Older people’s experiences of oral health and assisted daily oral care in short-term facilities

Good oral health is important for older people’s well-being and quality of life, and is essential for healthy ageing [1]. However, with increasing age, declining health, and dependence on care, older people are more likely to develop poor oral health [2].

The number and proportion of older people is steadily increasing in most populations worldwide [3]. For example, the proportion of people 80 years and older, often referred to as the oldest old, is expected to increase by 50% in Sweden over the coming years [4]. Also, a growing number of older people in need of care are expected to increase as the population continues to age [5, 6]. The oldest old are often described as a frail and multi-morbid group [7]. For the individual, frailty increases vulnerability due to diminished strength, endurance, and physiological function [8].

Various forms of transitional care have been developed internationally, including intermediate care, geriatric rehabilitation units, home rehabilitation, and care planning units [9‐11]. In the Swedish context, one such support organization for older people are named short-term care (STC). It is optional for the municipalities to provide such care, and there are no national guidelines for STC for older people [12]. STC staff include nurse aides, licensed practical nurses, registered nurses, occupational therapists, physiotherapists, and managers [13]. Some units have a rehabilitation profile, while others provide care for a mix of purposes such as rehabilitation, waiting for special accommodation, respite care, and even end-of-life care. The term STC can be misleading, as length of stay might exceed several months [12]. Approximately 9000 older people per year are admitted to Swedish STC [14].

The STC milieu is characterized by transition. From a physical perspective, the STC might be one station on the person’s journey from hospital or from home to special accommodation for older people [9]. From an existential perspective, this might be experienced as a crisis caused by acute illness that impacts further life, as a result of deteriorating chronic illness, or as a step closer to the end of life [10, 11, 15]. Therefore, for many it is an uncertain and worrying period in their life, not knowing if they will be able to continue living at home or will have to move to special accommodation [12].

In Sweden, older people in need of extensive care from the municipality have the right to a free-of-charge oral health assessment on an annual basis, in their home or special accommodation. Oral health care education is also offered to nursing staff to support them in assisting older people with daily oral care. Those who are entitled to this assessment also receive necessary dental treatment on the same economic basis as medical treatment [16].

Oral health is an important aspect of older people’s health and well-being. In general, oral health in Europe has improved, which has led to an increased number of older people retaining their natural teeth throughout their life [17]. In Sweden, approximately 60% of people aged 80–89 years have 20 or more teeth [18]. However, good oral health is more common among healthy older people than among frail persons in need of care in special accommodation [19, 20]. Further, poor oral health may have a negative impact on quality of life, nutritional status, and general health status [21, 22]. Frail individuals have a higher risk of developing poor oral health due to limitations in the ability to perform self-care and difficulties in visiting dental health care [2]. The reduced capacity for self-care may be due to mental and physical disability and various chronic diseases [23]. Thus, oral hygiene with daily removal of dental plaque by tooth brushing is essential to reduce the risk of dental diseases [24, 25]. Assisted daily oral care, including brushing of teeth or cleaning of dentures are often inadequate in nursing homes [26‐28], although residents who are unable to perform activities of daily living should be given necessary assistance with daily oral care [29].

Most published studies about older people’s oral health have had a quantitative approach. For example, a Swedish study showed that 50% of people in STC were dependent on help with activities of daily living. However, only about 20% of them received assistance with oral care, even though clinical assessments made by registered dental hygienists showed that many more of them were in need of this [30]. An earlier Swedish study found impaired oral health status and a need for help with oral care among people who were dependent on help from others with activities such as bathing and dressing [31]. As the oldest old often suffer from multi-morbidity, frailty, and other health problems, the probability of needing assistance or care increases [32]. Therefore, older people who need support in their daily activities are also likely to need assistance with daily oral care [33].

There is insufficient knowledge about how older people view their oral health and oral care [34]. Qualitative studies exploring such experiences are scarce, and to our knowledge all such studies to date have involved participants living in ordinary homes or in special accommodation [35‐37]. One such study, which reported on the perspectives of residents in a Canadian nursing home, found that having clean teeth was important to the participants, but as frailty increased, the importance of the mouth and the teeth decreased [38]. A recent Swedish study exploring older nursing home residents’ experiences of receiving assistance with bodily care found that these residents wished to be independent and care for their own bodies for as long as possible, and that they did not want to be a burden to the nursing staff [39].

