Staying interactive with patients suffering from dementia
by Susan P. Burzynski, RDH, MSEd
The author poses with her mother during a family outing in August 2013 at a restaurant in Amherst, N.Y..
Mom and I were sitting at her kitchen table when she said, "I haven't been in this place in years!" I know better than to correct her because it only upsets her, but my mouth got the better of me. "What?! Mom, you raised Diana and me in this house!" She squinted her eyes, set her jaw, and pinched her lips tight, and I knew I was suddenly a 10-year-old being sent to her room for doing something bad.
Wanting to know more about how I should react to my mom's comments and my patients with dementia, I went to the Alzheimer's Association website. According to them, dementia is a general term for loss of memory and other mental abilities that is severe enough to interfere with daily life. It is caused by physical changes in the brain, and these changes make the patient unable to do everyday tasks.
There are different types of dementia, something I did not know and was surprised to learn. Please refer to the sidebar for an explanation of dementia types. They are Alzheimer's disease, vascular dementia, dementia with Lewy bodies (DLB), mixed dementia, Parkinson's disease, frontotemporal dementia, Creutzfeldt-Jakob disease, normal pressure hydrocephalus, Huntington's disease, and Wernicke-Korsakoff syndrome.
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The Alzheimer website states that Alzheimer's disease is the most common type of dementia and accounts for 60% to 80% of the cases. After age 65, the possibility of developing Alzheimer's doubles every five years. However, this disease can strike someone in their 40s or 50s. It is estimated that approximately 200,000 Americans have early-onset Alzheimer's (also known as younger-onset).
According to the Alzheimer website, the symptoms of dementia vary from patient to patient. Warning signs are memory loss, challenges in planning or solving problems, difficulty completing familiar tasks at home, work, or leisure, confusion with time or place, trouble understanding visual images and spatial relationships, problems with words in speaking or writing, misplacing things and losing the ability to retrace steps, decreased or poor judgment, withdrawal from work or social activities, and changes in mood and personality.
Any of the following core mental functions can be considered dementia, according to the Alzheimer website -- memory, communication and language, ability to focus and pay attention, reasoning and judgment, and visual perception. As I write this article, I see most of these signs and symptoms in my mother. I have lunch with her every day, yet she accuses me of not having come around in years, and she wants to know why I'm coming around now. Her writing looks like an ant walking across paper, whereas before her dementia onset she had beautiful penmanship.
There are seven stages of dementia. Stage 1 shows no impairment, and the patient does not exhibit any memory problems. During stage 2 there is a very mild cognitive decline. In this stage no symptoms can be detected during a medical examination. Stage 3 shows mild decline that family members notice. The patient will have greater difficulty performing tasks in a social or work environment. Stage 4 shows moderate cognitive decline. For example, the patient may be forgetful of recent events or forgetful of their own personal history. Stage 5 is moderately severe cognitive decline, or moderate to midstage Alzheimer's disease. During this stage, patients may have difficulty choosing their clothing for the day or remembering details about themselves or their family. Stage 6 shows severe cognitive decline. It is during this stage that a patient may wander away from their caregiver, sleep during the day and be up all the night, or need help with their bathroom routine. I think my mom is in this stage. She will get up in the middle of the night and find another bedroom in which to sleep. We have taken her to a urologist thinking she was having a problem. The urologist explained to my dad that there is a short circuit between my mom's brain and her kidneys. Her brain makes her believe she must go to the bathroom, even when the kidneys did not send a signal. In the final stage, stage 7, patients are unable to complete any routine for themselves. Refer to Figure 2 for testing for dementia.
The hygienist in me wants to know what to look for with my mom and my patients in relation to their dental care. If a patient has difficulty handling a manual brush in the early stages, the dental professional may recommend a battery or electric brush. Elderly patients may not like the vibration of the battery or electric brush. The dental professional may recommend that a bicycle grip be placed on the handle of the brush to make it easier to maneuver. The dental professional may recommend a varnish if the patient still has trouble keeping the biofilm under control.
A 2001 article of the Journal of Dental Education concluded that xylitol could decrease the incidence of dental caries. In 2012, research conducted by the University of California and published in the Journal of the American Geriatrics Society stated that out of 5,468 adults with no previous diagnosis of dementia, with a median age of 81, those who brushed their teeth less than once per day had up to a 65% greater risk of developing dementia than those who brushed three times a day. The study also concluded that men who had difficulty chewing and did not wear dentures were at a 91% greater risk of dementia vs. women who were at a significantly lesser risk.
The Alzheimer Association website addressed the issue of risks to developing dementia. Age, family history, and genetics are things we cannot change. If a person has more than one family member with the disease, there is an increased risk for development of dementia. There are two types of genes -- risk genes and deterministic genes -- that determine the development of dementia. The risk genes have the strongest influence over disease development. The gene called apolipoprotein E-e4 (APOE-e4) was discovered in 1993, and is responsible for 20% to 25% of Alzheimer's cases and has the greatest known impact. Everyone inherits a copy of a form of APOE from each parent; however, if someone has both parents with the disease, their chance of developing dementia is higher. The Alzheimer's Association stated that APOE-4 has a tendency to make the symptoms appear at an earlier age.
The Association states that the second gene, the deterministic gene, is directly causative of the disease, thus guaranteeing development of dementia. As stated by the Association, dementia caused by this gene is called "autosomal dominant Alzheimer's disease" (ADAD) or "familial Alzheimer's disease." Patients with this gene often have symptoms develop as early as their 30s or 40s. Usually multiple members of the family and multiple generations are affected.
Damage to brain cells causes dementia, according to the Alzheimer's website. The ability to communicate, thinking, behavior, and feelings are affected. I see this in my mom. I will be speaking to her about my daughters and she will refer to them as "he." But I'm learning not to correct my mom. Oh no! She can go from a very docile woman to an angry mother bear and turn on us within seconds.
Dementia can be treated with medication. These include cholinesterase inhibitors (Aricept, Exelon, Razadyne, Cognex) and memantine (Namenda). Mom is on Aricept.
The woman I knew as my mom is locked up inside her somewhere. She was a stay-at-home mom, something I tried and failed at miserably. Mom sewed my sister's and my clothes from the cloth my dad brought home from the factory where he worked, and I can't tell you the difference between a straight stitch and a basting stitch. She cooked from scratch, and I fail in that department as well. Mom went back to school to get her GED, and took the Civil Service exam so she could work in a library to help pay for my hygiene degree. I can't thank her enough! She doesn't remember raising my sister and me. She doesn't remember she will be married 70 years this November. But she is my mom, and I remember her and tell my children about what a wonderful mom she was. I hope I never lose those memories. RDH
SUSAN P. BURZYNSKI, RDH, MSEd, has practiced clinical dental hygiene since 1971. She received her Bachelor of Science, as well as her Masters of General Education, in 2003, 2006 respectively, from Canisius College in Buffalo, New York. In 2007, Susan became a member of the American Academy of Dental Hygiene (AADH) where she serves on the publicity, finance, and audit committees. Susan received the Sunstar Award of Distinction at RDH Under One Roof in 2010, and in 2011 received a Fellowship from AADH.
Figure 1: Types of Dementia (www.alz.org/dementia/types-of-dementia.asp)
Figure 2: Tests for Alzheimer's Disease and Dementia