Murray Thomson W. Epidemiology of oral health conditions in older people. Gerodontology. 2014; 31:9-16
Office for National Statistics. Living longer: how our population is changing and why it matters. 2018. https://tinyurl.com/y3rwdj8j (accessed January 2021)
Population and fertility by age and sex for 195 countries and territories, 1950–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392:1995-2051
Guzman-Castillo M, Ahmadi-Abhari S, Bandosz P Forecasted trends in disability and life expectancy in England and Wales up to 2025: a modelling study. Lancet Public Health. 2017; 2:e307-e313
Gilmour S. The future burden of disability in the UK: the time for urgent action is now. Lancet Public Health. 2017; 2:e298-e299
Thomson WM, Ma S. An ageing population poses dental challenges. Singapore Dent J. 2014; 35C:3-8
Gil-Montoya JA, de Mello AL, Barrios R Oral health in the elderly patient and its impact on general well-being: a nonsystematic review. Clin Interv Aging. 2015; 10:461-467
Ortega-Martinez J, Cedeño-Salazar R, Requena C Alzheimer's disease: oral manifestations, treatment and preventive measures. J Oral Res. 2014; 3:184-189
McNamara G, Millwood J, Rooney YM, Bennett K. Forget me not – the role of the general dental practitioner in dementia awareness. Br Dent J. 2014; 217:245-248
Hilton C, Simons B. Dental surgery attendance amongst patients with moderately advanced dementia attending a day unit: a survey of carers' views. Br Dent J. 2003; 195:39-40
Fiske J, Frenkel H, Griffiths J, Jones V Guidelines for the development of local standards of oral health care for people with dementia. Gerodontology. 2006; 23:5-32
Emmett C. The Mental Capacity Act 2005 and its impact on dental practice. Br Dent J. 2007; 203:515-521
Jablonski RA, Kolanowski AM, Azuero A Randomised clinical trial: efficacy of strategies to provide oral hygiene activities to nursing home residents with dementia who resist mouth care. Gerodontology. 2018; 35:365-375
Oral healthcare in the older population: An increasing challenge to the uk dental profession Hannah Barrow Martin Ashley Dental Update 2024 48:2, 707-709.
Authors
HannahBarrow
BDS, MFDS RCSEd
Dental Core Trainee, Pinderfields General Hospital, Aberford Road, Wakefield
The percentage of the UK population that is over 65 years old is growing and this brings a number of complex challenges for the dental profession. Patients are struggling to attend for appointments and those who do are attending with increasing physical and mental morbidities and greater care needs, with dementia, in particular, bringing significant difficulties and complications during dental management. This article describes the oral manifestations of dementia and provides clinical advice to practitioners in supporting these patients, and discusses communication, diagnosis, treatment planning, consent, the dental practice environment and home care advice.
CPD/Clinical Relevance: This article highlights the challenges an older population brings to the dental profession, focusing on the complications dementia creates. It describes its oral manifestations, as well as providing clinical advice to help practitioners support these patients in all aspects of their care.
Article
The UK population is undergoing a ‘demographic transition’,1 explained by an increased life expectancy and a fall in the birth rate, leading to an increase in those in older age groups. Increased migration from a large proportion of the earth's countries is bringing greater diversity. In 2016, 11.8 million residents in the UK were aged 65 years or over, accounting for 18% of the population.2 However, by 2066 it is anticipated that this number will increase to 20.4 million residents aged 65 years or over, accounting for 26% of the population, an increase of 8.6 million.
Looking further, this growth predicts that the fastest increase will be in the 85 years and above age group. In 2016, there were 1.6 million people in the UK who were 85 years and above, making up 2% of the population. It is forecast that by 2066, there will be 5.1 million people over 85, accounting for 7% of the total UK population, an increase in 3.5 million. The greatest increase will be among the ‘oldest old,’ those over 85 years (Table 1).3
Year
Age (years)
65+
85+
2016
11.8 million/18%
1.6 million/2%
2066
20.4 million/26%
5.1 million/7%
These increases can be partly explained by mortality rates decreasing over the last 50 years with advancements in medicine. There has also been a fall in birth rate, attributed to improved maternal education leading to fewer childhood deaths, improved reproductive health services meaning contraception is more accessible and a decrease in the under-5 mortality rates owing to advances in disease prevention, including vaccines.4,5
Challenges of an elderly population
These changes in our population will alter our demographic structure and will have wide-ranging implications in all aspects of society, leading to challenges in years to come. Overall, it will mean an increase in the UK's ‘dependency ratio’, the proportion of older people in relation to the working population.6 If the population changes as predicted, it will lead to a greater number of older people and a smaller working population in years to come, therefore increasing the ratio. Economically this means that more people will need supporting, for example via pension benefits, while fewer younger people will be working and paying income taxes. Increased government spending will be required for healthcare and pensions as the needs of the population change.
