Age-old interaction: Simple strategies for caring for our elderly dental patients
By Kyle Isaacs, RDHEP, BHS
Working with the elderly is a rewarding experience. Collectively, they have diverse experiences and wisdom to share with the rest of us. Many have lost their friends and significant others and more often than not are alone most of the day. Each time I see a patient in a facility, I am reminded of the poor way we take care of our elders, and it makes me sad to see them lying alone in their beds. It's bad enough that they are in this situation, but add to that the downward spiral of their oral health due to lack of care.
Imagine how this will play out in 2060 when it is projected that there will be 98 million elderly (two times the number of elderly living in 2014).1 With the population of elders growing and more of them retaining part or most of their natural dentition, the probability of increased access-to-care issues, oral health discrepancies, and comorbidities is likely to contribute to a huge health-care crisis among this age group. Did you know that only 20% of those over the age of 75 have gone to a dental office in the past five years-that's only one in five.2 Some of us see the elderly in our practices, but many older people are either homebound or living in long-term-care facilities (LTCF), making it difficult for them to receive the care necessary for oral and systemic disease prevention. This lack of oral care contributes to the precarious state of their physical, mental, and emotional health.
Assisted Living
As people get older, many will have difficulty being able to do activities of daily living (ADLs).1 ADLs can include remembering to take medications, making appointments, bathing, using the toilet, paying bills, preparing food, eating, and cleaning their teeth-many of the things we take for granted. Usually these deficits are due to difficulty with cognition and problem-solving as well as memory and are very common in people with dementia.3
Statistics show that 1.5 million elderly live in some sort of long-term-care facility.1 Eighty-three percent of those living in LTCFs will have difficulty performing ADLs, and for those with dementia, that number is probably closer to 100%.4
Another 2 million elderly are homebound, which accounts for 5.6% of the total elderly population.5 It is likely that many homebound elderly also have difficulty with ADLs. I have seen this firsthand with some elderly people I have known. For those with no family or friends to help, it is more probable that they will not get the preventive care they need. It is no surprise that the majority of those living at home are nonwhite women, have limited finances, and have less education than those not homebound. Of all homebound, only 12% receive any type of health care in their homes.5 Lack of daily oral hygiene and professional care increases systemic disease, hospitalizations, medical costs, poor self-esteem, poor nutrition, and death.
Some of these elderly can still access care in dental offices, but those who cannot slip through the cracks and are often easily forgotten. This population deserves respect and care as much as anyone else. Seniors present with different needs and have different health issues than younger people, so we need to understand these differences to provide the best treatment for this group.
Most of us treat the elderly in our practices, and unless you work in pediatric dentistry or orthodontics, at one time or another you will need to know best practices for working with them, especially those with dementia. As an expanded practice dental hygienist, most of my patients are elderly (older than 65), and many have some sort of dementia, which makes my work challenging. I have seen the ravages of poor oral hygiene among those unable to access care and am frustrated by what I see. I see only a small proportion of those unable to access care and know there are so many more in need.
I am always affected when I care for this population. I am not usually a spiritual person, but I can say that providing oral health care to these people has been a spiritual experience that is hard to describe. For many older patients, we are among the few people who give them attention. We touch them both physically and emotionally, making a difference in their lives. Not only are we providing much-needed oral hygiene preventive services, but we are also making a difference in their day and in their quality of life.
The Alzheimer's Risk
Although it is possible for people to be diagnosed with early-onset dementia (diagnosis younger than age 65), they are more at risk for Alzheimer's disease (AD), one of many types of dementia, as they age. AD is the most common form of dementia, accounting for 60%-80% of all cases.3 AD is yet another systemic disease with a connection to periodontal pathogens. A study conducted at the University of Kansas in 2012 found that subjects who eventually were diagnosed with AD tested positive for these pathogens years before their diagnosis.6 Other studies have revealed similar results, and although it is not clear what the connection is, there are various theories as to the possible link between AD and periodontal diesease.
Ultimately, would it not be safe to say that if we could treat the periodontal disease and decay and-better yet-prevent both, then we might be able to get a leg up on slowing down the progression of Alzheimer's? If nothing else, dental hygienists should be able to save more teeth, help improve health outcomes, and increase quality of life.
We know that the risk for AD increases with age, and we also know that the elderly population is growing steadily. It is likely that AD diagnoses will increase as well, making it imperative that we understand how to work with this group. Due to the cognitive decline, going to a dental office can be stressful. Many AD patients do not do well when taken out of their regular surroundings. It is unrealistic to expect people with dementia to take care of their oral hygiene without being prompted, and you never know how patients will be each time you see them. I know, because I have experienced this firsthand!
Behavioral issues can be a problem when trying to provide treatment, resulting in frustration and resistance to treatment. Without good daily oral hygiene, patients are more likely to have periodontal disease and decay, with all the ramifications of both.
