30 minute read
CE Credit: Oral Health and Dementia
This article offers 1.0 CE Credits. Test questions are available for review at the end of the article.
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Paul Glassman, DDS, MA, MBA, is a professor and associate dean for research and community engagement at California Northstate University College of Dental Medicine in Elk Grove, Calif. Conflict of Interest Disclosure: None reported.
ABSTRACT: There is a significant increase in the number of people over age 60 who are living with dementia. It is important that oral health practitioners understand conditions that lead to cognitive decline in older individuals as well as strategies for providing oral health care services for these individuals. These strategies include conducting office-based care as well as creating community-engaged oral health systems that can help people with Alzheimer’s disease and dementia obtain and maintain good oral health.
Keywords: Oral health, dental treatment, Alzheimer’s disease, dementia, cognitive decline, communityengaged oral health systems
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Improved living conditions, increasing lifespans and better health care have resulted in shifting disease patterns across the world.[1] One result has been a 113% increase between 1990 and 2010 in the worldwide number of people over age 60 living with dementia.[2] This is a far larger increase than the increase in those living with cardiovascular disease (22%), diabetes (80%) and vision and hearing impairment (49% and 42%). In 2020, the World Health Organization (WHO) reported that there were 50 million people living with dementia and over 10 million new cases each year.[3] The WHO also reported that the total number of people with dementia is projected to reach 82 million in 2030 and 152 million in 2050. These trends have major implications for health and the provision of health care, including oral health care.
A recent systematic review indicated the relationship between learning and memory, complex attention and executive function with poor oral health in old age.[4] Mechanisms for this association include reduced ability to perform daily mouth care procedures, difficulty accessing and receiving dental care and reduced salivary flow.[5–9]
Given the increasing number of people with some form of dementia, it is important that oral health practitioners understand conditions that lead to cognitive impairment in older individuals as well as strategies for providing oral health care services for these individuals.[10,11]
Dementia and Other Causes of Cognition Impairment
There are a number of conditions that can lead to cognitive impairment in older adults. These conditions are often categorized as the “3 Ds” — delirium, depression and dementia.[12] They can all produce presenting signs that include memory loss, lack of responsiveness, confusion and difficulty completing tasks of daily life.
Delirium is sometimes characterized as a disturbance of awareness. It is usually a sudden and temporary change resulting in a state of confusion. It typically results from a specific underlying cause such as serious medical conditions, an infection with systemic manifestations, recovery from general anesthesia or a side effect of medication.[13] The individual may exhibit changes in alertness, sleep patterns, short-term memory, disorganized thinking and emotional or personality changes. Although the manifestations of delirium often recede if the underlying cause is addressed, delirium can become chronic and permanent.
Depression is sometimes characterized as a disturbance of mood. Major depression is one of the most common mental disorders in the United States.[14,15] It is characterized by a period of at least two weeks when a person experiences a depressed mood or loss of interest or pleasure in daily activities along with a majority of specified symptoms, such as problems with sleep, eating, energy, concentration or self-worth.[14] Symptoms of depression can also include tearful or sad feelings, weight change (usually decreased), trouble sleeping, psychomotor agitation, fatigue or loss of energy, feelings of worthlessness or guilt, loss of ability to concentrate and indecisiveness.
In contrast to delirium and depression, dementia is often characterized as a disturbance of cognitive function including problems with thinking, memory and reasoning.[16] It can include:
• Aphasia or language impairment affecting the production or comprehension of speech.
• Apraxia or loss of ability to carry out movements such as writing, gait and complex tasks.
• Agnosia or loss of ability to recognize objects or persons.
• “Executive function loss” or loss of ability to plan ahead and foresee consequences.
There are a number of causes of dementia. Most are progressive and not amenable to treatment. However, in some cases the manifestations of dementia, as is the case with delirium, can be brought on by an underlying medical condition or infection or tumors that can be treated. For this reason, it is critical that an oral health practitioner who recognizes altered mental functioning in one of their patients, including any of the manifestations listed previously, ensure that the patient has had a thorough medical work-up and diagnosis.