In relation to healthcare, an ageing population comes with increasing physical and mental morbidities, and therefore more care needs.7 Chronic illnesses specifically place a long-term burden on healthcare systems, and if the population changes as anticipated, the number of people with these chronic conditions will increase.8 In 2016, of those aged 60–64 years, 29% had two or more chronic conditions, and for those aged 75 years and above the proportion rose to almost half.2
There is, therefore, a need to change and adapt the UK health and social care system to meet these increasing needs.9,10 This has been identified in the NHS Long Term Plan11 where it addresses ‘supporting people to age well’.
Within dentistry itself, an older population also presents unique challenges. As people age their oral health needs and risks change. The most common oral conditions among older people are tooth loss, dental caries, periodontitis, dry mouth and oral pre-cancer/cancer.12 The presence of these can have direct effects on an older person's quality of life, for example through mastication and effects on nutrition, speech and self-confidence, and being pain free.
As a profession, in the future we will have the challenge of a greater number of older people who need these conditions managed. Complications will arise in the increased number of people needing domiciliary care, of patients with complex medical histories presenting, and consent and co-operation in patients suffering from diseases such as dementia.
The need to meet the demands of this older population will necessitate a ‘diverse and capable work force’ and the aim to work together in multidisciplinary teams on the surveillance and improvement of oral and general health within the dental field should be a key objective going forwards.13.
Dementia
Dementia is a condition closely associated with the older population and presents unique challenges to the dental profession. It is estimated that 850,000 people have dementia in the UK, but it is predicted that 1 million people will be living with the disease by 2025, and by 2050 this will exceed 2 million.2
Dementia is a term for a set of symptoms that show an ‘acquired and persistent deterioration of intellectual function’ that is severe enough to interfere with a person's daily functioning.14 The specific symptoms a patient displays depends on which part of the brain is affected, and which disease is the cause.
There are different of causes of dementia. Alzheimer's disease is the most common, with a 62% incidence.15 However, there are other causes, such as vascular dementia, mixed dementia, and rarer types, such as Lewy body dementia.
Alzheimer's disease is caused when an abnormal protein (amyloid) surrounds brain cells and another protein (tau) damages the internal structure. Research is ongoing into how these proteins are involved in the loss of brain cells.16 Ultimately, dementia leads to the death of brain tissue and is a progressive, degenerative disease that leads to the ‘gradual deterioration of memory, orientation, emotional stability, abstract thinking, motor skills and personal care’.16 Day to day, this can mean problems in recalling events, following a conversation, judging distances and remembering the day of the week. Mood is also often affected, with those living with the disease becoming easily upset, angry or frightened.
A diagnosis is reached not by a single test, but by a series. Often an initial assessment is carried out in a non-specialist setting. A history is taken of any behavioural concerns, followed by a physical examination, including blood and urine tests, then cognitive testing, for example the Memory Impairment Screen (MIS), and finally a referral to a specialist dementia diagnostic service where structural imaging is often carried out to finalize a diagnosis and rule out any other causes of the symptoms.17
There is no cure for dementia, but certain medications can alleviate symptoms or temporarily slow the progression of the disease in some people. Research into risk factors shows age is the main risk factor in many dementia cases; however, there is evidence that smoking can increase risk, as well as there being links to alcohol use, poor eating habits and lack of physical activity. Although there is no cure for dementia, people can live with the disease for several years as it progresses.
In a similar, but opposite, way to a child gradually recognizing the need for, understanding of and dexterity to undertake daily hygiene routines, a person with dementia gradually loses the ability to shower, wash their own hair, shave or cut their nails. Because keeping their own mouth adequately clean every day requires a similar understanding of routine, of dexterity and of use of specific equipment, daily dental hygiene habits will also be lost as the disease progresses.
