 million.

Against that backdrop, issues of concern include the following:

• Chronic disease prevalence—heart disease, hypertension, cancer—increases with age.
• Health care utilization increases with age—while the over 65 population comprises 12% of the population, it accounts for 26% of all physician visits, 35% of hospital stays, 34% of all prescriptions filled, and 38% of EMS responses.
• Health care utilization increases with the number of chronic conditions—compared to those with only one chronic condition, Medicare beneficiaries with five or more conditions see more than three times as many physicians (on average, 14 different physicians per year), visit physicians more than four times as often, and receive almost five times the number of prescriptions.
• Nearly 70% of Medicare spending today is on behalf of the 23% of beneficiaries with five or more chronic conditions.

What is the workforce shortfall? Currently, there are 7100 geriatricians in the United States. By 2030, the number is projected to increase to 7750, whereas the need is for 36,000. Many available fellowships in geriatric medicine remain unfilled; new certifications in geriatric medicine have plateaued at a low level; and geriatricians have the lowest average earnings of any medical specialty.

New certifications in geriatric medicine, 1998–2004.

The dental workforce is also unprepared. Geriatrics is not recognized as a specialty for certification; there are only 13 programs for academic geriatric dentistry; no residency is specific to geriatrics; and geriatrics is not specifically tested on board exams.

Other components of the health care workforce—nurses, social workers, direct care workers, and family caregivers—are also lacking in numbers and subject to burnout, Raphael observed. Only 1% of pharmacists is trained in geriatrics, very few schools of podiatry include geriatrics, and there are only 1600 geriatric psychiatrists in the United States.

The most important recommendation to come out of the IOM report "is to enhance the geriatric competence of the entire workforce," Raphael stressed. "All of us who work in health care are going to be working with older adults, and therefore, all of us need to be competent in dealing with the issues that older adults face."

This will only be accomplished when all residents in settings where older adults receive care are trained in geriatrics, and when licensure and certifications require demonstrated competence in the care of older adults. Moreover, "targeted financial incentives" are needed to recruit and retain geriatric specialists, she concluded.

Bolstering medical education

Delving more deeply into the medical education needs for treating an aging population, Kenneth Brummel-Smith of the Florida State University College of Medicine, observed that although less than 4% of medical school graduates go into geriatrics, "we are the most satisfied of all physicians." That said, like Raphael, Brummel-Smith pointed to increasing shortfalls; the drop in numbers of primary care physicians from 62% of physicians in 1980 to less than 50% currently means that the pipeline for geriatricians—all of whom are family physicians or internists—is declining. Specialties without specific training in geriatrics include such important fields as ophthalmology, neurology, dermatology, and otolaryngology.

However, "some strides" have been made in geriatric medical education, Brummel-Smith acknowledged. "More schools have departments of geriatrics, and almost all schools report some dedicated casework." Nevertheless, only 23% have a required rotation in geriatrics (compared with 100% for pediatrics rotations) and only 48% integrate geriatrics into other clerkships.

To help close the gap in geriatrics education while opening the door to connecting medicine and dentistry, "collaborative and team-based training" is needed, Brummel-Smith said. He presented highlights of a special program at Florida State, created by a legislative mandate requiring "a continuing focus on the aging human throughout the four-year curriculum," that accomplishes these objectives.

The model program includes a "graduated curriculum that exposes students to health older adults first, to help negate some of the negative attitudes," he explained. Highlights include:

Year One: Introduction to the Older Person

• Normal aging, myths and stereotypes
• Psychosocial/spiritual development
• Communication skills and physical examination of the older person

Year Two: The Older Adult at Risk

• Family dynamics and caregiving
• Pharmacogeriatrics
• Functional assessment
• Geriatric syndromes

Year Three: The Older Adult in Sickness and Health

• Chronic illness/ multiple illnesses
• Rehabilitation
• Death and dying

Year Four: The Older Adult and the Health Care System

• Care across multiple sites/transitions, including dentistry

Implicit in the approach is an effort to "geriatricize" clinical skills training by integrating the concept of aging throughout the lifespan, Brummel-Smith said. "We stress the importance of communication skills, the fact that all of us want to function as independently as possible, no matter what age we are; the fact that all of us live in social settings and utilize social supports, particularly when we're ill; and the idea that therapeutic review is more than just knowing the pharmacodynamics and kinetics of a drug. It also means knowing what non-drug approaches are available, and what types of approaches patients decide on for themselves. Ultimately, it's about integration, not specialization," he concluded.

Bolstering dental education

Dental schools, like medical schools, fall short on geriatrics education. Moreover, "the clinical care experiences that dental students receive are on well elderly—not those who are functionally impaired or frail," Douglas Berkey of the University of Colorado Schools of Dental Medicine and Public Health told conference attendees. As a result, "they don't have an opportunity to struggle with some of the real challenges associated with geriatrics and gerontology. Students and residents are not prepared to identify, prioritize, and treat the oral health care needs of this most at-risk group."

