SNPG902 School Of Nursing Spring 2018

Introduction

Aged care facilities refer to special-purpose health facilities that are designed in a way that helps in providing accommodation and different other kinds of support to older adults. This commonly includes assistance in their intensive care, daily living, and independence of aged and frail person (Broad et al., 2013). In other words, aged care facilities are aimed for providing assistance to those individuals who are no longer able to live in their homes, due to bereavement, illness, disability, and emergency. Their immediate carers are not usually able to address these conditions properly, without help. Dementia is an umbrella term that is used for describing a range of symptoms that are associated with a gradual and progressive decline in memory functions and thinking skills. These symptoms are severe enough to lower the ability of an affected person to perform activities of daily living (Prince et al., 2013). The condition most commonly arises due to physical alterations in the brain. Oral hygiene and health is often overlooked by adults having dementia in, during their stay in aged care centres. Good oral health has been identified imperative for the overall health, quality of life and wellbeing of all individuals. This report will draw evidences from scholarly articles in the form of a literature review, followed by recommendations to manage oral hygiene in dementia affected patients in an aged care.

Literature review

The primary aim of the literature review was to draw evidences from scholarly paper that contained substantive findings and theoretical contributions to the concept of oral health maintenance in dementia patients. The research question for the review was as follows:

What is the relationship between oral health and poor outcome in dementia patients?

The search strategy was developed by the identification of essential key words and terms that matched the research question. Each component of the research question was evaluated for identification of the search terms. The keywords used were ‘dementia’, ‘Alzheimer’s’, ‘older’, ‘elder’, ‘frail’, ‘aged’, ‘oral health’, ‘hygiene’, ‘wellbeing’, ‘maintain’, and ‘manage’. The singular, plural and variant spellings of the terms were also taken into consideration (if any). These terms were combined with the use of boolean operators ‘AND’ and ‘OR’. Combining them with ‘OR’ broadened the retrieved hits, while ‘AND’ helped in narrowing down the extracted results (McGowan et al., 2016). Two databases namely, Google Scholar and PubMed were used for extracting articles that were relevant to the research question. Following an evaluation of the abstracts and full-texts, eight articles were selected for inclusion in the review.

Upon comparing the oral health between older adults with and without dementia, it was found that elderly people diagnosed with dementia most often show a dependence on the nursing professionals and their caregivers. They frequently encounter oral care resistance from the patients that contributes to oral health shortcomings. Univariate analysis conducted for the major target variables and indicated the presence of high amount of plaques in dementia patients, when compared to the non-dementia group. Furthermore, the mean community periodontal index of treatment needs for dementia group reported significant worsening than the counterparts, and all dementia patients reported presence of periodontitis in one of the sextants, thereby proving the correlation between dementia and poor oral health (Zenthöfer, Schröder, Cabrera, Rammelsberg & Hassel, 2014).

Similar findings were illustrated by Noble, Scarmeas and Papapanou, (2013) who presented evidences for the epidemiological associations between reduced oral health and cognitive impairment in dementia. Inattention to oral health was identified as a precursor to old age and was associated with impairment in physical movements, and cognitive difficulties among person aged more than 75 years. The authors also elaborated on the fact that aged people who are less likely to make dental visits on a regular basis are more vulnerable to incidence of dementia. Other authors also presented similar views in relation to the link between risks of dementia and poor oral hygiene. Following the acceptance of proinflammatory states as factors that increase the risks of dementia and cognitive impairment, poor oral health was recognised as a potential exposure that exists in close correlation with systemic inflammatory responses. Gingival bleeding, tooth loss, and loss of periodontal attachment were closely associated with poor cognitive function. The authors were also able to establish a link between psychomotor speed, poor attention, gingival bleeding and absence of periodontal attachment (Stewart et al., 2015).