Oral manifestations of dementia
Oral health is likely to decline for a number of reasons when people are living with dementia. They have a unique set of factors that compromise oral health and increase their risk of dental disease. Symptoms caused by dental disease can produce more challenging behaviour in those with dementia as they struggle to communicate issues in their mouth.
Dental problems occur more frequently in people with dementia. This is often because oral care begins to be forgotten, as there is disinterest by the person and they can become resistant and combative when attempts are made to help them.16 Oral hygiene is thus compromised and increased levels of periodontal disease, higher levels of decay and poorly fitting dentures may be found.18 Additionally, many people living with dementia require medications, such as antidepressants or antipsychotics, that can cause xerostomia, vomiting or gingival overgrowth, making them more at risk of oral disease such as caries. Dentures are successfully removed less often and misplaced more often, especially in hospital and care home environments. They are also cleaned less regularly and tend to lose stability and occlusion as dementia progresses. Decreases in salivary flow and reductions in motor skills also contribute to poor oral health.14
As dementia progresses the person loses the ability to communicate dental problems. This can lead to the pain or discomfort that the person feels being expressed in a different way, examples include pulling at the mouth or face, avoiding food, aggression and withdrawal. Consequently, patients are more likely to present with behaviour that challenges the provision of healthcare.
Attendance for dental appointments is also less likely, with carers of people with dementia reluctant to take those they care for to the dentist.19 Dental appointments can cause agitation, disorientation and challenging behaviour for those living with dementia and who may also be less able to tolerate dental procedures.
This is clearly demonstrated in a thought-provoking short film, ‘The Appointment’ by Health Education England (HEE) aimed at dental professionals, but also suitable for health and social care staff and carers, to raise awareness of the issues faced by a person with dementia when attending a dental appointment.20
Clinical advice
There are many ways individual dental practice teams can support people living with dementia, who are likely to have increased difficulty accessing and accepting dental care.15,16,18
Communication
The following are suggestions to enhance communication with patients with dementia:
The first way is through communication and behaviour with patients, as this can make a significant impact to how those living with dementia cope with a dental appointment. Calmer patients lead to improved compliance and more effective treatment.
From the initial meeting, greet the patient as you would any other, this allows you to assess hearing, communication and understanding. If possible, shake hands and tell them your name and role. Always address the patient by their preferred title and refer to people and things by their name, for example, ‘your daughter, Sarah.’
Ensure the patient is accompanied from the waiting room to the surgery so that the unfamiliar environment causes no stress. Keep language simple and to the point when speaking, using short sentences and giving simple commands one at a time. If the patient has difficulty hearing, or noise makes them anxious, turn off background noise.
On meeting the patient find out what they did for a living or what their interests are. This can make the patient feel more comfortable and often sets up a situation for improved compliance during the appointment. Similarly, reminiscing can allow for a talking point and allow the patient to relax in your presence and in the foreign environment. The use of music can be relaxing and comforting too. Check with the patient or the family/carer whether the patient has a favourite artist or genre. Ask reception staff to enquire about these things prior to the appointment, if possible.
Avoid showing frustration when communicating with the patient. Accept that they will get confused and try to avoid correcting them, as this can lead to them feeling angry or upset. In the later stages of dementia, a patient may speak language that is unrecognizable, try to nod, smile and respond to this as it can help in settling the patient. All the while looking out for clues, eg words or body language, that may help you identify any problems.
When taking a history ask about one aspect at a time. Sometimes the response may be unrelated; rather than correcting the person, try to distract them and draw them back to the area of interest.
Booking appointments at the optimum time for a patient in terms of behaviour and carer family availability, can help to make the most of an appointment, as well as making sure alterations and reminders are communicated in an appropriate way. Consider a telephone reminder on the day before.
Treatment planning
The following are suggestions to facilitate the clinician's treatment planning for patients with dementia:
Dental treatment planning for a patient with dementia should be based on the clinician's judgement together with the patient, the carer and patient's family, if possible. It is important to establish an individual long-term care plan with the objective to ‘eliminate pain, control infection and prevent new disease’. Treatment plans should be flexible and anticipate a decline in the patient's health over time. Oral care should be planned to prevent serious problems in the later stages of the disease.