Causes of Dementia
As indicated, there are a number of causes of dementia.[17] The most common is Alzheimer’s disease, but causes also include frontotemporal disorders, Lewy body dementia and other neurodegenerative disorders and vascular conditions.
Frontotemporal disorders are the result of damage to the neurons (nerve cells) in parts of the brain called the frontal and temporal lobes.[18] They are caused by a family of brain diseases known as frontotemporal lobar degeneration (FTLD), which results in the severe loss of thinking abilities. These disorders are progressive and result in increasingly severe symptoms over time. People can live with these disorders for a decade, and no treatment is currently available.
Lewy body dementia (LBD) is a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain.[19] These deposits, called Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior and mood. LBD is one of the most common causes of dementia. The disease starts with mild symptoms and progresses over time. It typically takes five to eight years from diagnosis to death, but some people can live up to [20] years after the diagnosis.
Other neurodegenerative diseases such as Parkinson’s and Huntington’s primarily cause progressive difficulty with movement.[20,21] However, the diseases can, as they advance, produce mental and behavioral changes, sleep problems, depression and memory difficulties.
Dementia may also be related to vascular disease that causes brain damage by restricting blood flow to certain areas of the brain.[22] One type, vascular dementia, is caused by a series of small strokes. This can result in what is known as “stairstep decline” with periods of stable symptoms and then occasional sudden progression of symptoms following a small stroke. This is in contrast to other forms of dementia, which tend to exhibit a relatively steady decline.
Finally, the most common form of dementia is Alzheimer’s disease, which affects an estimated 5.5 million Americans.[23,24] Alzheimer’s disease is an irreversible, progressive brain disorder that slowly destroys memory, thinking skills and, eventually, the ability to carry out basic activities of living. Most people with Alzheimer’s disease find that the first symptoms appear in their mid-60s and slowly progress over five to 10 years. However, about 200,000 Americans under age 65 have youngeronset Alzheimer’s disease.[25] Dr. Alois Alzheimer first described the progressive changes in 1906. On autopsy, the brains of people with Alzheimer’s are found to contain many abnormal clumps known as amyloid plaques and tangled bundles of fibers called neurofibrillary tangles. Changes in brain structure can now be detected by brain imaging even before symptoms start as neurons die and parts of the brain begin to shrink.
Stages of Alzheimer’s Disease
Before describing the stages of dementia, it is important to distinguish between normal age-related memory loss and symptoms of Alzheimer’s or dementia.[26] Many older adults experience some form of memory loss but are unlikely to have dementia. What is sometimes described as “age-related memory impairment” does not impact the ability to carry out activities of daily living and is unlikely to progress to interfere with those activities. Age-related memory impairment is described as an individual having some difficulties with memory, but these difficulties are not noticeably disrupting daily life and are not affecting the ability to complete tasks as they are normally done. Individuals with this condition have no difficulty learning and remembering new things and have no underlying medical condition that is causing the memory problems.
Alzheimer’s disease and dementia in general are described as progressing through stages.[27,28] In the early stages of Alzheimer’s disease, people can experience mild cognitive impairment (MCI). They may have increasing memory problems but are still able to go on with their daily lives. There are a number of studies underway to try to detect biomarkers or other early signs of this disease. Some common early signs include:[25]
• Memory loss that disrupts daily life.
• Challenges in planning or solving problems.
• Difficulty completing familiar tasks.
• Confusion with time and place.
• Trouble understanding visual images or spatial relationships.
• New problems with words in speaking or writing.
• Misplacing things and losing the ability to retrace steps.
• Decreased or poor judgement.
• Withdrawal from work or social activities.
• Changes in mood or personality.
As the brain damage causing dementia continues, symptoms can progress. The term moderate Alzheimer’s disease describes people with greater memory loss who may have symptoms that include wandering and getting lost, trouble handling money and paying bills, repeating questions, taking longer to complete normal daily tasks and personality and behavior changes.
In the later stages of severe Alzheimer’s disease, people will lose the ability to communicate and will become completely dependent on others for care.
