Management of Geriatric Patients in Clinical Settings Comorbid with Psychiatric Disorders: A KAP Study

Background and Objectives: Comorbidity with psychiatric disorders raises health risks and has an impact on the condition, treatment and prognosis of elderly patients, necessitating holistic dental care for this age group. Thus, present study was conducted to assess knowledge, attitude, practice and awareness of psychiatric disorders and their relation to making for dentist patient relationship whereas remaining participants believed in dentist-based decision making which was found to be statistically significant (<0.001). Conclusion: More evidence and research in this field is increasingly important and required to improve evidence-based clinical practice and therapy for geriatric patients.


INTRODUCTION
A robust growth in the number of elderly people in the general population in the recent years is termed as "greying of the world" [1]. Globally, the number of people aged 60 years and older in the population are increasing. In 2019, the number of people aged 60 years and older were 1 billion [2]. It has been expected that the elderly population of India by 2050 to be 22.0% of world's total population [3]. This transformation may be due to changing trends in lifestyle and social life but on the other hand has led to rise in systemic diseases as well as psychiatric disorders.
Psychiatric disorders are a leading cause of deteriorating oral health problems worldwide which in turn is more worsened with systemic diseases and acts as major contributor to the overall burden of disease [4]. The incidence of mental health problems is expected to increase among adults in general as well as in older population in particular [5]. Even though psychiatric disorders are common in the elderly population, they remain undiagnosed in about 50% cases [6]. WHO estimated the incidence of global depressive disorder among older adults to be 10 -20% [7]. Among all mentally ill individuals, 40% were diagnosed to have a depressive disorder [8].
Not only overall general health is the matter of concern but condition and quality of health and health related issues which makes an individual to speak, eat and socialise without any discomfort, embarrassment and active disease contributing to general well-being is the major reflection of oral health with interplay of health dimensions involving mental health as one of the essential one [9]. In health care delivery care systems, oral health education and promotion along with conceptual health is drastically turning the table on upper and positive side of health spectrum but holistic approach is still lacking behind [10,11]. So, managing geriatric patients with comorbid psychiatric disorders may be a challenge for dental professionals to provide treatment as well as provide guidance for the same.
To encourage and raise holistic approach and also to improve doctor-patient relationship as a part of health care approach, it is a need to first assess the knowledge, attitude and practice about the same. However, till date there is paucity of literature regarding assessment of knowledge, attitude and practice among dental students and professionals for managing geriatric patients comorbid with psychiatric disorders and it will be one of the first of its kind to be conducted in Uttar Pradesh with the aim to assess knowledge, attitude, practice and awareness of psychiatric disorders and their relation to oral health among dental undergraduates, interns, postgraduate students and faculties treating geriatric patients.

Study Settings
A cross-sectional study was conducted to assess the knowledge, attitude and practice amongst students and fraternities for treating geriatric patients with psychiatric disorders.
The study was conducted in the months of January to March 2022.

Source of Data
A total sample of 300 dental students and academicians with clinical practice were included in the study from the Ghaziabad institute. A total of 57 academicians and 243 students viz, BDS 3 rd year, BDS 4 th year, Interns and postgraduates from various specialities.

Sample Size Determination
All the dental students and faculties present on the day of the study were included as the part of the study.

Inclusion criteria
1. Subjects who were present on the day of questionnaire distribution. 2. Subjects who gave informed consent.

Exclusion criteria
Subjects who have not been exposed to the clinical examination and treatment of patients.

Data Collection
The data was collected over a period of 3 months from January 2022 to March 2022.

Questionnaire
The questionnaire was divided into four sections. The content validation for questions was obtained from a medical expert and four dental experts. The questionnaire was provided to them through electronic mail and the corrections were made according to the responses obtained via electronic mails individually. Face validation was obtained from 5 dental students by providing them the questions and later the corrections in the questions were made accordingly.
In the questionnaire SECTION A-Assessed the demographic details of the participants (age, designation, gender, college). SECTION B-Comprised of 6 questions to assess the knowledge out of which 4 questions were close ended and 2 were based on Likert scale. SECTION C-Comprised of 5 questions to assess the attitude all of which were based on Likert scale. SECTION D-Comprised of 5 questions to assess the practice of which all were close ended. The internal reliability of the questionnaire was determined with Cronbach's alpha coefficient (.003).