In the early stages of dementia, employ ‘aggressive prevention and recall’ and ideally perform restorative dental treatment that is high quality and requires low maintenance. This can usually be done in general dental practice. Speak to the patient, and their carer or family, about their oral hygiene routine and how adaptations can be implemented, eg an adapted handle on the toothbrush. Prescription of high fluoride toothpaste should also be considered, with professional application of fluoride varnish twice yearly also being valuable.15 These actions are in keeping with ‘Delivering Better Oral Health’ for patients at higher risk of developing dental disease.21
In moderate stages of the disease, aggressive prevention and recall should continue to be carried out; however, referral to specialist services for sedation or general anaesthesia may occasionally be necessary for any treatment required.
In advanced stages of the disease, maintaining oral comfort is key. Complex and time-consuming treatments should be avoided and interventions should be as non-invasive as possible.
Discussion with the patient and family/carer about the impact of medications on salivary flow, and how to reduce and manage this impact is important, as well as discussing potential problems with chewing or swallowing.
Providing a written treatment plan to patients that has enough detail that it can be understood by the patient and the carer/family is advantageous. Also ensure to repeat and explain the treatment plan at every appointment.
As dementia progresses, it can be increasingly impractical for people living with the disease to attend the surgery, as it is outside their normal environment. In this situation, domiciliary care may be the best option. Dental surgeries can direct patients to their local domiciliary provider.
The British Society of Gerodontology guidelines on the standards of oral health care for people with dementia can be helpful when considering strategic, long-term plans for people.22 The guidelines also discuss how construction of a removable prosthesis at the earlier stages of the disease can prove succesful. A well-fitting denture can be copied or easily modified if needed at a later stage. The guideliness also cover denture marking, which can be valuable when those living with dementia spend their time in care homes or respite care, allowing dentures to be returned if misplaced and found.
Generally, those caring for the person living with dementia, such as in a nursing home or in a domiciliary environment, are unlikely to be competent or confident to deliver mouth care for the patient. It is valuable to train and guide carers on how to deliver simple but effective mouth care, such as tooth-brushing and denture hygiene. Such training is free to access online at: www.futurelearn.com/courses/mouth-care-matters and https://www.e-lfh.org.uk/programmes/mouth-care-matters/
Consent
In the middle and later stages of dementia, there will be a point where the patient no longer has capacity to consent to their dental treatment. For consent to be valid, it must be given by a person with the capacity to make the decision, it must be voluntary, based on appropriate information and be understood. Being unable to communicate information or retain and weigh up options deems a person unable to make a decision regarding their care.23
During late-stage dementia, consent should be gained in accordance with the Mental Capacity Act, 2005. This states that the treatment must be in the patient's best interests and must consider, as far as practicable, the person's wishes, feelings, beliefs and values. Commonly, a person appointed by the patient to make decisions on their behalf will hold a lasting power of attorney (LPA). In this case, ensure that the person is authorized to make decisions on healthcare, as they may only be authorized to make decisions of a financial nature. If there is no appropriate LPA in place, a clinician must proceed with a best interests' decision; however, it is advisable to get a second opinion from a colleague.
Other aspects of consent to be aware of are independent mental capacity advocates (IMCA), do not attempt resuscitation orders (DNAR) and advanced healthcare directives. An IMCA is appointed when a person has no family or friends for support. The IMCA represents them in any serious medical treatment decision, for example, a dental clearance that can be life changing.24 It is also important for clinicians to be aware of DNARs, especially if a general anaesthetic is involved in the treatment plan. Lastly, advanced healthcare directives are decisions made by the person about their future at a time when they still have capacity to make a decision. Being aware of these legalities is vital to be able to gain valid consent from a patient with dementia at each stage of the disease.
