Assessment and management of oral health in nursing homes for older adults: Evaluation of structure, process and outcome

Abstract

The oral health of older adults living in nursing homes in Sweden is generally poor, affecting their overall health and well-being negatively. This thesis aimed to explore and evaluate how oral health is assessed and managed in nursing homes, focusing on the preventive oral health care process using the ROAG-J (Revised Oral Assessment Guide – Jönköping) within the national quality register Senior Alert. The goal was to identify strengths and weaknesses in current practice to inform future improvements. Studies I and II were register-based and utilised Senior Alert data from 2011 to 2016, covering about 100,000 residents. The data included oral health assessment (ROAG-J), preventive actions and variables from other Senior Alert risk assessments. Study I found that approximately half of the residents in Swedish nursing homes had received at least one oral health assessment in 2016, with those with the greatest care dependency exhibiting the poorest oral health. Oral health was generally assessed as good using the ROAG-J, possibly indicating underreporting by nursing staff. Study II showed that approximately 60% of the residents that were assessed as having oral health problems also had received at least one preventive action, but overall, no clear improvements in oral health status were observed longitudinally. Study III was qualitative, exploring healthcare workers’ experiences of using the ROAG-J as well as planning and performing preventive oral care. Six focus groups with registered nurses and nurse assistants in nursing homes were conducted and analysed using reflexive thematic analysis. Results indicated that Senior Alert’s structured approach increased awareness and the prioritisation of oral health among staff. Challenges included resident resistance to oral care, the complexity of providing oral care to older adults with natural teeth and organisational issues such as unclear routines, insufficient training and unclear responsibilities. Study IV was a web- based survey including 464 respondents in leadership roles (managers, coordinators and registered nurses). Their views on oral health needs, routines, barriers and facilitators to good oral care were examined. Results showed widespread use and positive perceptions of the ROAG- J and Senior Alert. However, many residents were perceived to have substantial oral care needs, while staff often lacked sufficient training and materials for using the ROAG-J. Difficulties were reported especially when assisting with oral care in cases of non-cooperation among persons with dementia. In conclusion, oral care in nursing homes is complex and challenging, particularly among residents with cognitive impairment and care-resistant behaviour. A structured approach using the ROAG-J within Senior Alert can help increase the prioritisation and awareness of oral health and oral care; however, limited resources, insufficient training, unclear routines and a lack of defined responsibilities hinder both assessments and daily oral care. Future improvements require increased and continuous training, clearer role definitions, active leadership and enhanced collaboration with dental care services. Further research should focus on the development of educational interventions, the reliability of ROAG-J assessments, older adults’ experiences and preferences of oral care and interprofessional approaches to promote oral health.