Difficult to Say
To compound the problem, many elderly-especially those with dementia-are unable to communicate effectively when they are experiencing discomfort. When something is just not right or they are scared, many cannot speak or they may have a tough time finding the right words. This can cause frustration with both the caregivers and the patient, resulting in poor communication and lack of understanding about what the patient needs. When working with someone with dementia, you do not want to get into a battle by trying to control them; however, it is easy to fall into this role when the person with dementia acts out.7
Paying attention to nonverbal cues and learning what questions to ask and how to ask them are so important and can make everyone's lives so much easier. At times it can feel as if you are taking care of a baby, but people with dementia are adults and need to be treated with respect. Don't use baby talk; talk to them as you would to any other person in a normal voice. Offer choices and allow them to have a sense of control. Trying to tell them what to do and controlling them will likely create frustration for all.7
When it comes to professional dental hygiene services, there are some things you can try to make the appointment go more smoothly. Before beginning treatment, it is important to face the patient, initiate eye contact, and smile. Always approach them from the front, touch their shoulder, and explain in simple terms what you are going to do.8 If at all possible, ask caregivers what the patient liked to do in the past-e.g., what was their profession, hobbies, music, food, pets, traveling, and the like. By doing this, it will not only give you something to talk about, but it will also offer a distraction to the procedure. This will increase the likelihood of better cooperation during treatment and allow the patient to see you more as a friend rather than a health-care professional, putting them more at ease.7
Remember to pay attention to nonverbal communication-both theirs and yours. A blank stare can mean that they do not understand, and if they are looking at your eyes, they are most likely listening.7 People with dementia generally are more easily distracted, and it is more difficult for them to pay attention. Limiting distractions when providing care is imperative for cooperation.7 Uncooperative behaviors are often nonverbal ways of telling us that something is not right, which can create frustration for everyone.7 I find that I have to work fast and do the best I can in that moment! If a patient asks you the same question over and over, write it down along with your answer and hand it to them, tell them to look at it, and they will feel more in control and you will be less likely to get frustrated.
As the aging population grows, we need to be ready to provide the best care possible-not only to prevent oral disease, but also to cut costs, increase health disparities, promote a better quality of life for our seniors, and provide fulfilling positions for dental hygienists who want to take care of this often-forgotten group. After seeing my elders and providing dental hygiene care, I almost always feel moved and elated. I also know I have made a difference in their day as well as helped them with their physical, emotional, and mental health. Use all the tools you have to alleviate fears and increase communication so you can create a successful appointment.
Power of Music
Hello, vaudeville! It is time to warm up your vocal cords and get ready to belt out some tunes. Did you know that music can be used to either relax or arouse a person to action? Upbeat music will motivate while softer music is more likely to induce calmness.8 Dementia patients are not predictable and can be agitated easily. The more compliant your patient, the more successful the appointment will be for everyone. Singing or humming can go a long way with getting your patient to cooperate, and it helps to diminish outbursts.8 Don't worry if you cannot carry a tune; they won't care!
There is a wide array of music genres, and the various kinds can elicit different reactions. Using music that is pleasant and familiar to the person has been shown to have a positive effect on depression, cognition, difficult behaviors, stress, and agitation.9 Music therapy for people with dementia has been shown to decrease pain, thereby reducing the need for pain medications. It also enhances the feeling of having control of their lives, which increases quality of life, promotes social interactions and an interest in being involved with activities, strengthens the ability to recall information, and promotes movement, which strengthens overall physical health.10 Sounds like a win-win to me!
Kyle Isaacs, RDHEP, BHS, lives near Corvallis, Oregon, where she works four days a week in a dental office. She also owns a company, Miles 2 Smiles LLC, and provides dental hygiene care in churches, private homes, and schools. She is a member of the American Dental Hygienists' Association and serves on the board of trustees for the Oregon Dental Hygienists' Association. She loves to volunteer and comes from a family with many dental professionals. She has been a dental hygienist for 32 years.
References
1. Administration on Aging. Profile of older Americans: 2015. Administration for Community Living. US Department of Health and Human Services website. http://www.aoa.acl.gov/Aging_Statistics/Profile/2015/6.aspx. Published June 2015. Modified May 23, 2016.
2. Gorman A. Why going to the dentist is so hard for the elderly. The Washington Post website. https://www.washingtonpost.com/national/health-science/heres-why-going-to-the-dentist-is-so-hard-for-the-elderly/2015/12/07/2f8050fc-8c80-11e5-baf4-bdf37355da0c_story.html. Published December 7, 2015
3. 2015 Alzheimer's Disease Facts and Figures. Alzheimer's Association. Alzheimer's & Dementia. 2015;11(3)332+. https://www.alz.org/facts/downloads/facts_figures_2015.pdf?123.
4. Scannapieco FA, Shay K. 2014. Oral health disparities in older adults: oral bacteria, inflammation, and aspiration pneumonia. Dent Clin North Am. 2014;58(4):771-82. doi: 10.1016/j.cden.2014.06.005.
5. Cook L. Study: 2 Million Elderly Americans Were Homebound in 2011. US News & World Report website. http://www.usnews.com/news/blogs/data-mine/2015/06/03/study-2-million-elderly-americans-were-homebound-in-2011. Published June 3, 2015.
6. Stein PS, Steffen MJ, Smith C, et al. 2012. Serum antibodies to periodontal pathogens are a risk factor for Alzheimer's disease. Alzheimer's & Dementia. 2012;8(3):196-203. http://www.sciencedirect.com/science/article/pii/S1552526011001129.
7. Brush J, Mills K. I Care: A Handbook for Care Partners of People with Dementia. Bloomington. In: Author Solutions, LLC. 2014.
8. Rosella L, Fanton J. Dental Care for the Challenging Patient. http://www.nyshfa.org/files/2014/04/DentalCarePPHandout.pdf?123. Published April 8, 2014.
9. Music therapy for dementia. A Place for Mom website. http://www.aplaceformom.com/senior-care-resources/articles/dementia-therapy-and-music. Published 2015. Modified April 29, 2015.
10. Schaeffer J. Music therapy in dementia treatment-recollection through sound. Today's Geriatric Medicine website. http://www.todaysgeriatricmedicine.com/news/story1.shtml. Published 2016.
11. Clair AA, Tomaino CM. Education and care. Alzheimer's Foundation of America. http://www.alzfdn.org/EducationandCare/musictherapy.html. Published 2016.