Although exit surveys of graduating dental students acknowledge a desire for more geriatric dentistry, opportunities are few and far between, Berkey said. Historically, there have been only three sources of such training: the government's Health Resources and Services Administration, Veterans Administration programs (which no longer exist), and a Masters of Science degree program at the University of Minnesota. As dentists who trained in the mid 1980s through the early 1990s prepare to retire, "there will be a significant brain drain in this area," Berkey warned.

A 1995 publication from the Bureau of Health Professions identified a number of potential solutions to "retool" geriatric dental education. These included having a formalized set of competencies and standards, requiring predoctoral geriatrics education, establishing core competencies in national boards and regional licensure exams, and deploying continuous quality improvement measures to bolster dental education and care. Yet little progress has been made in any of these areas, Berkey said.

However, going forward, most dental care for older adults will likely be provided by generalists, Berkey emphasized. "So if we can provide opportunities for advanced geriatrics training in general dentistry, that would be very good," he concluded.

Coping with multimorbidity

In the final presentation of the day, Cynthia Boyd of the Johns Hopkins University School of Medicine and the Bloomberg School of Health reminded attendees that many older adults have multiple comorbidities, rendering both medical and dental care very difficult. And although medical professionals tend to think of patients in terms of their systemic diseases, the fact that they also have dental issues, particularly periodontal disease, "is often unrecognized," she said.

Physicians who care for patients with multimorbidity face challenges that include managing treatment for various diseases, prioritizing which conditions are most important, and deciding how to use evidence-based medicine in the decision making process, Boyd said. Whereas 50% of older women have only arthritis, fewer than 20% of people who have heart disease, chronic lower respiratory tract disease, diabetes, or stroke have only one of those diseases. Complicating the picture is heterogeneity in health status even among those with multimorbidity, and lack of clinical practice guidelines that include older adults—much less older adults with comorbidity—when addressing a specific disease.

Boyd advocates a conceptual framework that does not rely on separate treatment of specific diseases and conditions, but brings together teams of professionals working together for the patient's health. Slide courtesy of Cynthia Boyd

Even when a treatment regimen for a patient with multimorbidity was cobbled together from existing guidelines, it was incredibly complex. Boyd cited the case of a 79-year-old woman with five conditions whose treatment regimen was developed according to guidelines and taking potential drug interactions and synergies into consideration. It included 12 medicines in 19 different doses; non-pharmacologic therapies, such as dietary modifications that were to take place at specific times of the day;, and non-pharmacologic therapies and self-management techniques that were "supposed to be done whenever you can all day long," Boyd explained. The costs in time and money of such a regimen are out of reach for many patients. And that's before considering that the patient also "is probably at very high risk of also having oral health problems, and that some of the medicines might affect the person's dental management."

Boyd's analyses of the evidence for various approaches to patient management has led her to endorse a conceptual framework in which the patient is more than simply the sum of his or her diseases and conditions. Both physicians and dentists need to acknowledge that these conditions "occur within the context of a patient, and that includes not just their physiologic health, but also their psychosocial circumstances," she emphasized. Health care teams made up of physicians, dentists, nurses, other providers, as well as informal caregivers are "essential for implementing care plans," she concluded.

As the baby boom generation gets older and lives longer, the United States health care system shows few signs of being ready to address its needs. A 2008 report from the Institute of Medicine points to a fundamental lack of preparedness in the healthcare workforce for this demographic shift. Medicine and dentistry are already experiencing higher demands for individuals trained in geriatrics, even as woefully few professionals choose to work in that area.

Marie Bernard, deputy director of the National Institute on Aging, was a leader in the preparation of the IOM report. In her keynote address to an October 16, 2009, New York Academy of Sciences symposium, she stressed the need to prepare for what she calls the upcoming "silver tsunami."

Sheer population numbers alone mean that cardiovascular disease, stroke, Alzheimer's disease, and other disorders related to aging are likely to increase in prevalence in coming years. The picture is similar in dentistry. Although there has been a marked reduction in the percentage of adults 60 and older who have lost all of their teeth compared with prior generations, root caries, oral fungal infections, and osteonecrosis of the jaw (a rare side effect of taking bisphosphonates to prevent osteoporosis) are emerging as areas of increasing concern.

Although the number of available first-year geriatric medicine fellowships is rising, a growing percentage remain unfilled.

In addition, while good dental care will be important for the aging population—and mounting evidence suggests that oral health is a reflection of and contributes to systemic health—few dentists are trained in treating older adults or cognizant of their often complex oral health needs. Meanwhile, because Medicare does not cover routine dental care and many Americans lack dental coverage, the cost of such care is out of reach for many who need it.

