Content. DementiaManagementCapacityDental problemsPracticalities. 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 personalityThere are a number of types of dementia.
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1. Dementia and Dental Care: Problems and 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
AD + CVD
Lewy body dementia
Parkinson’s disease 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
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
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
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)
Tardive dyskinesia (antipsychotics)
Glossitis (carbamazepine, valproate)
Discoloration of the Tongue.
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
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
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
Necessary to prevent harm
Proportionate to likelihod and seriousness of harm
24. Factors Leading to Oral Disease Forget oral hygiene
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
26. Right Attitude Minimize distractions
Airconditioning, fans, suction devices, phones, TV
Simple explanation, reinforcement
Gentle touching, reassurance
Intervene early in disease
27. Dental Care During Disease Carer education
Artificial saliva MILD
Brush on fluoride gel
Ratchet style Mouth prop?
Maintain old prosthetics MODERATE
Profound local anaesthesia needed
Pain awareness SEVERE
28. Anaesthesia Mivacurium, succinylcholine
Inactivated by plasma esterases
Donepezil 2 weeks
Galantamine 1-2 days
Rivastigmine 3-4 days
29. Dementia Status by Tooth Count
30. Risk Factors for poor oral health in patients with dementia in residential care
Oral hygiene care assistance
Poor use of dental care
31. Higher Caries Incidence in Community Dwelling patients with dementia Male gender
High carer burden
Oral hygiene care difficulties
Use of neuroleptic medication
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
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)
Problems with late stages