Since providing bodily care involves handling of body fluids such as urine, sweat and blood it might be perceived as distressing and breaching personal integrity. Bodily care inevitably involves the nursing staff touching the bodies of older people and often performing a task that the older person would prefer to perform on their own and in private, such as brushing teeth and washing the genital [40]. There are several common barriers which hinder nursing staff in assisting older people with oral care. The older person may not want to accept the assistance that is offered, and nursing staff may lack knowledge, education, or training in providing oral care [41]. In addition, nursing staff have expressed that being able to take care of one’s own oral care is strongly associated with personal integrity and self-esteem [42]. Nursing staff have also reported not wanting to nag residents who decline assistance with oral care [43]. Older people’s motivation and capacity to prevent oral disease may be lost as frailty increases [37], for example because they want to use their energy for things other than maintaining their oral health [44]. Another reason to decline assistance with daily oral care might be the perception that one’s oral health is satisfactory. Koistinen and colleagues (2019) found that 85% of the older people from 36 Swedish STC units were satisfied with their oral health, even though clinical assessment by registered dental hygienists showed that 77% of these individuals had oral problems such as coating and food debris [30].

The theory of selective optimization with compensation (SOC) was developed to model adaptive development in a framework of the psychology of ageing, and describes how older people use different strategies to fulfil life goals and manage age-related declines [45]. SOC proposes that older people can accept age-related losses, and adapt and cope with changed function, by focusing on gains and strengths rather than losses and by finding ways to compensate for other limitations [46]. The three processes — selection, optimization, and compensation — have been investigated in a number of studies, mainly with a quantitative approach [47, 48]. Carpentieri and colleagues (2017) provided valuable knowledge about how older people themselves talked about their SOC strategies. Those who were engaged and talked about their SOC strategies had high level of well-being despite low physical function. Low well-being despite higher physical function were found among those who were little engaged in SOC strategies [49].

In Sweden, as well as in many other countries, the proportion of older people who have remaining teeth is growing. Thus, the demands for staffs’ knowledge and skills about oral care have increased. In order to understand how older people experience their oral health and their need for support with daily oral care while staying in a short-term care unit, qualitative studies are needed. Such knowledge might provide a deeper understanding that can improve nursing staff’s assistance with oral care. The aim of this study was therefore to describe how older people in short-term care experience their oral health and daily oral care.

The median age of the participants was 86 years (74–95 years). The participants were old, frail, and dependent on help with activities of daily living. Their characteristics are described in Table 1.

The participants’ experiences of oral health and daily oral care can be expressed as one main category: Adapting to a changed oral condition while striving to retain independence. This main category was built up from three categories and nine subcategories (Table 2).

To our knowledge, this is the first study describing older people’s experiences of oral health and assisted daily oral care in a STC context. Older people admitted to STC are in transition, and may experience this as an uncertain period, not knowing if they will be able to return home or will have to move to special accommodation. This period of their lives could have a negative impact on their oral health, and so exploring their experiences of oral health and daily oral care is important.

We will discuss these older people’s experiences of oral health and daily oral care using the theory of SOC [45], and will also examine barriers to receiving assisted daily oral care.

The main category in our findings was Adapting to a changed oral condition while striving to retain independence. The participants’ strong desire to continue performing daily oral care by themselves could be the result of selecting an activity they can still perform and that gives them satisfaction. Moreover, continuing to work at maintaining a certain activity, such as daily tooth brushing, is an example of optimization as described in SOC [45]. Not wanting assistance with daily oral care can be interpreted as the participants’ choice to maintain some degree of independence despite needing compensation via assistance from staff to manage personal hygiene, dressing, and mobility. The participants were able to imagine having assistance with oral care if they were no longer capable of performing oral care themselves, which is another example of compensation.

Other studies conducted among older people found that selection of activities was focused on maintaining activities of daily living as independently as possible [52, 53]. Participants in the present study described how they had adapted to changes in oral health. Such descriptions may be related to their having experienced dental visits as not being of particular importance, or being considered as too expensive. Another obstacle may be lack of energy, forcing the participants to select between a visit to dental care and other, more valued, activities. Participants with dentures described having adapted to their dentures; they prioritized proper chewing, and compensated for their chewing difficulties by cutting their food into small pieces. Similar strategies were described in a study by Khabra and colleagues (2017) conducted among community dwelling older people who received rehabilitation and nursing assistance. The participants in that study described how they used SOC strategies, optimization, and compensation to adapt and manage their changing dental status. They had adapted to their dentures over time, and had modified their food choices and chewing accordingly [54].