Diagnosis and Treatment of Alzheimer’s Disease
Although there is no single gene that directly causes Alzheimer’s disease, there is a genetic component to the disease.[29] Those people who have a parent or sibling with Alzheimer’s are more likely to develop the disease than those who do not have a firstdegree relative with Alzheimer’s. Those who have more than one first-degree relative with Alzheimer’s are at an even higher risk.
A diagnosis of Alzheimer’s disease is made using a variety of tests and indicators.[30] These involve a health history, mental status exam and blood tests for heart, lung, liver, kidney or thyroid problems to rule out other underlying causes of symptoms. In addition, brain, imaging tests such as a computerized tomography (CT) scan or a magnetic resonance imaging (MRI) scan can reveal brain structure shrinkage. A single proton emission computed tomography (SPECT) scan can reveal blood flow through the brain, and a positive electron tomography (PET) scan can reveal how different areas of the brain respond during certain activities such as reading and talking.
There are currently no cures for Alzheimer’s disease. However, there are some medications that treat some symptoms for a limited time.[31] The U.S. Food and Drug Administration (FDA) has approved two types of medications: cholinesterase inhibitors (Aricept, Exelon, Razadyne) and memantine (Namenda) to treat the cognitive symptoms (memory loss, confusion and problems with thinking and reasoning) of Alzheimer’s disease. While they can slow down or delay the worsening of symptoms, they do not prevent the ultimate progression of the disease.
Dental Treatment and Dementia
Considerations in planning, creating and maintaining oral health for people with dementia can be separated into three primary categories: planning treatment, supporting behavior during dental treatment and supporting daily mouth care.
Planning Treatment
Planning oral health care treatment for people with dementia includes all the same steps in data gathering, diagnosis and treatment planning that are used with people without dementia. However, as is the case when planning treatment for people with a wide variety of complicated conditions, there are additional components of this process that oral health providers must include in order to produce a plan that is appropriate for that individual (FIGURE).[9,32,33]
The first step in planning treatment is gathering data. In gathering data about a patient with dementia, it is important to expand the typical data gathered in a medical and dental history to investigate and understand the following:
• The ability of the individual to function on a daily basis. These abilities are characterized as limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL).[34] ADLs are the most basic activities of daily living including feeding, dressing, bathing and walking. IADLs are activities needed to be able to live independently in a community. These include cooking, cleaning, transportation, laundry and managing finances. Although there are formal assessment tools for these limitations, valuable information can be obtained by including questions about these abilities in a health history. It may be necessary to ask both the patient and someone who lives with them or helps to care for them to obtain a full picture. Limitations in ADLs and even IADLs can predict problems completing “daily mouth care” routines or being able to receive dental care in an office environment.
• Health conditions that can impact oral health and oral health care. Many health conditions can impact oral health or the ability to receive oral health care. One that is of special concern is the high incidence of xerostomia in people with dementia. In a study of individuals in health care centers with mild cognitive impairment or dementia, over 70% of those with cognitive impairment had xerostomia compared with only 37% of those without cognitive impairment.[35]
• Oral health-related abilities of the individual. This includes an understanding of what the individual is able to do. Some people, in spite of a specific limitation in ADLs or IADLs, can still do some things that are important for oral health. This might include performing independently or allowing, with support, completion of “daily mouth care” procedures. It might also include the ability to sit in the dental chair and allow some types of procedures to be performed.
• Social situation of the individual. This includes a full understanding of the individual’s living arrangements, who they live with, whether someone else has responsibility for helping them with ADLs or IADLs and whether they are connected with social service or other supportsystems organizations. It also includes their ability to have transportation to office appointments, as well as their financial situation. It is critical that the oral health professional understand the level of support available for the individual both to know who to work with in planning treatment, who will be responsible for carrying out various aspects of the treatment plan and what kind of care could be realistic for this individual.
