Prior knowledge of the condition, as well as specific strategies for the management of behavioral problems, gives hygienists the tools they need for effective treatment of dementia patients.
by Cathleen Terhune Alty, RDH
Mr. Andrews, an 85-year-old widower with 14 natural teeth and a long-standing history with your dentist-employer, has just entered the office and is 15 minutes late for his appointment. Mrs. Lewis and her four loud, active children, all under the age of 6, are also in the reception area. As the little children in the waiting area are wildly running circles around the room, Mr. Andrews' daughter apologizes for being late for the appointment and hurries her father into the operatory. She comments to you that her father recently has been diagnosed with dementia and is taking an antibiotic for a recurring bladder infection. One of Mrs. Lewis' children screams and bumps Mr. Andrews from the back. As he is escorted back to your chair, you hear one of the children yell, "Ewww ... what's that yucky smell?" As Mr. Andrews is seated, you turn quickly to review his chart. When you ask how he has been, you notice he is not responding. You look up from the chart and ask again, a little louder this time, in case he didn't hear you. He is flushed, staring at the wall ahead of him. As you reach out to touch his arm, he starts swinging his arms wildly, cursing, and knocking things out of his way. "Get away from me!" he bellows. "I won't have this!"
What happened? It is a classic scenario for people with some forms of dementia to have aggressive outbursts, manifested by any of these stimuli: anxiety; an underlying medical condition; a break in their normal routine; a noisy, confusing room; being rushed or bumped; being spoken to from behind; a loud voice; and/or being touched suddenly.
Of course, not all patients with dementia will respond with agitation, nor will any two patients be alike in their response. However, prior knowledge of the condition and practical, individualized appointment planning, as well as specific strategies for the management and prevention of their behavioral problems, is important.
We tend to think that dementia means Alzheimer's disease, but, in actuality, dementia is an umbrella term used to describe any loss of intellectual or cognitive function. Some memory loss due to aging is normal, but dementia is not a normal condition. The Alzheimer's Association says that in addition to Alzheimer's, several other diseases also cause dementia, such as Parkinson's, Creutzfeldt-Jakob, Huntington's, and multi-infarct or vascular diseases, caused by multiple strokes in the brain.
The American Psychiatric Association defines dementia as short- and long-term memory impairment with at least one of the following:
- impairment of abstract thinking or judgment
- personality change
- other disturbances in higher cortical function.
Dementia also may have these associated features: depression; addiction; learning problems; psychosis; hyper- or hypoactivity; involuntary movement; agitation; anxiousness; suspicious, erratic personality; apathy; and/or sleep disturbances.
According to the Alzheimer's Association, many conditions can cause dementia, including depression, drug interaction, thyroid, and other problems. It is claimed that more than 4 million Americans — 10 percent of our over-age-65 population and 50 percent of our over-age-85 population — have Alzheimer's disease. The majority of these individuals are cared for in their homes by family members and friends. By 2025, it is estimated that 22 million people will develop Alzheimer's unless a cure for the disease is found. Many of these people will still retain natural dentition and will be cared for in private dental practices. By understanding how to help patients with dementia, we can be alert to the particular challenges and specific strategies associated with the dementia patient, offer effective treatment, assure safety, and offer caregivers individualized strategies for managing the oral health of their loved ones.
Many strategies can help when caring for a person who exhibit symptoms of dementia, and these strategies can include:
- providing the proper environment
- good communication skills
- being aware of medications and underlying health issues
- support and understanding for caregivers
The proper environment can greatly affect patients suffering from dementia, since they generally are sensitive to their environment. Dr. Jonathan Ship, professor of oral medicine and director of Bluestone Center for Clinical Research at New York University, says there must be a genuine sensitivity and respect for the patients. "It takes a special person with a special outlook to treat these patients," he said. "These are humans with feelings and emotions who are usually frustrated about their condition and unable to do anything about it. We have a unique opportunity to improve their quality of life."
Dr. Ship believes it may be a good idea to have special hours for these special patients. "Accommodating the patient and the family is important," he says. "For example, you could open early for these patients and better accommodate their needs. It is a tremendous job for the caregiver to get the patient transported to the office. Many patients with dementia wear diapers, and they may stink. This is a sensitivity issue for the patient."
The caregiver may be aware that there are certain times of the day when the person is upset or confused, or times when he or she is usually calm. A change in routine can be upsetting, so the caregiver may want to remind the person gently of the upcoming appointment. It is particularly important that the person not feel rushed or that things are moving too quickly. A calm, relaxed visit is the goal. If the office is quiet, instead of noisy and confusing, the patient may not become frightened or combative. A well-lighted area helps the patient with dementia properly navigate the room. Be prepared for unexpected bowel movements by having proper cleanup equipment and deodorizers on hand.