The impact of oral healthcare on the well-being and quality of life of Alzheimer’s disease patients were measured in another study that successfully illustrated the findings that individuals suffering from AH report more dental decay, fewer teeth and poor oral hygiene. Periodontal disease was also identified as the key factor that resulted in an increase in the OHIP value among dementia patients. Furthermore, the relation between poor quality of life with probing depth less than 4mm and gingival bleeding were clearly established in the literature, thus providing adequate evidence for the failure of dementia patients in maintaining their oral health. Foltyn, (2015) also supported the aforestated evidences in stating that delirium and a decline in neurocognitive capabilities, as commonly observed in dementia patients with poor oral health. The author stated that older adults diagnosed with dementia have often been found to report frailty, falls, incontinence, vision and hearing impairment, and medication noncompliance. All of these are found to directly interfere in their capabilities in taking self-care such as, grooming, dressing and showering, which in turn contributes to their failure to maintain adequate oral hygiene. Mouth pain was also identified as a common problem in dementia patients that directly led to devastating effects in the elderly such as, compound psychosocial issues, disruption in family dynamics and poor appearance. Hence, chronic periodontal infection, rapid dental decay and dry mouth were some common symptoms found in dementia affected person. Tooth loss has also been recognised as a major factor that increases the susceptibility of cognitive decline and dementia among patients. In other words, older men and women with less teeth are considered more likely to develop dementia at a later stage in their life. Lowered masticatory capability was found to impair the nutritional intake, thereby resulting in inflammation that acted as a risk factor for progressive decline in memory (Batty et al., 2013).

Furuta et al., (2013) also gave similar opinion on the association between the two factors and stated that cognitive ability and nutritional status are found in direct correlation with the swallowing function and oral health status among older patients. Upon conducting path analysis, the authors found that cognitive impairment and poor status of oral health create a direct negative impact on the denture wearing, and subsequent dysphagia. All of the aforementioned factors were thus found to directly interfere with the activities of daily living. Controlling bacterial dental plaque with maintenance of oral hygiene was also identified essential, in order to prevent the onset of oral diseases such as, periodontal disorder and caries. The older adults, suffering from mild impairment in their cognitive capabilities are always at an increased risk for such oral disease. The findings elaborated on the fact that gingival inflammation, bacterial plaque accumulation and deficient oral hygiene act as major indicators for cognitive impairment, a characteristic feature of dementia (Gil?Montoya et al., 2017).

Recommendations

Hence, the findings illustrated above state that older patients suffering from cognitive decline due to dementia are unable to maintain proper oral health. The primary recommendation is to implement Tuckman’s teamwork theory to make all the professionals involved in the aged care facility adopt essential strategies for oral health maintenance.

Team management- The four stages of Tuckman’s teamwork theory will be effectively utilised in this scenario. The forming stage might show discrepancies between the opinions and ideas of the healthcare professionals in the team (Betts & Healy, 2015). However, upon utilisation of the theory, gradually all the members will develop a sense of belonging with the team in the storming stage and develop processes and ground rules, thereby clarifying each member’s role in the norming phase. This will be followed by the final performing stage where a due focus will be placed on the team relationship and the intended task of improving the oral hygiene. This theory will focus on the role of a nutritionist in ensuring that the dementia patients are not given food that are rich in sugar content, both at mealtimes and between meals. The storming stage will also make the nutritionist learn the need of restricting consumption of drinks that are not labelled sugar-free (Pretty et al., 2014). This teamwork theory will also make the concerned physician and nursing staff learn about the duties they are entitled with and develop an effective collaboration with other members of the team in order to encourage the dementia patients clean their dentures daily, or assist them in the task (Humphrey & Aime, 2014). Furthermore, an effective teamwork will also promote the dentist to provide consultation to the patients regarding designing of new set of dentures or providing them guidance regarding cleaning of the dentures with the use of a non-perfumed runny soap or denture paste.

Emotional intelligence- Although teamwork is an essential prerequisite in any organisation, it is often categorised as an unnatural act that takes into consideration discipline, strategy and practice for development and growth (Stoller, Taylor & Farver, 2013). Thus, emotional intelligence should be taken into account, while implementing strategies for managing and understanding self and the entire team. Emotional intelligence will get adequately utilised under situations that involve a close monitoring of the individual performance of each team member namely, the dentist, geriatrician, registered nurse, nutritionist, and allied health professionals (Goleman, Boyatzis & McKee, 2013). Social interactions between them regarding their thoughts on the strategies that can be adopted will also promote emotional intelligence.