• History or ability of an individual to receive treatment in a dental office. It may be possible to predict the individual’s ability to go into a dental office, sit in the dental chair and allow simple or complex dental procedures to be performed based on their history with similar circumstances. Of course, when dealing with a neurodegenerative disorder, a more recent history is more valuable than a history of events that took place in the distant past.
• Who can provide consent. This includes understanding whether the individual is able to provide their own consent for dental procedures or whether someone else is designated and allowed to do so. In general, people retain the ability to provide or deny consent for health care procedures unless they have used legal instruments or processes to assign or have that ability assigned to another legal guardian or decision-maker. The legal term for this ability is “capacity.”[36] Some individuals, at a stage when they still have this capacity, prepare a formal power of attorney designating someone else to be able to make health care decisions for them once they no longer have that capacity. However, all individuals experiencing cognitive impairment may not have done that and also may not be able to provide an informed consent, which requires that they make health care decisions after understanding the risks, benefits and alternatives to any proposed procedures.[37] In some cases, it is not clear to the oral health practitioner whether the individual has the capacity to make an informed consent. It might be possible for the oral health practitioner to ask the patient to repeat back to them what they were told about the risks, benefits and alternatives to the proposed procedure. If they can do that, the oral health practitioner can conclude that they have capacity to make that decision. If they cannot and no one is designated to provide a legal consent, the oral health practitioner may need to contact the patient’s next of kin, social service systems or organizations the individual is involved with or other resources to make that determination. Some social service systems or organizations have the ability to act as a “public guardian” and provide consent for health care procedures.[38–40]
• The prognosis for progression of the individual’s limitations. It is critical that the oral health practitioner understand the prognosis for progression of the individual’s cognitive limitations as well as other associated medical and social conditions. Individuals with similar sounding diagnoses may have a significantly different prognosis for how quickly their limitations will progress. For example, someone with mild cognitive impairment due to a developmental intellectual disability may have the same level of cognitive ability for many years, whereas someone with a similar current level of cognitive ability due to mild cognitive impairment from Alzheimer’s disease may have significantly less ability in a few years. While both individuals may be able to have the same kind of dental treatment performed now, they may differ in their ability to maintain their oral health in a few years. These predictable future differences are important to consider when planning treatment.
• The ability to use various treatment modalities. There are many ways that dental treatment can be delivered. These range from normal dental office routines to the use of behavioral, physical or social supports to the use of pharmacological agents in the office or operating room environment. A consensus development consent process conducted by the Special Care Dentistry Association resulted in a set of guidelines about the use of sedation, anesthesia and alternative techniques for people with special needs.[41,42] The resulting guidelines emphasize the use of nonpharmacological interventions that can reduce the need for pharmacological intervention. This is particularly important in people with dementia who are at increased risk for developing complications following sedation or anesthesia.[43]
• The impact of current oral health conditions. Some oral health conditions, although not “ideal” or even “optimum,” may cause relatively few problems for the individual. In contrast, addressing those problems may be extremely difficult for individuals and their caregivers or support systems. It is important for oral health practitioners to remember that there are situations where “the cure may be worse than the problem.”
Once the oral health practitioner has obtained the information described above, it is important to weigh the various factors and present a plan to the patient or appropriate decision-makers that properly weighs these factors. An example decision-making guide for weighing these factors is presented in the TABLE. The left column lists various factors that would lead to the conclusion that very limited treatment should be provided, maybe only treatment of pain and infection and any other palliative treatment. The right column lists factors that would lead to the conclusion that extensive or complicated treatment could be provided. These factors do not have precise definitions and require the practitioner to assess and weigh judgement. In addition, most individuals will have a mixture of these factors and therefore require careful consideration and presentation of the alternatives and of the risks, benefits and alternatives for that individual before a treatment plan is completed.
Behavior Support During Dental Treatment
If a decision is made to provide dental treatment in an office setting, there are a number of nonpharmacological approaches that can increase the likelihood of having a successful appointment.[44–47] These are, of course, more likely to be successful with people with mild impairment and less likely as the condition progresses.
Some things to try are:
• Obtain a good history about the individual’s behavior in other settings. Find out what things are likely to make an encounter with this individual go well and what might produce the opposite or unintended results.
