What are the oral health considerations for older adults with cognitive impairment? Treatment and Management

This summary is based on the article published in the Dental Clinics of North America: Cognitive Impairment in Older Adults and Oral Health Considerations. Treatment and Management (October 2014)

Leonard J. Brennan, DMD, Jason Strauss, MD

Context

• Cognitive impairment is a disease or condition that presents in individuals causing them to have trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life.¹
• Cognitive impairment is often first recognized by family and friends when a person begins to struggle with simple daily tasks.² Then, as the impairments increase to a more severe level, the problems with reading, writing, and understanding prevent independent living. ³
• Fear of “losing one’s mind” and the loss of personal control may be the single greatest worry and concern of the aging and a constant threat for everyone else.⁴
• Impairment is often followed by oral health deterioration, characterized by a dramatic and quick progression of periodontal disease, caries, and tooth loss.^{2, 5}
• The dentist and the dental team are called on to treat these patients in nursing homes and in office situations to maintain the patients’ oral function, diagnose pathology, restore esthetics, and deliver palliative care.

Purpose of the article

The article discusses types and causes of cognitive impairments, the demographics of the disease in our aging population, reviews patient management protocols, and stresses the importance of using an interdisciplinary approach to delivering rational patient care.

Key Points

• Worldwide incidences of degenerative cognitive diseases are increasing as the population ages. This decline in mental function frequently causes behavioral changes that directly affect oral health.
• The loss of interest and ability to complete the simple tasks of brushing and flossing can cause a rapid development of hard and soft tissue diseases that result in decreased function and increased dental pain.
• The challenge for the dental community is to understand and to identify the early signs of cognitive dysfunction so as to develop a rational treatment strategy that allows patients to comfortably maintain their teeth for as long as possible.

• The importance of a complete medical and dental history is essential to appropriately formulate a treatment plan for the patient.⁶ If possible, the health history should be sent to the care providers to be completed before the dental visit. If there are any questions that need to be answered they can be researched before the patient arrives.

Early Intervention

• Knowing that many cognitive impairment disorders are progressive, intervention in the early course of the disease is important.^{5, 6} Patient cooperation is often better. Patients tend to be more flexible and adaptive.
• It is of utmost importance to educate all caregivers and members of the caregiver team on the importance of diet, oral hygiene, ⁵ and the effect of medication on decay and periodontal disease.⁷

Older Adults Do Not Communicate Dental Problems

• Senior patients do not complain about or generally discuss the dental problems that cause them stress. Rarely do they mention dental pain, a denture sore spot, or inflamed periodontal tissues.
• The dentist must carefully ask questions and follow-up on their answers to be sure that “no pain means no pain and no problems really mean no problems.”⁸
• Check with all caregivers to obtain information that might provide insight. With the added component of cognition, it is extremely difficult to elicit a clear picture of dental problems.

Communication and Behavioral Strategies for the Cognitively Impaired

• Communication is challenging with an adult with cognitive impairments. Start each conversation with a self-introduction in a soft reaffirming tone and repeat if the patient becomes distracted or frightened.⁹
• It is important to make the patient feel secure with good eye contact, a gentle gesture, or reassuring smile. Always try to avoid patronizing talk with impaired seniors.⁹ Try not to use the words “dearie” or “sweetie.”⁹ Patients feel less anxious if there are fewer distractions in the operatory, people included, when treatment is initiated.¹⁰
• The use of a non-pharmacological approach in treating patients should be used whenever possible.53 Pharmacologic management can be an important tool, but should be used cautiously because they can elicit adverse and variable effects on individuals.^{11, 12}

Treatment Planning Considerations and Rational Care for the Cognitively Impaired

• After a patient is diagnosed with impairment, it is important for the dentist to begin early intervention.¹³
• At first diagnosis, a unified approach to care needs to be developed. It is important to take into consideration the patient’s personal abilities, skill levels, and interest in home care before designing a treatment plan.¹⁴
• Other factors that may influence decision making include social, economic, financial, family, medical, and transportation ssues.^{14, 15}
• Successful care of adults is not task oriented but is centered on the needs of the patient.¹⁵
• The Canadian Dental Association’s Committee on Clinical and Scientific Affairs produced a document on rational dental care for the cognitively impaired elderly patients for seniors that are homebound and living in LTC facilities, emphasizing the following ¹⁵:
• Establishing good preventive technique while the older patient is still relatively healthy.
• Diet education, hygiene education, and patient-specific measures to increase tooth resistance is of primary importance.
• Rational dental care individualized to a patient’s needs.
• Individualized treatment protocol for the patient that take into consideration the person’s ability to handle stress, and reasonable treatments that are less extensive.
• Consider the ability of a patient to maintain dental treatment.

The Importance of Using an Interdisciplinary Approach in Providing Dental Treatment for the Cognitively Impaired Patient

• The interdisciplinary model may provide the most complete working example for successfully treating seniors. ¹⁶
• Individuals of different disciplines need to collaborate in developing the best treatment plan for the patient and then continuously communicate and monitor progress.
• It is equally important that the entire disciplinary team understand the direction and goals of the dental treatment plan. ¹⁶

References

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4. Research! America. America speaks: poll data summary, vol. 7. Alexandria (Egypt): Research! America; 2006. p. 25–6. Available at: http://www.researchamerica.org/uploads/americaspeaksv7.pdf
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10. Kayser-Jones, W.F. Bird, M. Redford, et al. Strategies for conducting dental examinations among cognitively impaired nursing home residents. Spec Care Dentist, 16 (2) (1996), pp. 46-52.
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14. Ettinger RL. Clinical decision-making in the treatment of elderly. Gerontology 1984;3(2):157–65.
15. CDA Committee on Clinical and Scientific Affairs. Best practices for aging adults in private practice. Dent Assist 2012;81(1):38.
16. Satin DS. Health management for older adults: developing an interdisciplinary approach. New York: Oxford; 2009.