Collaborative Health Care for Older Adults

Agenda

Abstracts

Keynote Address

Health and Aging—Opportunities for Medical/Dental Collaboration

Marie A. Bernard, MD, National Institute on Aging/National Institutes of Health, Bethesda, Maryland

Dr. Bernard will present a summary of research that has been funded by the National Institutes of Health of relevance to the medical and dental health of the aging population. Particular focus will be placed on research funded by the National Institute on Aging and the National Institute of Dental and Craniofacial Research. The application of the evidence to the care of elderly populations will be discussed. Opportunities for collaboration between medical and dental professionals will be emphasized.

Session I: Health and Medical Considerations

Epidemiology of Stroke

Joshua Z. Willey, MD MS, Division of Stroke, Department of Neurology, Columbia University Medical Center, New York, New York

Stroke is the leading cause of disability in adults in the United States and the third leading cause of death. One American has a stroke every 40 seconds, and in the United States alone there are more than 780,000 strokes per year, with the majority being new events. The number of hospitalizations in the United States continues to increase. The cost associated with the care of stroke patients in 2008 was $65.5 billion; the cost of care per patient is almost double for severe strokes. Stroke is disproportionately a disease of individuals of lower socio-economic status, African-Americans, the elderly, and women in the older age groups. The majority of stroke survivors have some form of a residual disability, though 50-70% will nonetheless regain functional independence. A small proportion of stroke patients will receive acute stroke treatment, and as such prevention remains the cornerstone of stroke treatment. In this talk the epidemiology of stroke will be reviewed, with particular attention to established and new risk factors, and the unique aspects of stroke in the geriatric population.

Issues Related to Pain and Pain Management in Later Life

M. Carrington Reid, MD, PhD, Weill Cornell Medical College, New York, New York

As human life expectancy continues to rise, significant numbers of older adults will experience persistent pain conditions. At present, pain is a highly common, costly, and frequently disabling disorder in later life. Prevalence studies estimate that as many as 30 to 40% of older adults living in the community experience persistent non-cancer pain, with higher rates observed among institutionalized elders. Arthritis and arthritis-related diseases are the most common causes of pain in older populations, however, painful neuropathies associated with diabetes and herpes zoster also occur commonly and can be equally disabling. Advancing age and belonging to a minority group are strong and independent risk factors for underassessment and undertreatment of pain. The deleterious consequences of inadequately treated pain are far-reaching and include impaired quality of life and sleep, decreased immune function, cognition, mobility, as well as activity of daily living disability. Persistent, unrelieved pain also creates a significant mortality risk through late-life suicide. Although considerably less is known regarding effective treatments, an emerging literature suggests that both nonpharmacologic (e.g., cognitive-behavioral therapy) and pharmacologic (e.g., opioid therapy) treatment modalities can help to reduce pain and improve function among affected individuals. This presentation will describe: 1) recent research findings related to the epidemiology of pain in older adults; 2) relevant physiologic changes associated with aging that are important when considering pharmacologic treatment choices; 3) provider- and patient-level barriers to effective management of pain in this age group; and 4) community-based initiatives (in New York City) for improving the management of pain in later life.

Epidemiology of Alzheimer’s Disease and Degenerative Diseases of the Aging Brain

Richard Mayeux, MD, MS, Columbia University Medical Center, Sergievsky Center/Taub Institute, New York, New York

Alzheimer’s disease is the most frequent cause of dementia in western societies. It is estimated that approximately five million people in the United States and possibly 20 to 30 million worldwide suffer from the disease. By age 85 years and older 15-30% are affected, and the incidence rate increases from approximately 1% among people aged 65-70 years to approximately 6-8% for people aged 85 years and older. It is expected that these numbers will quadruple by the year 2040, by which 1 out of 45 Americans will be affected, leading to a considerable public health burden. Rare mutations can lead to familial, dominantly inherited Alzheimer’s disease with onset below the age of 50 years. For late onset, more typical forms the ε4 variant of APOE increases “susceptibility” in a dose-dependent fashion, but is not directly causal. Variant alleles in SORL1, a neuronal sorting receptor critical to the processing of APP, have also been associated with late-onset disease. Few environmental risk factors have consistently been associated with Alzheimer’s disease, but risk is augmented among individuals with cardiovascular and cerebrovascular disease and their antecedents. Oligogenic segregation analyses have predicted the existence of three to seven additional genes with the potential to alter the risk of AD. The concerted effort to identify the genetic basis of the common, late-onset form of AD underway will, no doubt, clarify the role of environmental and other health factors on risk and have profound influences on the treatment of this disease.

