Help elders avoid aspiration pneumonia: Grab a toothbrush
Aspiration pneumonia is a cyclical beast. When elders get aspiration pneumonia it weakens their whole body, impacts their general medical status, and ultimately increases their risk for additional aspiration and aspiration pneumonia. Pneumonia increases risk for hospitalization, decreased quality of life, increases healthcare costs, and increases risk of death.
But first, What is aspiration pneumonia?
Aspiration pneumonia is different from community acquired pneumonia. The goal of the pneumonia vaccine is to prevent community acquired pneumonia. The vaccine will not prevent aspiration pneumonia, because aspiration pneumonia has a different cause.
Aspiration pneumonia may develop when someone aspirates (or breathes in) foreign matter into the lungs. Foreign matter may include beverages, food, reflux of gastric contents or acid, and
saliva. When foreign matter gets into the lungs, bacteria may grow and develop into what we call aspiration pneumonia.
In a healthy adult the body has several protections in the swallow mechanism to prohibit foreign matter from entering the lungs. Dysphagia, or swallowing deficits, disrupts these protections increasing the risk of aspiration and aspiration pneumonia. In the healthy adult the immune system is robust and able to tolerate small amounts of aspiration; however, the aging adult often has a more complex medical status and a compromised immune system.
How does aggressive oral care help reduce risk of aspiration pneumonia?
Recent research has explored this topic. We have learned that improving oral care reduces the risk of elders developing aspiration pneumonia and reduces the risk elders will die from aspiration pneumonia. (1) So by providing oral care daily, we are providing elders with a reduced risk of respiratory distress via aspiration pneumonia and death.
Aggressive daily oral care routines in elders living in long term care settings were found to improve swallowing function by reducing latency time of swallow and increasing salivary secretions. (2) Reducing latency time of swallow means that the swallow reflex is less delayed. A delayed swallow may result in increased fatigue during meals and increased risk of food or liquid spilling back into the throat before the body has prepared to protect the airway. Increased salivary secretions impacts the “self cleaning” of the oral cavity by making it easier for people to swallow food particles that are breeding ground for bacteria. Both of these outcomes improve the ease and safety of eating.
Oral care was also found to be beneficial for elders with natural, false, or without teeth. (3) One of the misconceptions I find among elders and their caregivers is that if they have dentures or don’t have teeth they don’t need to follow an oral care routine. This is not the case. Dentures (partials, etc.) need to be cleaned according to their dentist’s recommendations. In addition, gums and tongue need to be cleaned with a soft bristled brush or tongue scraper tool. This is especially important in elders with dry mouth.
Who needs help with daily oral care routines?
Probably more people than you would think. Elders who live in institutionalized homes have poorer oral health than those who live at home independently. In a study of 1041 elders living in institutionalized homes in the UK, researchers found “261 found it hard to care for their mouth. Although 343 residents preferred assistance in cleaning their teeth and dentures, only 94 reported that the staff had helped them.”(4)
Occupational therapists (OTs) and speech-language pathologists (SLPs) are good resources in identifying who may need assistance with oral care routines. OTs can identify elders who need assistance due to mobility impairments and sequencing activities of daily living (ADLs). OTs are able to screen to determine which elders have rehabilitative potential and would benefit from therapy to improve their independence with oral care tasks. OTs may also be able to provide skilled therapy to some elders to recommend and train in the use of adaptive equipment.
SLPs can identify elders who may need assistance with oral care due to their oral motor function, dysphagia (swallowing problems), cognitive status, or other factors that place them at increased risk for aspiration pneumonia. SLPs can help train caregivers regarding the level of cuing an elder needs in order to provide adequate oral care with increased independence. SLPs may also provide specific recommendations for frequency of oral care and other recommendations to reduce an elder’s individual risk for aspiration pneumonia due to dysphagia or cognitive dysfunction.
What can we do to insure appropriate oral care is provided?
Brushing our own teeth may seem simple enough, though if you talk to most dentists you’ll find that many of us are even brushing our teeth wrong. Brushing someone’s teeth is a different story. Caregivers should be specifically trained in helping elders with oral care tasks or providing oral care. An inservice with a dentist for caregivers would be an excellent opportunity for improving the oral care elders receive.
When I ask elders where their toothbrush is, even those with relatively intact cognition often can’t tell me. I often can’t find their toothbrush, toothpaste, or mouthwash. Oral care tools should be placed in a dedicated spot together. Specific recommendations from OTs and SLPs could be written on a laminated card and placed with the oral care tools to recommend elders and caregivers of strategies.
Establish an oral care screening program. This is a great opportunity for nursing, OTs, and SLPs to partner together to improve the quality of life of the elders they serve. By improving oral care, we are decreasing the risk of hospitalizations, pneumonia, and death, while reducing healthcare costs and improving quality of life.
(1) van der Maarel-Wierink, C.D., Vanobbergen, J., Bronkhorst, E.M., Schols, J., and de Baat, C. (2012). Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology, 1-7.
(2) Marik, P.E., Kaplan, D. (2002). Aspiration Pneumonia and Dysphagia in the Elderly*. CHEST Publications, 328-336.
(3) Yoneyama, T. et al. (2002). Oral care reduces pneumonia in older patients in nursing homes. American Geriatrics Society, 50(3), 430-433.
(4) Simons, D., Kidd, E.A.M., and Beighton, D. (1999). Oral health of elderly occupants in residential homes. The Lancet, 353, p1761.