As researchers continue to explore connections between oral health and systemic health with regard to the more prevalent conditions related to aging, other problems are also emerging at the interface of medicine and dentistry. One example is oral cancer. Recent data show such cancers are most common at ages 55–64, and that mortality "is absolutely skewed to older ages," Bernard said. That could be due to multiple morbidities in older individuals, but lack of dental coverage could also play a role. "These days, a primary care physician is increasingly pressured to spend 15 minutes or less in a patient encounter, and so the tendency is to address the presenting reason for the visit, rather than doing a thorough evaluation," Bernard observed. "Therefore, many times the dental health professional is the only person who might see a harbinger of oral cancer—and if the person's not seeing a dental health professional, how will it be picked up?"

The sense of taste also diminishes with age, due to changes in taste buds and perhaps, secondarily, to a diminished sense of smell. Dry mouth and other salivary disturbances may also result from medications prescribed for systemic diseases. Such changes "clearly have implications for nutrition and health because if food isn't tasty and satisfying, you're not going to consume much."

Going forward, "there will be plenty of [funding] opportunities" for scientists engaged in research dealing these and other age-related diseases and conditions, Bernard emphasized.

Medical issues of interest to dentists

While it might seem logical that medical professionals would recognize the importance of  maintaining oral health, and that dentists would understand the health needs of their older patients, neither of these things is happening today. But efforts such as this symposium, organized in collaboration with the Columbia University College of Physicians and Surgeons and its College of Dentistry, are underway to develop collaborative approaches in which medical and dental professionals could coordinate to provide care for the whole person. The morning session looked at several medical conditions with connections to oral health.

Periodontal infection has emerged as a potential risk factor for some of the major diseases of the elderly, including cardiovascular disease and stroke. Joshua Willey of Columbia University Medical Center remarked that although researchers don't yet know whether the link is causative or if periodontal infection is simply a marker of overall ill health, it provides another reason for interdisciplinary collaboration among dentists and medical professionals.

Richard Mayeux of Columbia University suggested a potential connection between poor oral health and the development of Alzheimer's disease. Many researchers now believe that periodontal disease may contribute to cardiovascular disease by increasing the infectious burden. Mayeux's group's research has shown that "if you have hypertension, diabetes, and heart disease, your risk of eventually developing Alzheimer's disease should you survive is about threefold greater." M. Carrington Reid of Weill Cornell Medical Center stressed in his presentation that chronic pain, which is common across multiple systemic and oral conditions, is "an underrepresented cause of disability and suffering in later life." He underscored the need to overcome ageism among clinicians, who may be unwittingly fostering pain in their patients by telling them it's simply part of aging.

Oral health issues of interest to medical doctors

Approaching the need for collaboration from the dental side, Daniel Malamud of New York University's College of Dentistry and College of Medicine, provided insights into the promise of salivary diagnostics. A number of these noninvasive tests are in development for detection of, among other conditions, HIV, tuberculosis, chronic obstructive pulmonary disease, asthma, oral cancer, and markers of cardiovascular disease.

David Zegarelli of Columbia University's College of Medicine reminded the audience that diseases of the oral mucosa—particularly candidiasis—can reflect systemic conditions such as a compromised immune system. And Jeremy Mao of Columbia University's College of Dental Medicine demonstrated future convergences between dentistry and medicine, as new technologies—in particular, tissue engineering and stem cell advances—emerge. For example, regenerative medicine investigators are involved in differentiating adult dental stem cells into a variety of cell types, including cartilage-like cells to treat arthritis and neuron-like cells that might ultimately treat Alzheimer's and other neurodegenerative diseases.

Strategies for building medical/dental partnerships

Reprising the theme articulated by Bernard in her opening address, speakers in the final session focused on the dire need to build and "retool" the health care workforce to accommodate the aging population. Carol Raphael of the Visiting Nurse Service of New York stressed the need for geriatrics education across the board, while Cynthia Boyd of the Johns Hopkins University School of Medicine and the Bloomberg School of Health reminded attendees that many older adults have multiple comorbidities, rendering both medical and dental care challenging for all health care providers, regardless of education and clinical background.

Kenneth Brummel-Smith of the Florida State University College of Medicine presented the curriculum for a unique program that seamlessly integrates geriatrics into the core medical curriculum. However, Douglas Berkey of the University of Colorado Schools of Dental Medicine and Public Health stressed that few programs of this type exist in dental schools.

Summing up the goals of the event in an interview, Ira Lamster, Dean of the Columbia University College of Dental Medicine and a member of the scientific organizing committee, said, "A conference like this is critically important. When we increase the dialogue between physicians and dentists, the ultimate result is improved patient care."