Oral Health Group
Feature

Oral Health and Dementia: Obstacles, Assessments, and Management of Patients with Dementia


June 1, 2014
by Tania P. Pynn, BScN, RN, MHS, Joy E. Kolic BScN, RN

INTRODUCTION
Good oral health for anyone is important for general health, well-being and quality of life, as it offers significant benefits to self-esteem, dignity, social integration, and general nutrition. Conversely, poor oral health can lead to pain, tooth loss, ill-fitting dentures, and can negatively impact self-esteem, and the ability to eat, laugh, or smile. Oral disease can have an unfavorable effect on a person’s quality of life and have a significant impact on the functional, social and psychological well-being of older adults.1-4

FIGURE 1A. Ill-fitting dentures – Patient had not had them relined in 20 years.

FIGURE 1B. Large multi-lobulated epuli developed as a result of poor fit of denture.

FIGURE 2. Implants in mandible – implant in #33 area failed after 3 years due to peri implantitis.

FIGURE 3. Appearance of patient who was not able to wear dentures after significant weight loss.

The impact of proper and improper oral health is no different for those who have dementia, in fact, studies have shown that the rate of poor oral health is greater in individuals with cognitive impairment.2,5-7 Dementia rates have been on the rise, in part due to advancements in science and medicine, and as such dementia should be considered a major influence on patient’s oral health.1,8 Alzheimer’s disease (AD) is the most common of elderly dementias, accounting for approximately 67 percent of all dementias.5,6,9,10 The disease progresses and increases in severity resulting in impairment of cognitive skills, memory loss, language problems, a gradual disorientation in time and space, difficulties in performing normal daily activities and inabilities to learn new things which may affect quality of life.6,8,11 Patients who are experiencing a cognitive decline face additional problems when it comes to maintaining positive oral health and adequate hygiene practices. Not only do patients with dementia have less remaining natural teeth, they also may present with a higher prevalence and incidence of caries and more untreated lesions.5,11-13

Depending on the stage and severity of the dementia; oral care can become difficult to properly perform both independently or with assistance from others. Many studies have correlated that the more cognitively intact a patient is, the better their oral health will be based on their oral examinations.2,13,14 On the other hand, studies have shown that older adults with dementia have a poor clinical oral health status, including great tooth decay and plaque, missing teeth, and a higher rate of periodontal disease.2,14

The purpose of this article is to review the issues associated with oral health and persons with dementia, as well as giving insight and direction into maintaining oral health through the stages of the disease.

CASE STUDY
In August 2007, Mrs. Brown, a relatively healthy 75-year-old female, was visiting family in Thunder Bay, Ontario. Mrs. Brown had been independent and able to carry out all of her own activities of daily living. Her husband was available for minimal support if required. During her visit, a sudden and unprovoked fall left this woman lying face down at the bottom of a flight of stairs. The fall triggered endless examinations by specialists and general practitioners only to reach limited and inconclusive answers or solutions. The tumultuous journey of cognitive decline began.

Six years later, in advanced stages of her dementia, Mrs. Brown had quickly deteriorated cognitively, functionally, and physically. As well, she was diagnosed with adult onset diabetes and control of her blood sugars was becoming a critical issue in her care. Mrs. Brown was on numerous medications including Calcium, Citalopram, Euro-Fer, Forsavance, Galantamine, Januvia, Metformin, Pantoprazole, Aricept, Ibuprofen, Haldol, and Colace. Occasionally, Mrs. Brown would also receive insulin injections to help regulate her uncontrolled blood sugar levels. Decisions for care were falling on the shoulders of her son, who lived at home, and her husband. She became completely dependent on her family, as well as additional support from home care agencies for her activities of daily living. Mrs. Brown’s husband did not want her going into a long term care facility nor into palliative care or respite accommodations, so she continued to remain at home.

Mrs. Brown was losing weight rapidly, at the height of 5’1″; she had gone from 155 lbs to 120 lbs in less than three months. Mrs. Brown had developed dysphagia and was constantly coughing and choking on her food as she ate. A threat of aspiration was evident. She began to lose interest in eating. She forgot how to hold her utensils and what to do with the utensils when they were put in front of her. Family members began to try many techniques to help maintain an adequate level of nourishment and she became upset when the family members’ tried to ‘force’ her to eat and would adamantly refuse oral intake. They offered finger foods so utensils were no longer required and offered nutrient rich shakes to increase her caloric value. Small and frequent meals were offered and eventually syringe feeding was a last resort to try to encourage any intake at all.