Diagnosis
A timely dementia diagnosis can help to facilitate a long-term oral care plan and means that patient will be more receptive to treatment and can take an active role in decision-making. As dental professionals see their patients regularly, often for many years, they are more likely to be able to recognize changes in a patient's behaviour that may indicate a possible dementia diagnosis. If cognitive impairment and memory deterioration are noted, it is useful to mention to the patient that contact is being made with their general medical practitioner for support. Abiding by GDC standards and seeking consent for this is important, as well as thoroughly explaining your reasoning. Clinicians need to be prepared to justify decisions and actions taken. Dementia remains widely undiagnosed with less than half of those living with the disease in England having received a formal diagnosis.
Dental practice environment
The physical environment of the dental practice can have an effect on a person's behaviour and compliance. The NHS recommends seating with arms to aid the infirm and that enough seats are available to enable carers or family members to sit beside the person living with dementia.16 Additionally, having a quiet waiting area can be beneficial as being surrounded by unfamiliar noises can cause distress. Well-defined areas with good lighting can help reduce confusion, and clear colour contrasts on furniture and doorways allows it to be more easily seen and used appropriately. Clear signs at the appropriate height will help people orientate themselves, especially for the toilets and the exit. Using bold text and avoiding over stylized images can also be of benefit.25 Finally, plain and even flooring is recommended, as people with dementia are often unsteady on their feet and can interpret patterns or shine as hazards they could trip over.
Home care advice
Most people with dementia will either remain living at home or move to live in a care or nursing environment. It is unfortunately not yet routine practice, for care staff to carry out an oral health assessment, thoroughly and regularly document the oral health status and what care has been delivered and whether attempts at treatment have been unsuccessful.
Ensuring that oral care is undertaken at home, to as high a standard as possible, is important for oral health. It is widely known that inadequate plaque control is the primary aetiological factor for caries and periodontal disease.26,27 For those people with dementia living in nursing or care homes, oral care provided by nursing home staff can often be challenging for carers. Resistance is often met when attempting to carry out oral care for these patients. Care-resistant behaviour (CRB) is displayed by 63.4% of residents,28 with 95% of staff who encounter this behaviour simply omitting oral care. Certain strategies reduce the intensity of the resistance, allow for longer durations of oral care to be provided, and mean residents are twice as likely to be receptive. This can lead to a higher standard of oral health and reduce the likelihood of problems.
For patients displaying CRB, the recommended strategies to use are:27
Establish rapport: approach the person at eye level with a pleasant and calm manner;
Provide oral care in front of a sink and/or mirror to attempt to trigger memories and habits;
Avoid ‘elder speak’;
Chaining: carer to start the oral care and encourage the person to finish it;
Cues using gestures;
Distraction: eg place a familiar item in the person's hand while providing oral care;
Bridging: the carer shows the toothbrush to the person, mimics brushing their own teeth, then gives a spare toothbrush to the person who may mirror the brushing action;
Rescue: a second carer is brought in if resistance is met with the first;
Hand over hand: the care gently guides the hand of the person and brushes together.
Discussing these methods with carers and relatives, and educating them about these strategies can help them achieve a better standard of oral care at home.
Conclusion
Dementia has many manifestations and it is important, above all, to treat people living with the condition with kindness and respect. It is important to ensure that fear, stress and potential embarrassment for the person is minimized, and support and back up can be provided for all involved with the person and their care.22 Dental professionals have a responsibility to look after dementia patients' oral care and are often best placed to spot possible memory problems early. Improving skills in the complex management of dementia patients is essential with the population demographic changes that are expected in the coming years. Training in mouth care techniques for other healthcare professionals and the families of those living with dementia is of increasing importance.
Further resources
Charity resources
Training all members of the dental team to become ‘Dementia Friends’ is valuable. This is a scheme run by the Alzheimer's Society that aims to change the way people think, act and communicate towards people living with dementia. The 45-minute session is designed to help understand what it is like to live with dementia and how carers can apply this understanding. Local sessions are available and can also be arranged for a dental practice on the Dementia Friends website (www.dementiafriends.org.uk/).
Some patients may have a copy of ‘This is me’. This is a booklet produced by the Alzheimer's Society for people living with dementia. Not all people living with dementia will have this booklet, but it is worth acquiring and suggesting it to carers/family. The booklet contains information, such as present and past life history, how the patient communicates, what they like to be called, next of kin, likes/dislikes and interests (www.alzheimers.org.uk/get-support/publications-factsheets/this-is-me). Table 2 lists sources of further information and reading.
