Dementia and Dental Care: Problems and Practicalities

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Dementia and Dental Care Problems and
Practicalities
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Content

• Dementia
• Management
• Capacity
• Dental problems
• Practicalities

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What is Dementia

• Dementia is a global term which refers to a set
  of symptoms with evidence of decline in memory
  and thinking which is of a degree sufficient to
  impair functioning in daily living and is present
  for 6 months or more.
• It is associated with changes in behaviour,
  motivation and personality
• There are a number of types of dementia

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Common causes of dementia

• Potentially reversible
• Depression
• Drug toxicity
• Metabolic disorders
• Nutritional deficiencies
• Infections
• Hydrocephalus
• Subdural haematoma

• Non-reversible
• AD
• Vascular dementia
• AD CVD
• Lewy body dementia
• Parkinsons disease dementia
• Fronto-temporal dementia

US Dept of Health and Human Services, 1996
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Diagnostic Criteria for Frontotemporal Dementia

• Behavioural disturbances, including early loss of
  personal and social awareness
• Affective symptoms, including emotional unconcern
• Speech disorder, including reduction, stereotypy
  and perseveration
• Physical signs, including primitive reflexes,
  incontinence, akinesia and rigidity
• JNNP 199457416-18

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Diagnostic Criteria for Dementia with Lewy Bodies

• Progressive cognitive decline interfering with
  social or occupational functioning. One (possible
  DLB) or two (probable DLB) of
• Fluctuating cognition with pronounced variations
• Recurrent visual hallucinations
• Spontaneous motor features of Parkinsonism
• McKeith et al Neurology 1996471113-1124

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Prevalence of Dementia Associated with
Parkinsons Disease Over Time
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WomenMen
0.9
0.8
0.7
0.6
Proportion with PDD
0.5
0.4
0.3
0.2
0.1
0
35
40
0
5
10
20
25
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Duration of PD (years)
Robbins JM et al. PARC Working Paper Series WPS
01-2001 .
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NINDSAIREN Criteria for Vascular Dementia

• Dementia
• Cerebrovascular disease
• Focal CNS signs
• Evidence of CVD by brain imaging
• A relationship between the two manifested by one
  or more of the following
• Dementia onset within 3 months of stroke
• Abrupt deterioration in cognition or fluctuating
  stepwise course
• Neurology 199443250-60

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AD a progressive CNS disorder impairing
patients ability to function
Disease progression Symptom progression Normal
Preclinical (silent) AD No noticeable cognitive
decline Mild Cognitive Impairment First evidence
of cognitive decline(MCI) Mild AD Forgetful
family and friends notice problems Moderate
AD Confused may be agitated, anxious,
apathetic Moderately severe AD Can no longer
manage personal affairs loss of independence
disoriented in space and time Severe
AD Full-time care needed institutionalised
incontinent delusional obsessive Very severe
AD Loss of speech locomotion consciousness
Adapted from Reisberg et al., 1982
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Relative timescales for drug use in AD
Function
Symptom
Motility
Cognition
Cholinesterase Inhibitors
Memantine
A n t i p s y c h o t i c s
Mood
Behaviour
mild
moderate
severe
Time
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Likely Medications
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Adverse Orofacial Reactions

• Sialorrhea (cholinesterase inhibitors)
• Xerostomia, dysgeusia (antipsychotics)
• Stomatitis (antipsychotics)
• Tardive dyskinesia (antipsychotics)
• Glossitis (carbamazepine, valproate)
• Sialadenitis
• Gingivitis
• Oedema
• Discoloration of the Tongue.

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Capacity
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Capacity

• Assessment always necessary prior to treatment
• Reasonable belief that capacity is lacking before
  treatment can be lawfully carried out without a
  patients consent
• Reasonable belief
• Objective
• Reasonable steps
• Professional clinician vs lay carer
• May involve discussion with family members, lay
  and professional carers
• May involve review of records

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Referral to Dementia Specialist for Capacity
Assessment

• Complex treatment decision
• Long term effects on patient
• Disputed capacity
• Ultimate decision with dentist

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a person lacks capacity where at the material
time, he is unable to make a decision for himself
in relation to a matter because of an impairment
of or disturbance in the functioning of the mind
or brain . The impairment may be temporary or
permanent . a person is unable to make a
decision if he is unable To understand the
information relevant to the decision To retain
that information To use or weigh up that
information as part of the process of making the
decision To communicate his decision.
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Capacity Lacking