Session II: Health and Medical Considerations

Saliva and Salivary Diagnostics: Implications for the Geriatric Population

Daniel Malamud,PhD, New York University College of Dentistry and New York University College of Medicine, New York, New York

It is now widely accepted that most molecules present in blood can also be detected by sampling the oral cavity. These molecules include ions, antigens, antibodies, nucleic acids, steroid hormones, tumor makers, inflammatory mediators, and many drugs. While many commercial tests have become available, challenges still remain, particularly when a quantitative measurement of the analyte is required. Our own studies have focused on utilizing oral sampling for detecting or tracking systemic diseases, particularly infectious diseases. However, others have identified salivary markers for asthma and chronic obstructive pulmonary disease (COPD), cardiovascular disease, and cancer. We present an overview of the field of oral-based diagnostics, and focus on the utility of these tests for the geriatric population.

Disease of the Oral Mucosa in Older Adults

David J. Zegarelli, DDS, Columbia University College of Dental Medicine, New York, New York

There are diseases of the oral mucosa having a predilection for older adults. Two of the more common include oral lichen planus and candidiasis. These entities can occur singly and in combination with one another. Lichen planus has many clinical forms (6) and is therefore not only common but “multiforme”. It is also seen with increased frequency in patients having oral squamous cell carcinoma. Oral candidiasis is an opportunistic superficial mucosal infection. Presenting symptoms often include the patient stating that the mouth “burns” or is “sensitive”. Lastly, patients with oral lichen planus can have secondary candidal infection.

Stem Cells and the Future of Dentistry: Impact on the Elderly

Jeremy J. Mao, DDS, PhD, Columbia University College of Dental Medicine, New York, New York

Dental medicine will be transformed from repair to regeneration. Repair is exemplified by amalgams, gutta percha and titanium dental implants. The new paradigm will be the regeneration of dentin, dental pulp, muscle, mucosa, cartilage, bone, periodontal ligament and other structures by bioengineering approaches. The magnitude of this impact on dental care worldwide will be, over time, greater than amalgam or dental implants. However, a number of critical barriers must be overcome for the translation of scientific discoveries to clinical practice. First, whether transplantation of stem/progenitor cells is a realistic approach for clinical application of some of the dental and craniofacial disorders must be examined. Virtually all craniofacial structures are products of neural crest derived mesenchymal cells. Mesenchymal stem/progenitor cells are the offspring of mesenchymal cells during development. Therefore, it seems to be a foregone conclusion to isolate, expand and transplant stem/progenitor cells for the healing of traumatized or diseased dental and craniofacial tissues. Not so fast, perhaps. Cell transplantation is being attempted in large animal models and clinical trials to treat fatal and medically debilitating diseases such as cardiac infarcts, Parkinson’s disease and spinal cord injuries. Most dental and craniofacial disorders are not fatal. Whether the cost and medical need in association with the transplantation of stem/progenitor cells for a number of dental and craniofacial disorders is justified is not a foregone conclusion. For example, it is virtually impossible to harvest dental pulp stem cells from a patient who needs a root canal treatment, and whose rest of the dentition is healthy. Second, dental stem cells have potential to differentiate into cells that potentially form non-dental/craniofacial tissues. Whether dental stem cells can be utilized autologously or allogeneically to treat fatal and medically debilitating diseases such as diabetes, neurodegenerative diseases, muscular dystrophy, and rheumatoid conditions is well worth exploring. Third, dental/craniofacial regeneration can and should benefit from the fruit of tissue engineering in the past two decades. Cell homing is an emerging approach that relies on tailored biomaterial scaffolds with or without delivery of bioactive cues for tissue regeneration, frequently without the need for cell transplantation. Microencapsulation, immobilization and controlled release represent additional important approaches for the delivery of bioactive cues in tissue regeneration. Finally, we must initiate clinical trials to translate laboratory discoveries towards the translation into products. Despite the potential for failure, it is a far worse option not to get clinical trials started. This lecture will provide a platform for dispassionate debate of a number of critical issues in dental/craniofacial tissue engineering. Collectively, we are obligated to move dental/craniofacial tissue engineering forward with products towards commercialization in the foreseeable future. Dental and craniofacial tissue engineering is an opportunity that dentistry cannot afford to miss.