Quality management- Quality of the care delivered to dementia patients can be managed encouraging adoption of the recommended practices in order to assist the residents for maintaining their oral health. Quality management will also be facilitated by incorporating practice recommendations such as, wearing dentures, cleaning them over a sink or bowl of water, taking dentures overnight, and encouraging other forms of oral care (Free et al., 2013).

Changing care routine- This recommendation will be followed by providing short and clear instructions to all health professionals and adequately demonstrating them what steps should they follow in order to assist the older dementia patients adhere to oral hygiene standards. Management of the condition will also involve providing adequate guidance to the team members regarding the ways by which the teeth and mouth can be taken care of, in the older patients. This can directly be implemented by following the behavioural theory of management that was developed with the aim of responding to the needs to account for motivation and behaviour among employees (Amanchukwu, Stanley & Ololube, 2015). This theory will be applied in order to gain a better understanding of behaviour of the team members in the aged care centre such as, conflict, motivation, group dynamics, enhanced productivity and expectations.

Certain medications are also found to result in dry mouth in patients, in addition to the onset of a range of oral health issues (Thomson, 2015). Thus, effective collaboration needs to be initiated by following the human relations theories, in order to allow all concerned health professionals gain an awareness of the possible avoidable factors that can contribute to a deterioration in the oral health of the patients affected with dementia.

Conclusion

Good dental care has been identified imperative for the maintenance of healthy gums, teeth and tongue. Thus, it can be concluded from the literature that poor oral hygiene is allied with dementia, and further so amid people in progressive stages of the neurological illness. Suboptimal oral well-being such as, dental caries, tooth loss, gingivitis, and edentulousness appear to be related with augmented risks of the development of dementia and subsequent cognitive impairment. Older adults diagnosed with dementia and its associated conditions such as, Alzheimer’s disease thus demonstrate an elevated risk for suffering from tooth decay and associated gum diseases, which can be attributed to loss of ability to brush their teeth in an effective manner. Medications and less attention given to personal grooming habits worsen the condition and complicate the overall oral health status of such older patients. Hence, an effective team work is required for addressing the major health issue and can only be achieved by the implementation of proven management theories. Implementation of the Tuckman’s theory of team management or behavioural theory of management is essential for ensuring that adequate steps are taken by all concerned healthcare staff working in the aged care facility for maintaining oral health and hygiene of the target population.

References

Amanchukwu, R. N., Stanley, G. J., & Ololube, N. P. (2015). A review of leadership theories, principles and styles and their relevance to educational management. Management, 5(1), 6-14. doi:10.5923/j.mm.20150501.02

Batty, G. D., Li, Q., Huxley, R., Zoungas, S., Taylor, B. A., Neal, B., … & Patel, A. (2013). Oral disease in relation to future risk of dementia and cognitive decline: prospective cohort study based on the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) trial. European Psychiatry, 28(1), 49-52. https://doi.org/10.1016/j.eurpsy.2011.07.005 

Betts, S., & Healy, W. (2015). Having a ball catching on to teamwork: an experiential learning approach to teaching the phases of group development. Academy of Educational Leadership Journal, 19(2), 1. Retrieved from- https://www.researchgate.net/profile/Stephen_Betts/publication/305380247_HAVING_A_BALL_CATCHING_ON_TO_TEAMWORK_AN_EXPERIENTIAL_LEARNING_APPROACH_TO_TEACHING_THE_PHASES_OF_GROUP_DEVELOPMENT/links/578b271108ae254b1de13108/HAVING-A-BALL-CATCHING-ON-TO-TEAMWORK-AN-EXPERIENTIAL-LEARNING-APPROACH-TO-TEACHING-THE-PHASES-OF-GROUP-DEVELOPMENT.pdf 

Broad, J. B., Gott, M., Kim, H., Boyd, M., Chen, H., & Connolly, M. J. (2013). Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. International journal of public health, 58(2), 257-267. https://doi.org/10.1007/s00038-012-0394-5

Cicciù, M., Matacena, G., Signorino, F., Brugaletta, A., Cicciù, A., & Bramanti, E. (2013). Relationship between oral health and its impact on the quality life of Alzheimer’s disease patients: a supportive care trial. International journal of clinical and experimental medicine, 6(9), 766. Retrieved from- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798211/pdf/ijcem0006-0766.pdf 