Mrs. Brown would become severely dehydrated and almost comatose to the point where she was frequently being admitted through the emergency department for rehydration and then sent back home. Mrs. Brown’s revolving door care in her local Southern Ontario hospital was minimal and inconsistent.

Irregular oral care by hospital staff contributed to Mrs. Brown’s sores in her mouth, cracked lips, and coated tongue. Mrs. Brown had been edentulous since the age of 36 and had full upper and lower plates. She had ill fitting dentures which were replaced by two dental implants (Fig. 1A and B) in the jaw over 10 years ago (Fig. 2); however, one implant had failed over the years and with the frail bones of Mrs. Brown and the fear of breaking her jaw, it was decided by her oral surgeon not to continue with a new implant. With her deteriorating physical and cognitive state, Mrs. Brown was no longer able to visit her dentist; therefore a dental examination had not been done in over three years. Her dentures had become loose and uncomfortable. She experienced severe oral mucosal dehydration, and ulcers developed in her mouth and on her lips which caused Mrs. Brown a great deal of discomfort but she was unable to fully explain the pain due to aphasia. She stopped wearing her dentures which further impacted her ability to receive adequate nutrition (Fig. 3).

Her weight again plummeted from 120 lbs to less than 100 lbs. In December 2013, Mrs. Brown was readmitted to the hospital, again in a near comatose state; she began intravenous rehydration
but no oral intake was attempted. A discussion was had with the family and a Do Not Resuscitate (DNR) order was placed on Mrs. Brown’s chart. Intravenous was stopped and 12 hours later Mrs. Brown succumbed to her illness.

DISCUSSION
As the aging population undergoes an increase in frailty, the management of oral healthcare becomes more difficult and poses many challenges to the care providers; therefore treatment possibilities will depend on various modifying factors in each patient.15-17 Poor dental care in patients with dementia has been well documented and studies have identified a strong connection between oral health and dementia.2,5,6,10,18 Although oral diseases are inevitable in the aging population, it does not have to have a negative effect on the person’s quality of life.15 To improve the quality of life in persons with AD, adequate oral health is crucial and can be achieved by maintaining natural teeth, and having proper fitting prostheses. These tasks can become difficult because of the decline in cognition and functional performance.6,19 The patient may forget to remove their prostheses, resulting in increased food debris and dental biofilm on their teeth or dentures. The patient’s caregiver may not have the skill, time, or knowledge necessary to perform proper oral care when the patient is unable to do these tasks themselves.6,18

Management and treatment of a patient with dementia can be a challenge, not only by their caregiver, but also by their health care providers. In the dental field, the challenges are no different when planning and carrying out a treatment regime for a patient with dementia. Dental professionals provide oral healthcare to many vulnerable elderly patients which make up a large part of their practice. In an American study of dentists, they identified that elderly patients make up approximately ten percent of the typical patient load for 92.6 percent of dentists in private practice.8,20 The Canadian Dental Association identified that approximately 95 percent of people 65 years and older still live in the community setting with five percent of this population being completely homebound, 17 percent have some kind of mobility issue and 70 percent can still travel to see their dentist.15,21

Goals of Oral Health in Patients with Dementia
Ideal oral health is imperative for the overall well-being of patients with dementia and many studies agree that the focus of dental interventions in the dementia patient should be on prevention of dental disease.1,8,15,17 Because dementia is a progressive condition, it is also critical to improve the oral health of patients with dementia early on in the disease process.15-17 Potential benefits of optimal oral health in a patient with dementia include: reduced tooth loss; early detection of oral cancer; less oral pain; and less intraoral infections. Improvements in nutrition, overall health, appearance, and socialization have also been observed.8

