dementia and dental care: problems and practicalities

1. Dementia and Dental Care: Problems and Practicalities

2. Content Dementia Management Capacity Dental problems Practicalities

3. 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

5. 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 Parkinson’s disease dementia Fronto-temporal dementia Dementia is often categorised as being reversible or non-reversible. Examples of reversible dementia include depression, medication effects (e.g. effects of anticholinergic agents and benzodiazepines), metabolic disorders, nutritional deficiencies,infections, hydrocephalus and subdural haematoma.Elderly depressed persons, unlike most young individuals, can present with confusion, memory impairment, and attention deficits, all of which can be mistaken for dementia and may complicate the diagnosis of AD. Older people may suffer from a number of different chronic conditions that require treatment. Since hepatic and renal function decline with age, the older person is generally more sensitive to drugs and, as a result, is more vulnerable to adverse side effects that may manifest as confusion.Common metabolic disturbances that can alter cognition include electrolyte imbalances such as hyponatraemia, hypernatraemia and dehydration. Thyroid disturbances, particularly hypothyroidism, may be associated with impaired cognition. Nutritional deficiencies, such as vitamin B12, thiamine, and folic acid deficiencies, may manifest as altered cognition. Confusion can be the earliest important sign of an underlying infection in the elderly patient.AD is the most common form of non-reversible dementia. However, there is overlap among the different types of dementia, such as AD with vascular risk, VaD with AD, and AD with Lewy bodies. Other non-reversible causes of dementia include Pick’s disease, Parkinson’s disease and fronto-temporal dementia. Dementia is often categorised as being reversible or non-reversible.

6. 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 1994:57:416-18

7. 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 1996;47:1113-1124

8. Prevalence of Dementia Associated with Parkinson’s Disease Over Time

9. NINDS–AIREN 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 1994;43:250-60

10. AD: a progressive CNS disorder impairing patients’ ability to function Patients with AD progress from being almost fully independent at the time of diagnosis to a state where they are unable to perform even the most basic functions. Progressive deterioration is seen particularly in three key symptom domains: ADL, behaviour, and cognition (Bouchard and Rossor, 1996). Therefore, caregivers play an increasingly important role in assisting and managing AD patients as the disease progresses.  Functional impairment is recognised by the decline in an individual’s performance of ADL, which worsen as the disease progresses (Gauthier et al., 1997). During the early stages of AD, participation in complex activities such as household finances, dining and participation in hobbies decline, while middle stages are delineated by a decline in selecting clothes and meaningful discussions. The later stages of the disease are characterised by a loss of more basic ADL such as those related to self-care (Gauthier and Gauthier, 1990).Behavioural and psychiatric symptoms begin to emerge in the early stages, and become more prominent as the disease progresses (Cummings, 1997). Patients with AD commonly exhibit a diverse array of behavioural symptoms at some stage during the disease. Behavioural disorders include: personality changes (apathy and irritability), mood changes (depression), psychosis, anxiety, agitation, aberrant motor behaviour and neurovegetative alterations (e.g. sleep disturbances). This slide indicates how increased disease severity over time correlates with increased burden, particularly for the caregiver. MCI often occurs as a component of AD progression but may also have aetiology distinct from AD. Patients with AD progress from being almost fully independent at the time of diagnosis to a state where they are unable to perform even the most basic functions. Progressive deterioration is seen particularly in three key symptom domains: ADL, behaviour, and cognition (Bouchard and Rossor, 1996). Therefore, caregivers play an increasingly important role in assisting and managing AD patients as the disease progresses. Functional impairment is recognised by the decline in an individual’s performance of ADL, which worsen as the disease progresses (Gauthier et al., 1997). During the early stages of AD, participation in complex activities such as household finances, dining and participation in hobbies decline, while middle stages are delineated by a decline in selecting clothes and meaningful discussions. The later stages of the disease are characterised by a loss of more basic ADL such as those related to self-care (Gauthier and Gauthier, 1990).

12. Likely Medications

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

14. Capacity

15. 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

16. Referral to Dementia Specialist for Capacity Assessment Complex treatment decision Long term effects on patient Disputed capacity Ultimate decision with dentist

18. Capacity Lacking No-one else (relative, spouse, carer) can give or withhold consent on a person’s 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

19. 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

20. 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 person’s 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 patient’s clinical notes.

21. 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

22. 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

23. Restraint Necessary to prevent harm Proportionate to likelihod and seriousness of harm

24. 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****

25. Dental Management: Useful Information Disease stage Capacity Prognosis Drug regimen Comorbidity

26. 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

27. 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

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

29. Dementia Status by Tooth Count

30. 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

31. 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

32. 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

33. 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 2002;17:249-253

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