Statistical Analysis
Data was analysed using SSPS 20.0 software package. Descriptive statistics such as mean, standard deviation and percentage were used. Association was evaluated using Chi-square cross tab. Any p value less than 0.05 was considered significant.

Demographic Profile
A survey related to knowledge, attitude and practice amongst dental students and practitioner for managing patients with perceived mental health care needs was conducted with the study participants bearing maximum age of 60 and minimum age of 20 (mean age 27.06 years). The gender distribution of the study population was 148 participants male and 152 females. Majority of the study population were dental students (BDS Interns) ( Table 1).

General Findings
Prevalence of knowledge for systemic disorders like diabetes mellitus comorbid with psychiatric disorders amongst geriatric patients was significantly higher amongst the study participants (75.3%). Similarly, 57.7% responded that gender predilection plays an important role in psychiatric disorders and 77.0% of the participants agreed to the fact that history taking of psychiatric illness should be a part of medical history taking. 34.3% agreed that disorders like

Oral Findings
For the oral findings it was observed that 50.3%were aware of the dental disorders like TMJ dysfunction and bruxism associated with axis I psychiatric disorders. It was also seen that majority of study population (64.3%). acknowledged that edentulism in geriatric patients can contribute to sleep disorders. Also, majority of dental professionals (53.3%). agreed that mouth burning syndrome is associated with psychiatric disorders (Table 2). Year believed in dentist-based relationship followed by 64.9% practitioners and 56.0% Interns believed in shared decision-making (p<0.001).

DISCUSSION
Researchers have determined that technical errors, systemic illness, improper maintenance of oral hygiene or financial instability contributes to dissatisfactory dentures. However, it is unfortunate that the focus is mainly on the treatment procedures from the first step till the last step rather than on managing them [1]. Moreover, geriatric population have a higher incidence of psychiatric disorders as compared to other age group population due to drastic changes in lifestyle dynamics and societal relations in addition to health [2]. Year students, postgraduates and interns. Moreover, 72.5% of Interns agreed that they assess a patient's mental health before beginning dental therapy. Differences in answers could be related to the fact that BDS students are more dedicated to taking case histories of every patient who comes to them as opposed to dental faculties who are juggling academics and patients. There is a cocurriculum in the academics for BDS students to take extended case histories of patients [12][13][14].
On evaluating the attitude of study subjects, it was revealed that irrespective of the academic year or designation, 53.8% BDS 3 rd Year students,36.2% BDS 4 th Year students, 36.3% Interns,55.0% postgraduates and 31.6% MDS faculties neither agreed nor disagreed to the question that psychosis is not found in geriatric patients these are all as a result of age-related process. The probable reason might be due to unawareness of the psychological related health of all age groups amongst which affects the daily life activities of such patients. Lastly, it was revealed that 70.8% BDS 3 rd Year students and 77.5% postgraduates believed that dentist-based relationship is best for treating geriatric patients followed by 64.9% MDS Faculties and 56.0% interns believe shared -decision making to be the best. This finding attributes to the reason that BDS students and postgraduates are supervised by mentors and they work with certain principles whereas practitioners can work according to their own beliefs and treatment preferences.

CONCLUSION
The dearth of literature on the subject as well as general dentist's and student's ignorance on the subject of impact of psychiatric disorders on oral health is perplexing and to be thus implicated on a large scale. As a result, more evidence and research in this field is increasingly important and required to improve evidence-based clinical practise and therapy for geriatric patients.

RECOMMENDATIONS
1. There should be regular webinars on behavioural lifestyle and quality of life affecting oral health. 2. Dental professionals should share a healthy and shared decision-making relationship with patients. 3. Dental professionals should be trained in the recognition and management of both physical and mental disorders needed to cater health needs of this ever-increasing part of the population.

CONSENT AND ETHICAL APPROVAL
The nature and the purpose of the study was elucidated to the institutional review board and the ethical clearance was acquired. Informed consent was obtained from all the study participants.