Assessment of Patients with Dementia
With the progressive nature of dementia, it will become foreseeable that verbal communication between the patient and their healthcare provider will not be the best form of identifying health issues. The patient may not be able to express how they feel, if they have pain, and what may be the root cause of their pain. They will need to rely on those around them to provide a history and interpret changes in behaviour so that adequate and proper dental and medical interventions can be sought.1,22 Behavioural changes can be indicators to the healthcare provider that the patient may be experiencing dental problems. These behavioural changes can include: disturbed sleep, refusal to eat; leaving dentures out when previously they had worn them; refusal to participate in their daily activities; aggressive behaviour; increased restlessness, moaning or shouting; and/or pulling at the face or mouth.1,8

A thorough assessment of a patient who suffers from dementia is essential to provide interventions that are effective and safe for the patient. Developing a therapeutic relationship and rapport with the patient and family members needs to be established and together a plan of care should be discussed. Assessment of the patients’ oral status, physical impairments, medical history (including all medications that they are presently using), degree of cognitive impairment which includes level of co-operation and mental state, are all necessary information for a historical assessment. Accurate information may not always be available from the patient directly so it is important to discuss medical issues with their other health care providers. If the patient is considered incapable of making their own medical decisions, the power of attorney for their medical care should be present at all planning and treatment appointments.8 A comprehensive head and neck examination, including a cranial nerve examination; comprehensive soft and hard tissue intraoral examination; X-ray examination; prosthetic appliance evaluation, if relevant; and other diagnostic tests, as required, should also be part of the oral health assessment.8

Details, which are of particular importance, include the presence of drug-induced xerostomia, involuntary facial movements (such as tardive dyskinesia and bruxism), and change in caries rate or periodontal status. These factors have a direct effect on what dental procedures can and should be performed. For example, xerostomia may promote a higher caries rate and result in rapid breakdown of natural teeth, and failure of dental restorations. Bruxism may result in the fracture of natural teeth.8,15

Cognitive assessments for patients with dementia are an important part of the overall health assessment. One of the standard tests used by specialists and healthcare providers is the Mini Mental Status Examination (MMSE), created by Dr. Marshall Folstein in the 1970s, which is a widely used method for assessing cognition.8,23 The MMSE is a short and quick assessment of a patient’s cognitive status and has been successfully used in the medical and dental field to help determine the level of mental ability in patients with dementia. The dentist may be able to get the patient’s most recent MMSE score when discussing the patient’s care plan with the physician and not necessarily have to repeat the MMSE. If no recent cognitive assessment is available, the dentist should administer the MMSE. The MMSE should be repeated at any time when there has been a noticeable change in the patients’ cognition.

Dementia, Decision Making, Power of Attorney, and Medical Team Members
The health care provider may not only face the issues of having to treat potential neglect in oral care in patients with advancing stages of dementia, but they may also be exposed to ethical and legal issues. In the early stages of dementia, decision making for one’s own care is still possible and encouraged, but as the condition progresses, the ability to make proper decisions regarding risk versus benefit becomes limited and challenging.1,8,24

It becomes a great problem for the health care provider when the patient is unable to comprehend the nature of their dental disease and the complexity of the proposed treatments. In such cases, ensuring that the person accompanying the patient is their power of attorney or has been identified as a substitute decision maker is essential to proceed any further in the plan of care. It is essential that the dental professional(s) be aware of the individual who has been given the responsibility legally for consent and treatment. No care should be initiated without the consent from the designate.1,8,24 Discussions with other healthcare providers involved in the patient’s car
e may also be necessary prior to initiating any treatments. Details on the medical history, cognition, comorbidities, medications, prognosis and progression of the dementia are all key points to consider prior to developing a treatment plan.8

Managing Dental Treatment
The progression and stage of the dementia affects how one will cope with dental treatments and interventions. People with dementia are coined as a heterogeneous group in their disability, as well as their clinical course and treatment success, therefore, interventions require preparation and organization with the multidisciplinary team to develop a creative individualized plan to avoid many future difficulties in care.1,15,22 What may work for some patients with dementia, may not for others, and what may work today for one person may no longer be effective next week or next month for the same person.1,22 Treatment plans may need to be shorter and evolve and change over time as the treatment in the dementia patient progresses and their disease state also changes.15,16

Some patients may find a visit to a dental professional very stressful, while others will not be affected at all by their regular visits. People who have had regular dental treatments throughout their lives and who have a rapport with their dental professional may be able to draw on old memories to help prepare them for what to expect during dental treatments. For other patients with dementia, the dental setting and unfamiliar faces of the dental team may increase agitation and confusion which can make treatment difficult or impossible.1,22,25

