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Dental team role in dementia awareness
HANDS ON Dementia Awareness Dental team role in dementia awareness Background.—General practitioners of medicine are becoming a rare breed. As a result, patients do not have the close personal relationship with their doctors that used to be common. Family dentists, however, often retain a personal relationship with patients, knowing what they do for a living, whether they have children, and where they vacation, among other things. Often dentists treat the entire family, so they know even more. As a result, the general dentist may be in a position to notice subtle changes in a patient’s behavior, such as memory loss or character alterations, that might signal the development of dementia. The role of dental personnel in dementia awareness was evaluated. Dementia Basics.—With an aging population, it is likely that dementia will affect a great percentage of the population. However, society and governmental agencies do not fully understand the reality of the condition and how it complicates life for so many families. In addition, dementia tends to manifest differently in different individuals and progresses at an individualized rate. As many as one third of the people over age 65 years will die with dementia, but the condition is often not diagnosed or diagnosed only when it has progressed. Barriers to diagnosis include the stigma attached to dementia and the misperception that it is a natural part of aging. A timely diagnosis allows the patient to access treatments and support services while he or she can still participate actively in care decisions. People who are diagnosed early in the course of the disease are able to help plan for short- and long-term situations. Support and accurate information can help people feel more in control and able to participate in important decisions. Most people with dementia live for years with the condition, and much can be done to increase their quality of life during this period. Signs and Symptoms.—The dental team may be able to observe subtle changes in memory or behavior or an altered ability to communicate. Having regular open conversations with patients and families may provide the context for a discussion about memory concerns. The most common signs and symptoms of dementia are difficulty recalling recent events or forgetting recent discussions; difficulty recalling names of people or objects; problems judging distance and seeing
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objects in three dimensions; losing track of the day or date or becoming confused about their environment; and difficulty concentrating, planning, and organizing, along with anxiety about suggestions or options that are offered to the patient. Should any concerning signs and symptoms be noted, a sensitive, tactful approach should be taken to initiate a conversation about these memory or behavior changes. Sometimes this is accomplished with gentle probing questions; sometimes frank, objective questions are more effective. The approach will vary depending on the dentist’s personality and the relationship with the patient. In all discussions, confidentiality is maintained. Appropriately sharing information should be emphasized as a means for providing safe and effective care to the patient. In all cases the dentist should explain to the patient the circumstances under which information can be shared, the requirement that the patient consent to the sharing of any information, and the need for the dentist to justify any decision to share. Dentists should share with the patient any concerns and indicate that they wish to write to the patient’s general medical doctor to suggest a thorough checkup is needed. If the patient’s mental capacity is in doubt, advice or confirmation may be sought from family members or caregivers. Providing Dental Care to Patients with Dementia.— Oral health is likely to decline as a patient’s dementia progresses. Often oral hygiene deteriorates, periodontal disease increases, decay levels rise, and patients experience difficulty wearing dentures. As a result, eating may be painful, which can lead to behavioral changes for patients who can no longer communicate effectively about their discomfort. The diagnosis of dementia should be followed by the establishment of a long-term dental care plan designed to eliminate pain, control infection, and prevent the development of new disease. If the patient is in the early stages of dementia, he or she is more likely to be receptive to treatment and to still be able to participate in making health care decisions. Treatment planning includes the stage of illness and degree of cognitive impairment. Dentists should be included in multidisciplinary care planning for people with a diagnosis of neurogenic disorders so oral care can be planned for the total extent of the disease process. In
addition, the care planning should include the patient’s caregiver and family. These are the best sources for assessing cognitive impairment and for advising how well the patient is maintaining dental hygiene routines, physical challenges that have developed, and adaptations that may be of value.