• Understand and discuss the value of having someone who knows the individual accompany them into the dental treatment area. In some situations, and with some individuals, this may be helpful and for others it may not.
• Schedule appointments early in the day rather than later, as people with progressing dementia tend to have better cognitive functioning in the morning compared to the afternoon.
• Approach the individual slowly from the front and position yourself so you are at the individual’s eye level.
• Use a calm demeanor and voice when speaking to the individual. Be patient, flexible and understanding. Smile.
• Allow enough time for the person to respond (counting to five between phrases is helpful).
• Focus on the person’s feelings, not the facts.
• Introduce yourself and remind them why they are there and what you’re going to do in simple terms. Depending on the level of impairment, you may need to do this multiple times during the appointment.
• Increase the use of gestures and other nonverbal communication techniques.
• Watch for signs that the individual is becoming agitated and be prepared to stop, provide a break or stop the appointment for that day.
• As dementia progresses, people may have good and bad days. If an appointment does not go well on a specific day, it is possible that rescheduling for a different day could produce better results.
It is important to match the strategy used to the individual’s cognitive and communication abilities. Not understanding their abilities could result in being perceived as “talking down” to them or treating an adult as a child when there is no need to do so.
Community-Engaged Oral Health Systems
As individuals experience increased cognitive impairment, the likelihood that they will access dental care in a dental office declines.[48] Therefore, providing oral health services for people with dementia may require reaching them in community caregiving settings. In addition, while a dental office may be needed for procedures that require surgical interventions, it may not be the best environment for many other activities critical to obtaining and maintaining oral health. These include the adoption of daily mouth care routines and the use of minimally invasive medical and early intervention procedures that can be accomplished in community settings outside of a dental office.[49]
There is growing recognition that delivery systems that “bring care to where people are” have significant potential to create important “community-clinical linkages.” This phrase refers to systems that involve and deliver health services in community settings and link those community delivery systems to office- or clinic-based care to create seamless, fullservice systems of care. These systems have important ingredients in prevention and control of chronic diseases including oral diseases.[50] They also allow the reach of dental practices to be extended beyond the walls of dental offices.
According to the American Dental Hygienists’ Association (ADHA), in 2021, 42 states had some form of “direct access” rule that allows dental hygienists the ability to initiate treatment based on their assessment of a patient’s need for dental hygiene services without the specific authorization of a dentist, treat the patient without the presence of a dentist and maintain a providerpatient relationship.”[5]1 In California, the license category that permits these duties is registered dental hygienist in alternative practice (RDHAP)[52] and there is a 150-hour training requirement to obtain this license. The training program this author started and directed for 16 years at the University of the Pacific, Arthur A. Dugoni School of Dentistry and the program this author started at California Northstate University have an emphasis on background and principles for providing dental hygiene services in community settings for traditionally underserved groups including people with dementia.[53] Graduates of these programs are able to bring oral health services to community locations. Further, in California, dental hygienists working in the virtual dental home (VDH) model of care, which links patients to a dentist and source of comprehensive care, can also place silver diamine fluoride (SDF) to stop the progression of dental caries lesions and, with additional training and certification, place interim therapeutic restorations at the direction of the dentist. These services are critical components of oral health systems needed to maintain oral health for people with dementia in community caregiving settings.
The VDH system of care is a system that uses allied oral health personnel including dental hygienists and assistants to bring care to community sites, involve dentists in the care through a telehealth system and keep as many people healthy through interventions performed in the community.[54] It has demonstrated the ability to keep most people healthy in community sites, refer people to dental offices when they need advanced surgical services that require that environment and increase patient and caregiver adoption of daily mouth care routines that are critical for maintaining oral health. This system is an example of a “community-engaged oral health system” that can reach people with dementia who are not accessing regular dental care in office environments.
Summary
Improved living conditions, increasing lifespans and better health care have resulted in a significant increase in the number of people over age 60 living with dementia.[1,2] It is important that oral health practitioners understand conditions that lead to cognitive decline in older individuals as well as strategies for providing oral health care services for these individuals.