Behavior management can assist the healthcare provider and help relax and settle the patient; interventions such as ensuring that the patient is accompanied by someone familiar who stays during the treatment and offers reassurance will be of great benefit for the patient. Other behavior management techniques that have shown to be effective is the use of a calm voice, minimizing distractions, avoiding force for the patient to comply, and assessing the usefulness of psychotropic medications such as Ativan or Xanax to provide mild sedation.1,8,22

Patient Management
Dementia is a disease of progression and is categorized in three different stages, those being early, middle (moderate) and later (severe) stages of dementia. When designing a plan of care for a patient with dementia, it is important to understand the stage of the disease they are in, as well as their overall health and prognosis.8,26

Early Stages of Dementia
In the early stages of dementia, most types of dental interventions are still possible and the patients may, and should be encouraged to contribute in developing their treatment plan. The patient’s level of cognition and memory are still relatively intact and compliance is appropriate.8 If utilizing the MMSE score as a measurement of dementia, a patient in the early stages would have a score between 21-24 out of a possible 30 points.

The treatment plan for a patient in early stages of dementia should be based on the premise that the patient will eventually be unable to look after their own teeth. Natural teeth, especially key teeth, should be identified and restored. Advanced restorative treatment may be an option if someone else is eventually prepared to carry out regular brushing for the person with dementia when they reach the stage where they can no longer do the task independently. Prevention of further periodontitis or decay is very important at this stage.

Middle Stages of Dementia
In the middle stages of dementia, there is a noticeable loss of cognitive abilities which results in the diminished ability to perform activities themselves and they become more dependent on their caregiver. The MMSE score for patients in moderate stages of dementia rests between 10-20 out of a possible 30 points.8

The focus of dental treatment at this stage is more likely to change from restoration to prevention of further dental disease with the elimination of pain or infection, while maintaining a good quality of life.8,12 During middle stages of dementia, the patient may no longer be able to feel comfortable with dental treatment, and in turn become agitated and irritable. The discussion of utilizing sedation or general anaesthesia for their dental interventions is necessary and may be the only option for some patients. The decision will be based on the patient’s ability to sit through treatment, the needs of treatment, general health and social support. At this stage, the power of attorney for medical care should be identified and present during treatment planning and interventions.

Later Stages of Dementia
In the later stages of dementia, the patient is in the terminal phase of their disease and cognitive abilities rapidly deteriorate. The MMSE for patients during the terminal stage is less than nine out of a possible score of 30 points.8 The caregiver is now completely responsible for the patient’s well-being, including all daily oral care and compliance with regularly scheduled dental appointments. At this stage, the patient may have experienced a decline in their physical health, which brings forth the issue around transporting the patient to and from appointments, often leading to missed appointments.5,10,11 Treatment at this stage should focus on prevention of dental disease, pain and infection; maintain oral comfort and the provision of any emergency treatment.18,27 In order to be effective in any invasive dental treatment, the use of sedation or general anesthesia will most likely be required.

CONCLUSION
Patients suffering with dementia present the healthcare provider with many issues and barriers which are specific to cognitive decline and progression. Education and awareness programs related to dealing with patients with dementia will not only benefit any healthcare provider, but also the caregivers. Dental education programs that encompass specific training in oral care of the older patient would also benefit the dental provider and help to ease the trepidation associated with dealing with patients with dementia.8,10

Early intervention and treatment is important before the dementia progresses into the moderate to later stages. A team approach is vital to ensure proper treatment plans are carried out based on the desires, needs, and safety of the patients. A positive rapport and developing a therapeutic alliance with patients, families and caregivers is essential when establishing long term oral health outcomes and goals. It is also necessary to involve and collaborate with other health care professionals to ensure the best outcome for the patient. OH


Tania Pynn is a lecturer at Lakehead University within the Faculty of Health and Behavioural Sciences. Her focus of teaching is on the aging population. She can be reached at tpynn21@gmail.com.

Joy Kolic is a Registered Nurse with the Senior’s Mental Health Program at St. Joseph’s Care Group. She is presently working on completing her Masters in Nursing and Nurse Practitioner designation with a focus on the aging population.

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