Foltyn, P. (2015). Ageing, dementia and oral health. Australian dental journal, 60, 86-94. https://doi.org/10.1111/adj.12287

Free, C., Phillips, G., Galli, L., Watson, L., Felix, L., Edwards, P., … & Haines, A. (2013). The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS medicine, 10(1), e1001362. https://doi.org/10.1371/journal.pmed.1001362

Furuta, M., Komiya?Nonaka, M., Akifusa, S., Shimazaki, Y., Adachi, M., Kinoshita, T., … & Yamashita, Y. (2013). Interrelationship of oral health status, swallowing function, nutritional status, and cognitive ability with activities of daily living in Japanese elderly people receiving home care services due to physical disabilities. Community dentistry and oral epidemiology, 41(2), 173-181. https://doi.org/10.1111/cdoe.12000

Gil?Montoya, J. A., Sánchez?Lara, I., Carnero?Pardo, C., Fornieles?Rubio, F., Montes, J., Barrios, R., … & Bravo, M. (2017). Oral hygiene in the elderly with different degrees of cognitive impairment and dementia. Journal of the American Geriatrics Society, 65(3), 642-647. https://doi.org/10.1111/jgs.14697

Goleman, D., Boyatzis, R. E., & McKee, A. (2013). Primal leadership: Unleashing the power of emotional intelligence. Harvard Business Press. Retrieved from- https://books.google.co.in/books?hl=en&lr=&id=ibQTAAAAQBAJ&oi=fnd&pg=PR7&dq=emotional+intelligence+teamwork&ots=Rt4MxsGHrY&sig=r2QvaPa92lRm9cysALmc0lqyOGo#v=onepage&q=emotional%20intelligence%20teamwork&f=false 

Humphrey, S. E., & Aime, F. (2014). Team microdynamics: Toward an organizing approach to teamwork. The Academy of Management Annals, 8(1), 443-503. https://doi.org/10.1080/19416520.2014.904140 

McGowan, J., Sampson, M., Salzwedel, D. M., Cogo, E., Foerster, V., & Lefebvre, C. (2016). PRESS peer review of electronic search strategies: 2015 guideline statement. Journal of clinical epidemiology, 75, 40-46. https://doi.org/10.1016/j.jclinepi.2016.01.021

Noble, J. M., Scarmeas, N., & Papapanou, P. N. (2013). Poor oral health as a chronic, potentially modifiable dementia risk factor: review of the literature. Current neurology and neuroscience reports, 13(10), 384. https://doi.org/10.1007/s11910-013-0384-x 

Pretty, I. A., Ellwood, R. P., Lo, E. C., MacEntee, M. I., Müller, F., Rooney, E., … & Wolff, M. S. (2014). The Seattle Care Pathway for securing oral health in older patients. Gerodontology, 31, 77-87. https://doi.org/10.1111/ger.12098 

Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: a systematic review and metaanalysis. Alzheimer’s & Dementia, 9(1), 63-75. https://doi.org/10.1016/j.jalz.2012.11.007

Stewart, R., Stenman, U., Hakeberg, M., Hägglin, C., Gustafson, D., & Skoog, I. (2015). Associations between oral health and risk of dementia in a 37?year follow?up study: the prospective population study of women in Gothenburg. Journal of the American Geriatrics Society, 63(1), 100-105. https://doi.org/10.1111/jgs.13194 

Stoller, J. K., Taylor, C. A., & Farver, C. F. (2013). Emotional intelligence competencies provide a developmental curriculum for medical training. Medical teacher, 35(3), 243-247. https://doi.org/10.3109/0142159X.2012.737964 

Thomson, W. M. (2015). Dry mouth and older people. Australian dental journal, 60, 54-63. https://doi.org/10.1111/adj.12284 

Zenthöfer, A., Schröder, J., Cabrera, T., Rammelsberg, P., & Hassel, A. J. (2014). Comparison of oral health among older people with and without dementia. Community dental health, 31(1), 27-31. https://dx.doi.org/10.1922/CDH_3309Zenthofer05