Communication strategies are important, because the person with dementia may have difficulty communicating with you. Dr. Ship says that an attitude of respect is important. "Ask questions about the old days: what jobs they did, their marriage, their kids. They may not remember what they did yesterday, but many do remember what they did in their 20s and 30s."
It helps to approach the patient from the front and establish eye contact before speaking. Speaking calmly in soothing tones may reassure a confused person. Always introduce yourself and call the patient by name. Don't say, "Remember me from your last visit?" Sometimes there will be no response to questions, or the response will be an inappropriate answer. Instead of getting frustrated or talking louder, it may help to remember that this patient has a disease and is not purposely trying to be difficult. Briefly explain to the patient what you are going to do, or what you need him to do for you, one step at a time. Reassure the patient throughout treatment that all is well, that he is safe, and that all is going according to plan.
Oral-care instruction could be directed to the patient, the caregiver, or both. Obviously, the patient's ability must be the first consideration in whether or not instruction is even possible. But if it is possible, use a "tell-show-do" approach with home-care instruction, as well as visual aids and slightly exaggerated gestures. If the patient becomes frustrated, upset, or agitated, stop the lesson and return to calm, soothing, reassuring tones until he has calmed down. If possible, try again but with a different approach. Don't be frustrated if no instruction is possible. Maybe some patients will need monthly recalls because of their inability to care for their teeth, and that would be acceptable.
The general health of the patient is always a concern prior to treatment, but especially so for a patient with dementia. The presence of an underlying medical condition, even something like a bad cold or dehydration, can adversely affect the behavior of a patient with dementia. Even though poor nutrition and lack of sleep can unfavorably affect healthy people, the negative effect is even greater in an elderly person. This can cause upset, fatigue, or agitation. Awareness of the patient's current medical status can mean delay or extra caution taken during the appointment to prevent any problems.
Many drugs are available today to help alleviate associated symptoms, such as agitation, sleeplessness, depression, apathy, and psychosis. Unfortunately, some drugs will have side effects, like nausea and/or dry mouth, that will adversely affect oral health. Many new drugs that may offer more relief and possibly a cure for dementia are now being researched. The use of anti-anxiety drugs for the appointment can be useful. Dr. Ship says he will use drugs that are short-acting and safe, and these medications work nicely to take the edge off the patient's anxiety. "A little goes a long way," he added.
Support to caregivers is important, because many of these family members and friends are exhausted with the task of caring for a loved one. The Internet contains a wealth of information for those who have been recently diagnosed to those in the final stages of dementia.
Cathleen Terhune Alty, RDH, is a frequent contributor. She is based in Clarkston, Mich.The Top 10 outcomes for dementia patients
This list helps health-care practitioners focus on the desirable outcomes when treating patients with dementia:
- Patient is free from oral pain
- Patient is not at risk for aspiration
- Emergency dental treatment is available if needed
- Mouth infections are prevented
- Daily mouth care is as important in daily care as shaving or brushing hair
- Discomfort from sore gums or loose teeth is prevented
- Teeth are brushed thoroughly once a day
- Staff is able to provide oral hygiene care as needed
- Dental care prevents eating problems
- Oral problems are recognized early
- From the Journal of Public Health Dentistry, Fall 2000
The Alzheimer's Association suggests that individuals exhibiting several of these symptoms be referred to a physician for an examination (Some symptoms also apply to other types of dementia.):
- Memory loss that affects job skills
- Difficulty performing familiar tasks
- Problems with language
- Disorientation with time and place
- Poor or decreased judgment
- Problems with abstract thinking
- Misplacing things
- Changes in mood or behavior
- Changes in personality
- Loss of initiative
- From the Alzheimer's Association
- Alzheimer's Association, www.alz.org, (800) 272-3900
- Alzheimer's Disease Education and Referral Center, www.alzheimers.org, (800) 438-4380
- American Federation for Aging Research, www. afar.org or www.infoaging.org, (212) 752-2327
- National Hospice and Palliative Care Organization, www.nhpco.org, (800) 658-8898
- Children of Aging Parents, www.caps4care givers.org, (215) 945-6900
- Incontinence Helpline (National Assn. for Continence), www.nafc.org, (800) BLADDER
- Eldercare, www.aoa.dhhs.gov, (800) 677-1116
- American Association of Retired Persons www. aarp.org, (800) 424-3410