The dental team must also be aware of the patient’s signs of dementia progression. These include difficulty expressing needs and wishes, inability to understand and explain dental symptoms such as pain, inability to contribute to the decision making process or to give informed consent, difficulty with dental interventions, and problems understanding why oral hygiene must be done and following through with it. General dental practices are usually able to care for patients in the early stages of dementia, providing good restorative and rehabilitative care. Restorations should require little maintenance, and advanced restorations should only be undertaken with the understanding that the patient’s caregiver may have to ultimately provide oral self-care. Preventive measures should be rigorous so that the individual and caregiver become accustomed to their performance. As the patient’s dementia reaches mid-level stages, maintenance and prevention are emphasized over restoration and rehabilitation. Cognitive impairment generally increases, although physical capabilities may remain relatively intact. Changes in behavior may occur that require that the dentist act in the patient’s best interests and choose the least restrictive treatment option. Adherence to the previously agreedupon treatment plan and good relationships with caregivers and family members will guide care. Specialist advice may be sought. Continuing care may require the use of sedation or general anesthesia during treatment. Once the patient reaches later stages of dementia, he or she may be unable to receive treatment outside of a normal environment. Local visiting nurse or aide services may be needed, or the patient may be cared for by nursing home personnel if he or she has transitioned there. The new dental team should be given all the information needed for an effective transition of care. Delivering oral care to older persons in nursing homes may be complicated by lack of adequate equipment and facilities, poor financial reimbursement, lack of training, and loss of time from private practice. The benefits of treatment must be weighed against the risks and difficulties associated with providing care in terms of cooperation, consent, medical status, and other considerations. Specific actions to be taken by nursing home or visiting nurse aides include the following:
Immediately perform appropriate preventive measures to minimize the presence of dental disease Provide dental interventions in the early stages of oral problems
Ensure dentures are marked with the patient’s name, clean them professionally on a regular basis, and have them replaced as needed Review the patient’s needs on a regular basis to avoid pain and minimize the need for further interventions Minimize the caregiver’s and patient’s fear, stress, and embarrassment by using an ‘‘open-door’’ approach and providing for backup and support
Not all patients with dementia suffer a decline in their dental care needs. Often past dental behavior and experiences will shape the patient’s ability to comply with oral hygiene behaviors. Having familiar surroundings, routines, and people may be reassuring and help in eliciting the patient’s cooperation. Dementia Friendly Behaviors.—When treating people with dementia, it is important to remember that patients have good and bad days, so dental treatment should be done on good days whenever possible. Because short attention spans are common, dental appointments should be limited to the patient’s ability to cope. Appointment reminders are often appreciated. Simple improvements in the practice environment may increase its accessibility for older patients in general and patients with dementia in particular. These include reducing noise and confusion; increasing light levels while minimizing glare; having nonshiny, evenly colored flooring; using large, easily read fonts for signs; and providing age-appropriate reading material. The British Alzheimer’s Society sponsors a national initiative called ‘‘Dementia Friends’’ that is designed to change the way the United Kingdom thinks, talks, and acts regarding dementia. Dementia friends learn about what it is like to live with dementia and how to use that knowledge to improve the lives of people with dementia.
Clinical Significance.—Every member of the dental team can take part in helping to detect patients who are having cognitive difficulty and in then alerting caregivers so these individuals can be evaluated further. In addition, they can provide sensitive but appropriate care for patients with dementia as long as possible. Small acts can add up to a friendlier atmosphere for those affected with dementia and other cognitive impairment.
McNamara G, Millwood J, Rooney YM, et al: Forget me not – the role of the general dental practitioner in dementia awareness. Br Dent J 217:245-248, 2014 Reprints available from J Millwood, Derbyshire Community Health Services, Dental Clinic Loughborough Hosp, Epinal Way, Loughborough, LE11 5JY; e-mail: [email protected]
Volume 60
Issue 2
2015
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Dental Abstracts
objects in three dimensions; losing track of the day or date or becoming confused about their environment; and difficulty concentrating, planning, and organizing, along with anxiety about suggestions or options that are offered to the patient. Should any concerning signs and symptoms be noted, a sensitive, tactful approach should be taken to initiate a conversation about these memory or behavior changes. Sometimes this is accomplished with gentle probing questions; sometimes frank, objective questions are more effective. The approach will vary depending on the dentist’s personality and the relationship with the patient. In all discussions, confidentiality is maintained. Appropriately sharing information should be emphasized as a means for providing safe and effective care to the patient. In all cases the dentist should explain to the patient the circumstances under which information can be shared, the requirement that the patient consent to the sharing of any information, and the need for the dentist to justify any decision to share. Dentists should share with the patient any concerns and indicate that they wish to write to the patient’s general medical doctor to suggest a thorough checkup is needed. If the patient’s mental capacity is in doubt, advice or confirmation may be sought from family members or caregivers. Providing Dental Care to Patients with Dementia.— Oral health is likely to decline as a patient’s dementia progresses. Often oral hygiene deteriorates, periodontal disease increases, decay levels rise, and patients experience difficulty wearing dentures. As a result, eating may be painful, which can lead to behavioral changes for patients who can no longer communicate effectively about their discomfort. The diagnosis of dementia should be followed by the establishment of a long-term dental care plan designed to eliminate pain, control infection, and prevent the development of new disease. If the patient is in the early stages of dementia, he or she is more likely to be receptive to treatment and to still be able to participate in making health care decisions. Treatment planning includes the stage of illness and degree of cognitive impairment. Dentists should be included in multidisciplinary care planning for people with a diagnosis of neurogenic disorders so oral care can be planned for the total extent of the disease process. In
addition, the care planning should include the patient’s caregiver and family. These are the best sources for assessing cognitive impairment and for advising how well the patient is maintaining dental hygiene routines, physical challenges that have developed, and adaptations that may be of value.
