Dental care and dementia
Dentists are really important for people with dementia. They can make a huge difference to the comfort and happiness of people with dementia during the last years of their lives. Life is hard for people with dementia and their carers, and the dentist can reduce pain, and make eating and drinking a pleasure again. Not least, they can make it easier to be near the person by making sure their carers know about oral hygiene and how important it is.
Dentists have told me they are astonished at how relaxed care workers are about bodily fluids and excrement, while finding it impossible to deal with someone's mouth. We need to sort that. For specialist advice about care for older people, dentists can turn to the Journal of Gerodontology1 and the work of Dr Janice Fiske. She is the author in England of a fact sheet from Alzheimer's Society.2
Dementia is a general term that is used to describe a loss of intellectual function. The cause in over half of affected people is Alzheimer's disease, when brain cells shrink. The next most common cause is vascular disease when the blood supply to brain cells has been cut off. There are other causes including alcohol related brain damage. All dementia is irreversible, though some people with alcohol related problems can get a bit better if they stop drinking and get treatment.3 It is worth the dentist knowing what kind of dementia the person has as this may help predict some of their behaviours, and their prognosis.
It has been estimated that there were around 71,000 people with dementia in Scotland in 2010 and the number is set double in the next 25 years. More than half are female. The older a person is, the more likely they are to have dementia. However, around 2,300 people with dementia in Scotland are under 65.4
The changes that take place in a person with dementia include:
• a deterioration in the ability to carry on with basic every day activities like oral care
• difficulty in working things out, like who you are, and what you are trying to get them to agree to
• changes in social behaviour, like apathy and social withdrawal, which will make consultations potentially difficult
• memory problems which may make compliance an issue
• disturbing behaviour such as aggression, wandering, or other things that make a consultation more complicated.
The person with dementia is often aware that they have a problem, but may not seek help. Even those around them who can see the difficulties are often reluctant to raise the issue or approach the family doctor. The dementia can progress slowly over seven or 10 years. In the beginning the person may be very fit and active, and in the end they may need care for every function.
Mild Cognitive Impairment (MCI) looks and feels like early dementia. Many people with MCI never get dementia. However, everyone who gets dementia seems to go through a period of MCI. Also, an older person who has an infection or depression may show some cognitive impairment that looks like dementia for a time. If treated, the cognitive symptoms go away. If they already had dementia, other illness or depression may make their existing cognitive impairment seem worse till the illness or depression is treated.
In Scotland, as long as the person can understand what is proposed, their consent is needed, even if the person has a diagnosis of dementia. The Adults with Incapacity Act indicates that if a doctor believes the treatment will benefit the person, the doctor should sign a certificate of incapacity under Section 47. A dentist can sign a Section 47 form for dental treatment. If there is a welfare guardian or attorney, this person can make a decision on behalf of the person with dementia. You need to decide when assessing capacity whether the person can understand the options, make a decision and communicate it with you.
When providing dental treatments it's good to discuss them with the family or carers. There may be a person who understands them very well and knows how to communicate with them who will be vital in making sure that the person is consenting and understands what is being done and that it is beneficial for them. But remember that the person with dementia is watching and reading your non-verbal communications all the time. Use touch and tone of voice, and a calm and careful manner to keep their confidence, even if they seem not to understand everything that is said.
Communication is not always simple, but the dentist can make it easier. As with any patient, the dentist should explain in simple terms what is being done and why. The person will take more time than other people to process information and questions. One important principle is to make sure that they know you are the dentist. A person in day clothes who comes to your house or your room in the care home and starts to try to open your mouth and shine a light in it might be very frightening, but if that person gives you a clue by wearing a dentist's white outfit it's a signal that he's doing his job, and not trying to kill you. I know that avoiding uniforms is good for dental phobias, but these patients are usually older, and their expectations are based on an earlier time in their lives when the person in the white coat was an authority figure, when she said "open wide" you did just that.
In May 2010 NHS Health Scotland, in partnership with the National Older People's Oral Health Improvement Group, launched the resource Caring for Smiles. It's a guide for oral health professionals to train staff in care homes how to improve oral care for dependent older people. It was developed in response to the Scottish Dental Action Plan target. It has a section on dementia and special care. People with dementia in care homes don't always have their oral health needs met.
In the early stages of dementia a person will still be able to clean their own teeth. They might need to be reminded or given some supervision. When advising family or carers on how to encourage oral care, remind them that the person may imitate actions. So giving them their brush with toothpaste on it and then standing in front of them brushing your own teeth and encouraging them to do the same is a good way of helping them to keep up their own dental hygiene.
Although electric tooth-brushes and adapted handles can help when older people have problems with dexterity, the person with dementia might become confused or alarmed, so don't leave it too late to introduce these new things. If a stage is reached where the carers need to take over this task, they need guidance and support on how to do it, but remember that they are the experts on the individual quirks of that person with dementia.
The dentist can show them techniques like standing behind the person and cradling their head, but they need to introduce this carefully to avoid distress. Everyone with dementia is different, and their level of tolerance will differ as well.
There is a national initiative to reduce the use of antipsychotics, and encouragement in the use of non-pharmacological methods in dealing with disturbing behaviour. However, many medications are still given to older people, and often in syrup form. Don't hesitate to ask if the medication has been recently reviewed to see if it is still necessary. Many carers will not have been warned about dry mouth side effects.
People with dementia have significant communication problems and staff who care for them are sometimes not trained to understand non-verbal communication. The commonest cause of disturbing behaviour is said to be undiagnosed pain. It is important to have regular mouth checks, whether the person has teeth, dentures or nothing at all. The Caring for Smiles education pack reminds care workers that the person may only demonstrate oral problems by going off their food, or rejecting their dentures, moan
ing and shouting, and by aggressive behaviour. It is particularly cruel if the person is sedated as a result, making their condition worse and not dealing with the cause at all.
People with dementia can have good days and bad days: dental care is better postponed to a good day, if possible, or scheduled to a person's best time of day. Make sure you and your staff have read guidance such as Ten Helpful Hints for Carers; practical solutions for carers living with people with dementia,5 which offers non-pharmacolgical solutions to the commonest disturbing behaviours.
2. Factsheet 448, http://www.alzheimers.org.uk Dental Care and Dementia
3. See this link for factsheet 438 about ARBD (other key word “Wernicke-Korsakoff”) from the Alzheimer's Society http://www.alzheimers.org.uk/factsheet/438
4. Dementia UK Consensus prevalence rates of dementia from Alzheimer's Society (2007). A report to the Alzheimer's Society on the prevalence and economic cost of dementia in the UK produced by King's College London and London School of Economics.
5. DSDC, 2009, from http://www.dementiashop.co.uk
About the author
Professor June Andrews is the Director of the Dementia Services Development Centre in the Department of Applied Social Science at the University of Stirling. She has considerable experience in management of change in health services, having set up and directed for three years the Centre for Change and Innovation, in the Scottish Executive Health Department. The purpose of the centre was to devise and implement interventions to drive change in clinician behaviour and health care organisations in order to achieve Scotland's targets around waiting times, access to health care and modernisation of the NHS in Scotland. In her current role she is applying these skills across sectors in the care of people with dementia, including the health, social services, private and voluntary bodies who provide care.