• No-one else (relative, spouse, carer) can give or
  withhold consent on a persons behalf.
• Treatment may only be carried out if the
  treatment proposed is considered by the treating
  clinician to be in the persons best interests.
• Only then will the dentist be afforded a
  defence against a potential trespass

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Assessment of Capacity

• Presume capable
• Avoid preconceptions (age, appearance behaviour)
• Decision specific assessment
• A person needs only to retain the information
  about the treatment for a short period of time,
  but long enough to enable him to make a decision
• Capacity may fluctuate
• Where acts or decisions are of a serious nature,
  then any decision made when the person has
  capacity during a lucid interval should be
  documented and confirmed by medical evidence

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Assessment of Capacity

• Communication or language problems consider
  using a speech therapist or interpreter, or
  consult family members on the best methods of
  communication
• Be aware of any cultural, ethnic or religious
  factors which may have a bearing on the persons
  way of thinking, behaviour or communication
• Consider whether or not a friend or family
  member should be present to help reduce anxiety.
• The capacity assessment carried out by the
  dentist (with advice from a multi-disciplinary
  team of specialists, as appropriate) should be
  recorded in the patients clinical notes.

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• Presentation/explanation very important
• Borderline capacity, may well tip the balance in
  favour of a finding of capacity
• Present in accessible format
• Keep it simple

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• what is involved in the proposed course of
  treatment
• why the treatment is necessary
• any alternatives to the treatment
• consequences of consenting and refusing treatment
  
• ie the risks and benefits.
• It is important to note that only reasonable
  belief is needed after reasonable steps have been
  carried out

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Restraint

• Necessary to prevent harm
• Proportionate to likelihod and seriousness of harm

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Factors Leading to Oral Disease

• Forget oral hygiene
• Hyposalivation
• Reduced anti-infective activity
• Reduced flushing of plaque and bacteria
• Interference with normal remineralization
• Dry lips, gingival bleeding, calculus,
  periodontal disease, caries
• Oral hygiene not high on carers list

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Dental Management Useful Information

• Disease stage
• Capacity
• Prognosis
• Drug regimen
• Comorbidity

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Right Attitude

• Minimize distractions
• Airconditioning, fans, suction devices, phones,
  TV
• Simple explanation, reinforcement
• Smiling
• Gentle touching, reassurance
• Caregiver present
• Intervene early in disease
• Short appointments
• Mornings
• Bladder emptying

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Dental Care During Disease

• Carer education
• Artificial saliva MILD
• Brush on fluoride gel
• Pain/infection control
• Ratchet style Mouth prop?
• Maintain old prosthetics MODERATE
• Anxiolytic
• Profound local anaesthesia needed
• Pain awareness SEVERE
• Iv sedation

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Anaesthesia

• Mivacurium, succinylcholine
• Inactivated by plasma esterases
• Donepezil 2 weeks
• Galantamine 1-2 days
• Rivastigmine 3-4 days
• Practicalities!!!!!

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Dementia Status by Tooth Count
Kim et al. Int J Ger Psych 200722850-855
Also Stein et al. J Am Dent Ass 20071381314-22
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Risk Factors for poor oral health in patients
with dementia in residential care

• Salivary dysfunction
• Polypharmacy
• Medical conditions
• Swallowing
• Dietary problems
• Functional dependence
• Oral hygiene care assistance
• Poor use of dental care

Adam Preston Gerodontology 20062399-105
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Higher Caries Incidence in Community Dwelling
patients with dementia

• Male gender
• Dementia severity
• High carer burden
• Oral hygiene care difficulties
• Use of neuroleptic medication
• Previous caries

Chalmers et al. Gerodontology 20021980-94
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Target Outcomes for long term oral health in
dementia. Delphi Approach (carers staff)

• Freedom from oral pain
• No risk from aspiration
• Emergency dental treatment available when needed
• Prevent mouth infections
• Daily mouth care (like shaving)
• Prevent discomfort from loose teeth or sore gums
• Teeth brushed thoroughly once daily
• Staff can provide oral hygiene
• Dental care provision to prevent eating problems
• Early recognition

Jones et al. J Public Health Dent 200060330-334
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Pain of Dental Aetiology

• 21 nursing home residents
• 9 dentists, 2 geriatricians assessed
• 60 assessed had a pain causing condition
• Less than half of these rated by geriatricians
• Think of the teeth!!!
• Cohen-Mansfield Lipson Am J Alz Dis Oth
  Dementia 200217249-253

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Summary

• Increasing problem
• Early intervention seems useful
• Much benefit in prevention
• Education for specialists (Memory clinic)
• Capacity
• Problems with late stages

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