The dental team must also be aware of the patient’s signs of dementia progression. These include difficulty expressing needs and wishes, inability to understand and explain dental symptoms such as pain, inability to contribute to the decision making process or to give informed consent, difficulty with dental interventions, and problems understanding why oral hygiene must be done and following through with it. General dental practices are usually able to care for patients in the early stages of dementia, providing good restorative and rehabilitative care. Restorations should require little maintenance, and advanced restorations should only be undertaken with the understanding that the patient’s caregiver may have to ultimately provide oral self-care. Preventive measures should be rigorous so that the individual and caregiver become accustomed to their performance. As the patient’s dementia reaches mid-level stages, maintenance and prevention are emphasized over restoration and rehabilitation. Cognitive impairment generally increases, although physical capabilities may remain relatively intact. Changes in behavior may occur that require that the dentist act in the patient’s best interests and choose the least restrictive treatment option. Adherence to the previously agreedupon treatment plan and good relationships with caregivers and family members will guide care. Specialist advice may be sought. Continuing care may require the use of sedation or general anesthesia during treatment. Once the patient reaches later stages of dementia, he or she may be unable to receive treatment outside of a normal environment. Local visiting nurse or aide services may be needed, or the patient may be cared for by nursing home personnel if he or she has transitioned there. The new dental team should be given all the information needed for an effective transition of care. Delivering oral care to older persons in nursing homes may be complicated by lack of adequate equipment and facilities, poor financial reimbursement, lack of training, and loss of time from private practice. The benefits of treatment must be weighed against the risks and difficulties associated with providing care in terms of cooperation, consent, medical status, and other considerations. Specific actions to be taken by nursing home or visiting nurse aides include the following:
Immediately perform appropriate preventive measures to minimize the presence of dental disease Provide dental interventions in the early stages of oral problems
Ensure dentures are marked with the patient’s name, clean them professionally on a regular basis, and have them replaced as needed Review the patient’s needs on a regular basis to avoid pain and minimize the need for further interventions Minimize the caregiver’s and patient’s fear, stress, and embarrassment by using an ‘‘open-door’’ approach and providing for backup and support
Not all patients with dementia suffer a decline in their dental care needs. Often past dental behavior and experiences will shape the patient’s ability to comply with oral hygiene behaviors. Having familiar surroundings, routines, and people may be reassuring and help in eliciting the patient’s cooperation. Dementia Friendly Behaviors.—When treating people with dementia, it is important to remember that patients have good and bad days, so dental treatment should be done on good days whenever possible. Because short attention spans are common, dental appointments should be limited to the patient’s ability to cope. Appointment reminders are often appreciated. Simple improvements in the practice environment may increase its accessibility for older patients in general and patients with dementia in particular. These include reducing noise and confusion; increasing light levels while minimizing glare; having nonshiny, evenly colored flooring; using large, easily read fonts for signs; and providing age-appropriate reading material. The British Alzheimer’s Society sponsors a national initiative called ‘‘Dementia Friends’’ that is designed to change the way the United Kingdom thinks, talks, and acts regarding dementia. Dementia friends learn about what it is like to live with dementia and how to use that knowledge to improve the lives of people with dementia.
Clinical Significance.—Every member of the dental team can take part in helping to detect patients who are having cognitive difficulty and in then alerting caregivers so these individuals can be evaluated further. In addition, they can provide sensitive but appropriate care for patients with dementia as long as possible. Small acts can add up to a friendlier atmosphere for those affected with dementia and other cognitive impairment.
McNamara G, Millwood J, Rooney YM, et al: Forget me not – the role of the general dental practitioner in dementia awareness. Br Dent J 217:245-248, 2014 Reprints available from J Millwood, Derbyshire Community Health Services, Dental Clinic Loughborough Hosp, Epinal Way, Loughborough, LE11 5JY; e-mail: [email protected]
Volume 60
Issue 2
2015
85