Strategies for helping individuals with Alzheimer’s disease and dementia obtain and maintain good oral health include gathering data beyond what is typically included in a health history and understanding the medical, legal and behavioral considerations critical to providing oral health services. In addition, fully effective systems of care for people with Alzheimer’s disease and dementia, referred to here as community-engaged oral health systems, are evolving and demonstrating the value of “community-clinical linkages” for developing full-service systems for care that can help people with Alzheimer’s disease and dementia obtain and maintain good oral health.
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C.E. CREDIT QUESTIONS
September 2021 Continuing Education Worksheet
This worksheet provides readers an opportunity to review C.E. questions for the article “A Team-Based Approach Oral Health and Dementia” before taking the C.E. test online. To take the test, you must first be registered at cdapresents360.com. To take the test online, please go to https://www.cdapresents360.com/learn/course/internal/view/elearning/131/oral-health-and-dementia. This activity counts as 1.0 of Core C.E.
1. Dental practitioners can expect to see relatively more patients with chronic diseases in their practice. In the next decade, the greatest increase in the number of people over age 60 living with a condition is among people with:
a. Dementia
b. Cardiovascular disease
c. Diabetes
d. Vision and hearing impairment
e. None of the above
2. Recent studies have indicated a relationship between learning and memory, complex attention and executive function with poor oral health in old age. The proposed mechanisms for this association include:
a. Reduced ability to perform daily mouth care procedures
b. Difficulty accessing and receiving dental care
c. Reduced salivary flow
d. All of the above
3. Dementia is often characterized as a disturbance of cognitive function including problems with thinking, memory and reasoning. It can include:
a. Aphasia or language impairment affecting the production or comprehension of speech
b. Apraxia or loss of ability to carry out movements such as writing, gait and complex tasks
c. Agnosia or loss of ability to recognize objects or people
d. “Executive function loss” or loss of ability to plan ahead and foresee consequences
e. All of the above
4. Which one of the following is a true statement about Alzheimer’s disease:
a. The most common form of dementia is Alzheimer’s disease
b. The most common form of Alzheimer’s disease is dementia
c. Alzheimer’s disease is a reversible condition
d. Changes in brain structure cannot be detected
5. Some common early signs of Alzheimer’s disease include the following except:
a. Memory loss that disrupts daily life
b. Challenges in planning or solving problems
c. Difficulty completing familiar tasks
d. Confusion with time and place
e. Delirium and depression
6. The first step in planning treatment of a patient with a history of Alzheimer’s disease in the family is gathering the following data except:
a. The ability of the individual to function daily
b. Health conditions that can impact oral health and oral health care
c. The individual’s history or ability to receive treatment in a dental office
d. Who can provide consent
e. Dental and medical insurance coverage
7. Selection criteria for limited treatment for people with dementia include:
a. Poor medical and cognitive prognosis
b. Limited communication
c. Difficulty with providing treatment in a dental office
d. Limited finances
e. All of the above
8. A number of nonpharmacological approaches can increase the likelihood of having a successful dental appointment. These include all of the items below except:
a. Scheduling appointments early in the day rather than later
b. Approaching the individual slowly from the front and positioning yourself so you are at the individual’s eye level
c. Using a calm demeanor and voice when speaking to the individual
d. Introducing yourself and reminding them why they are there and what you’re going to do in simple terms
e. If an appointment does not go well on a specific day, referring the patient to another dentist
9. The virtual dental home (VDH) system of care uses allied oral health personnel including dental hygienists and assistants to bring care to community sites. The VDH system:
a. Involves dentists in the care through a telehealth system
b. Keeps as many people healthy as possible through interventions performed in the community
c. Helps people with dementia who are not accessing regular dental care in office environments
d. Refers people to dental offices when they need advanced surgical services
e. All of the above
10. True or False: In more than two-thirds of U.S. states, “direct access” rules permit dental hygienists to assess patients’ needs for dental hygiene services and initiate treatment without the authorization or presence of a dentist.
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