Special considerations are warranted for patients of advanced years, especially those who are medically compromised. Learn the necessary precautions to ensure they remain safe in your practice.
Dental practices welcome patients of all ages, but special considerations are warranted for patients of advanced years. Older adult patients — especially those who are medically compromised or have special needs — require extra precautions to ensure they remain safe while receiving the care they need to maintain their oral health.
According to The Dentists Insurance Company's Risk Managagement Advice Line analysts, thoroughly reviewing a patient’s health history is one of the most important steps a dental office can take to protect their patients, especially older adult patients who may have a higher potential for being medically compromised and a higher likelihood of taking multiple medications. Some elderly patients may not understand the connection between their medical and oral health and may neglect to accurately complete their health history forms. It can be helpful to provide materials such as forms, brochures and appointment reminders in large print.
A follow-up conversation to confirm medications, health status and any recent hospital visits or illnesses can avoid potential problems. Consulting with the patient’s physician or a family member, with the patient’s consent, may also become necessary in certain situations.
A Case Study
In a case reported to TDIC’s Risk Management Advice Line, a 95-year-old patient came in with a loose bridge. The dentist discovered that the bridge abutments were decayed. He recommended extracting the two abutment teeth. The patient’s health history was unremarkable and did not indicate that she was taking any medications. The dentist proceeded with the extractions and the procedure was uneventful.
A few days later, the patient contacted the office and stated she had an infection in the treated area. The scheduling coordinator offered her a same-day appointment to have the extraction sites assessed by the dentist. After conducting an exam, the dentist debrided the extraction sites and prescribed antibiotics and pain medications.
A week later, the patient’s daughter contacted the office inquiring about her mother’s treatment and to report that her mother now had facial swelling in addition to ongoing pain. She then emailed to the office a picture of the area showing the pronounced facial swelling. The dentist expressed confusion and relayed to the daughter that the patient appeared to be in good health and there were no indications of any health concerns when she presented for the dental treatment. He advised the daughter that there was no mention of any medications on her mother’s health history form, so he was surprised that the patient’s infection had not resolved. The daughter expressed that this information was not accurate and that, in fact, her mother was actually taking medications for several conditions.
The dentist advised the daughter that, given the patient’s condition, she should take her mother to the emergency room immediately.
The dentist later learned that an incision and drainage were performed in the emergency room to treat the infection. The patient was given anti-inflammatories and antibiotics. In the end, she recovered well.
The TDIC Risk Management analyst advised the dentist to follow up with the patient to discuss his concerns about the discrepancies between the information provided by the patient on her health history form and the information provided by her daughter. The analyst also advised the dentist to obtain the patient’s consent to consult with her physician to determine what considerations needed to be made in providing appropriate future care. The analyst also reminded the dentist of the importance of obtaining the patient’s consent before speaking with her daughter and to be sure to document these conversations in the patient’s chart.
Health History
If the health history of a patient of advanced age does not contain any health concerns or medications, consider this a red flag. Digging deeper and asking additional questions or conducting further follow-up can go a long way in protecting patients’ health. Follow up on information that seems incomplete, such as an indication of high blood pressure, but no medications are listed. Many patients, especially those who are elderly, may not remember certain medications or illnesses they have had until they are questioned. Asking open-ended questions, such as, “How are you feeling today?” may elicit this information.
It is essential that dental offices establish a system for collecting a current medical history from all patients, but be particularly careful about reviewing and updating the health history of elderly patients at every visit. The form should be signed and dated by both the patient (or their appointed caregiver) and dentist to serve as evidence that the information is current and was discussed prior to treatment. TDIC offers policyholders a downloadable sample health history form.
If the dentist believes there could be an undisclosed underlying health condition or information that the patient is unaware of or seems unclear about, they should send a Consultation Request for Dental Treatment form to the patient’s physician, follow the physician’s recommendations and keep the physician’s response in the patient’s file.
Office Accessibility
Practice owners should also ensure that their facilities and resources are accessible and safe for all. For older patients, this means ensuring walkways can accommodate wheelchairs and walkers and are free from obstacles that can present hazards.
In another case reported to TDIC, a 99-year-old patient was dropped off at the dental office by a staff member from the assisted living facility where the patient lived. The staff member asked if a member of the dental team would walk the patient back to the facility, as it was a just a few blocks away, and staff agreed. After the appointment, the patient sat in her walker as a member of the dental team pushed her home. As the staff member was pushing the patient in her walker, they encountered a crack in the sidewalk. Both the patient and the staff member fell, with the employee landing on the patient. The paramedics were called and the patient and employee were both transported to the hospital. The patient sustained a broken femur and the staff member sustained bruising and complained of soreness.
Allowing a staff member to transport a patient opens the practice up to possible liability claims on behalf of both the patient and the employee. In this case, the employee filed a workers’ compensation claim due to her injuries. Practice owners are reminded to establish expectations with patients and their caregivers ahead of time and those expectations should be reflected in documented office policies. In the case of the walker incident, patient transportation was the responsibility of the care home, not the dental practice.
Mandated Reporting
According to the National Council on Aging, 1 in 10 people over the age of 60 are victims of elder abuse. As mandated reporters, dentists in some states are required to report suspected abuse such as physical abuse, emotional abuse, neglect or the inability of the adult to care for himself or herself. Signs of elder abuse may include bruises or burns, bed sores or scars, rapid weight loss, confusion, agitation and a disheveled appearance.
In some jurisdictions, dentists can be held liable if they fail to report suspected abuse. Failing to report abuse can endanger the patient and the practice. Dentists risk facing not only a fine or misdemeanor, but possibly a professional misconduct charge, license revocation and, in some cases, civil liability.
It is essential for dentists to know what their legal obligations are with regards to elder abuse. If in doubt, they should contact their local dental association or licensing agency. If abuse is suspected, dental staff should contact adult protective services in their city or county.
Treatment Decisions and Emergency Contacts
For independent patients, determining who is responsible for treatment and financial decisions is a nonissue. But for those who may depend on a caregiver or family member, office staff should ask whether the patient has given power of attorney to another individual. If not, dentists should always obtain consent from the patient prior to discussing treatment with a third party, including the patient’s family members.
Whether an elderly patient is independent or relies on a caregiver, it is a matter of safety to be certain that emergency contacts are accurately listed in the patient's record.
Older adults are valued patients at any dental practice and ensuring their safety and health requires particular care and precaution. Clear communication, thorough documentation, heightened observation and specific protocols can help mitigate any potential liability risks while keeping older adult patients safe.
When you have questions about patient care, risk management, or other difficult situations in your dental practice, contact TDIC’s Risk Management Advice Line.
TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 1.877.269.8844.