Session III: Policy Implications and Inter-Professional Relationships

Building the Health Care Workforce for an Aging America

Carol Raphael, MPA, The Visiting Nurse Service of New York, New York

As the nation's 78 million baby boomers begin turning 65, they will be confronted with a health care workforce that is woefully insufficient in size and in skills to meet their needs. This workforce is diverse and includes professional disciplines---medicine, nursing, oral health, rehabilitation and social work---as well as direct care workers and family caregivers. In addition, this workforce must adapt to the older population of tomorrow, which will be more culturally diverse, more medically and socially complex, and require and demand care that helps to prevent declines, avoid hospitalizations, and maintain quality of life and independence. To build the health care workforce of tomorrow, the nation must work today to enhance geriatric competence throughout all disciplines, increase the recruitment and retention of geriatric specialists, and improve the way care is delivered by spreading evidence-based models that have been shown to be effective and efficient, supporting research and demonstration programs for new models, redefining traditional job roles, and leveraging technology as an enabler.

Expanding Geriatric Education in Medical Training

Kenneth Brummel-Smith, MD, The Florida State University College of Medicine, Department of Geriatrics, Tallahassee, Florida

The coming tsunami of geriatric patients demands greater attention to geriatric education during medical training. A recent Institute of Medicine report has highlighted the acute need for increased training to prepare the healthcare workforce. All medical students, and almost all residencies, need to incorporate more geriatrics. This training must include not only common diseases and syndromes seen in older persons, but also key geriatric principles, such as reduction of polypharmacy, improving care transitions, and interdisciplinary care, palliative and end-of-life care.

Strides have been made in geriatric medical education. More schools have departments of geriatrics, and almost 100% of medical schools report some dedicated coursework. However, only 23% have a required rotation (while 100% require a pediatric rotation), and less than 50% integrate geriatrics into other clerkships.

The ideal strategy for expanding geriatrics must take a multi-faceted approach. Integration into existing course work is critical. A required rotation is also necessary. A model program of combined integration and dedicated experiences has been instituted at Florida State, which has led to the nation’s highest rating of geriatric training by medical students completing the AAMC Graduation Questionnaire.

Geriatric Dental Education and Training in the United States

Douglas B. Berkey, DMD, MPH, MS^{1, 2,} Rob Berg¹, DDS, MPH, MS, MA, University of Colorado Denver, Schools of ¹Dental Medicine and ²Public Health, Aurora, Colorado

As the aging of the population progresses at an unprecedented rate, more substantial efforts are required to retool geriatric dentistry education. Following the alarming parallels in geriatric medicine, reports on the future of dentistry from the Institute of Medicine, the US Surgeon General, and the American Dental Association all confirm that the dental workforce is not adequately prepared to address the complex oral health needs of older adults. Surveys of graduating dental students by the American Dental Education Association also highlight the inadequacy of their geriatric dentistry training.

A variety of strategies must be developed to transform training of oral health care providers to more effectively address the unique dental needs of older patients. Among the key areas of needed focus are: greater emphasis during accreditation of pre-doctoral dental school programs and post-graduate dental programs; incorporation of geriatric issues in national and regional licensure examinations; increasing the amount of experiential training in geriatrics during the first and second years of dental school curricula; expanding the diversity of clinical training experiences to include the very-old patient; promoting more postdoctoral training opportunities, especially within AEGD and GPR programs; creating opportunities for faculty training in geriatrics; identifying the most effective strategies for teaching geriatrics in each learning environment, individualizing instruction when possible; employing geriatric-specific CQI measures to improve dental education outcomes; and developing web-based resources to form a “clearinghouse” of information to help advance ongoing learning about the issues affecting older adults.

Success in improving our educational efforts to create a new generation of providers will ultimately depend upon skillful collaboration involving many institutions and organizations. Working together, dental and medical professionals, educators, and policy makers can drive the change needed to ensure that emerging dentists and seasoned practitioners are ready, willing and able to provide the best possible care for an aging America.

Improving Health and Health Care for Older Adults with Multimorbidity

Cynthia M. Boyd, M.D. MPH, Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland

Recently, accumulating evidence has pointed to the importance of multiple co-existing conditions, or multimorbidity, to the health and health care of older adults. Currently, evidence-based medicine is often focused on a single condition at a time. This framework proves challenging for older adults with multimorbidity. This issue is relevant to oral health of older adults, which can contribute to outcomes of other conditions and vice versa. Our results lend support to the idea that management of older adults should consider the person within the context of all of their conditions.

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