One reason for the perceived satisfaction with oral condition despite deteriorated function might have been that the respondents were comparing their oral conditions with those of previous generations who often had dentures or were edentulous. Earlier research has found that older people may adapt to oral disorders, and that adaptation usually involves comparison with other disabilities such as chronic disorders and functional limitations [38, 55]. The participants in this study were old and frail, and may have had other medical, personal, and social challenges which could have made them experience their oral problems as less important than other health problems. This would be in line with the findings of Donnelly and colleagues, who studied the relationship between perceived oral health, body image, and social interactions among older people living in long-term care facilities [38]. Another study exploring frail older people’s experiences of health found that those who perceived their symptoms and disorders as manageable were more likely to experience safety and control, and hence to also experience good health [56].

Older people’s desire to stay independent for as long as possible and to take care of themselves has been described in previous studies [39, 57, 58]. Being independent and having the ability to perform activities of daily living contributes to a sense of control [58] and influences older people’s perceived health and well-being [57, 59]. Similarly to our findings, Niesten and colleagues (2012) found that older people wanted to be responsible for taking care of their own teeth. The researchers suggested that the participants’ sense of control could be related to experiences of autonomy and independence, which were important factors for their quality of life [59]. Being able to perform daily activities contributes to a sense of control and autonomy; the ability to manage on one’s own means being able to maintain dignity and not feel like a burden to others [58]. For many people, being in STC is a new situation, and a place where they expect to be for only a limited period. They might arrive from their own home, where they were used to performing daily tasks like tooth brushing themselves. Daily oral care may be one of the activities they feel that they can continue doing independently even if they are dependent on assistance with other daily activities. This is an example of how individuals select those activities that are most realistic in relation to their resources [46].

Barriers to accept necessary assistance could lie both with the older person and the nursing staff [6]. The participants in this study mainly expressed these barriers as wanting to manage daily oral care independently. This striving to maintain some degree of independence for as long as possible has also been found in previous studies [37, 39]. However, such striving may also be a barrier for the older person to accept assistance with daily oral care when needed. Another barrier to getting assistance was that the participants felt that the staff had many duties, and they did not want to nag or be a burden to the staff. Similar findings have also been described in recent studies [39, 60, 61]. One explanation for not wanting to burden the staff could be that when older people are used to managing their bodily care by themselves, without having to take another person’s availability into account, it can be difficult to acknowledge and accept the need for help [58].

Some participants were uncertain if the staff would know how to brush their teeth in the same way as they preferred and expressed a lack of confidence in the staff’s knowledge and skills to assist them with oral care. This lack of confidence could also be a barrier to accepting assistance from staff. Low prioritization of oral care due to staff’s lack of knowledge and time has previously been described from the perspective of the staff [26, 43]. Nursing staff’s lack of knowledge about providing oral care caused feelings of inadequacy and insecurity, and the staff expressed a need for continuous education in the field. They also considered it difficult to ask for permission to assist with oral care because the mouth was seen as private and intimate [43]. Although bodily care is the heart of nursing, nursing staff may not be comfortable in providing such care, including brushing older people’s teeth’s [40] which may reflect a lack of oral health education [41].

Participants in the present study described a feeling of stress and not being given enough time to complete their oral care when the staff were standing by the door, waiting while the participants performed oral care. Older peoples’ wishes to maintain independence in managing oral care need to be acknowledged but should be balanced by a judicious provision of oral care support. It is therefore important to identify older people’s individual oral health needs and wishes, and to ask about assistance with daily oral care in a person-centred way. For this reason, it is important to have a close collaboration between dental and nursing staff [27], and to provide education in oral health, including clinical assessment of oral care, for health care staff.

The participants in this study lacked regular dental care, and did not think it was worth the cost or effort to visit the dental clinic. This may be due to their declining overall health, and the presence of other major changes in their lives; for example, some of them were waiting for transfer to special accommodation. Thus, it is especially important to ensure that people in STC entitled to a free-of-charge oral health assessment and “reduced-cost dental care” [16] actually receive those services.

The participants in this study were generally satisfied with their oral health and wanted to manage their daily oral care independently for as long as possible. However, they were willing to consider assistance with daily oral care when they got to the point of not being able to perform this themselves. They described both a need for assistance and barriers to such support. Based on our findings, there is a need to increase nursing staff’s attention towards older peoples’ oral health and their ability to assist older people with daily oral care.

Clinical practice guidelines for oral health care of older people and their specific need should be present. To allow follow-up and feedback to health care staff, data on oral status, needs for assisted oral care and outcomes should be systematically collected and used to support development of care.

Health care staff in short term care settings should be provided with education and training in assessing and performing oral care. Person-centered care should be an intrinsic part of such education. In addition, continuous follow-up and feedback on oral care practice needs to be implemented, including the perspectives of older people.