Alzheimer's Disease and Cognitively Impaired Elderly: Providing Dental Care

With the number of adults reaching older ages, the number of Americans who develop Alzheimer's disease and other neurological impairments will also increase. The dental management of these patients requires a great deal of understanding and patience coupled with background knowledge of the disease and proficiency in providing behavior modification techniques. This paper discusses five major areas that dental practitioners should consider prior to caring for patients with Alzheimer's disease or other neurological impairments.

On Nov. 4, 1906, Alois Alzheimer gave a presentation to a group of psychiatrists in Tubingen, Germany. In his lecture, he described for the first time a form of dementia that subsequently became known as Alzheimer's disease. The subject of Dr. Alzheimer's lecture was Auguste D., a 51-year-old woman from Frankfurt, Germany, who had been admitted to the Frankfurt hospital on Nov. 25, 1901. On examination, Dr. Alzheimer found a striking cluster of symptoms that included reduced comprehension and memory, aphasia, disorientation, unpredictable behavior, paranoia, auditory hallucinations, and pronounced psychosocial impairment. Dr. Alzheimer continued to follow Auguste D.'s case until her death on April 8, 1906. At autopsy, he studied the neuropathological features of her illness and found that the brain showed numerous plaques, neurofibrillary tangles, and arteriosclerotic changes.¹

More than 90 years have passed since Dr. Alzheimer shared his findings. Since that time, millions of people have been diagnosed with similar symptoms and given a diagnosis that is now feared more than any other in older adults: Alzheimer's disease. Because Alzheimer's disease affects the ability of a person to remember, think, and reason clearly, it is devastating not only to the person diagnosed with the condition, but also to the family that must deal with the implications of taking care of someone who can no longer take care of him- or herself.

Today, in the United States, it is hard to find a family that does not either directly or indirectly know of someone with Alzheimer's disease. Dentists should be aware of the growing number of older patients with cognitive impairments such as Alzheimer's disease. By understanding how these conditions can be managed, dental professionals can help make a positive impact on not only the oral health of their Alzheimer patients, but also the quality of their patients' families lives.

Definitions and Prevalence

The cause of Alzheimer's disease is not known, although risk factors include being of an advanced age (85 or older),² having trisomy 21,³ having a previous history of severe head trauma,⁴ or a having a first-degree relative with the disorder.⁵ A diagnosis of probable Alzheimer's disease² is made in adults age 40 to 90 years old when the patients have neurologic deficiencies in two or more areas that have progressively worsened, without disturbance in consciousness and without other medical problems that could explain the cognitive changes. A diagnosis of definite Alzheimer's disease² can only be made post-mortem, when the neuropathologic findings (which Dr. Alzheimer carefully noted in his case report) of neurofibrillary tangles and neuritic plaques are found in abundance in the cerebral cortex.⁶ There are no laboratory tests available that can positively diagnose Alzheimer's disease. The physician must rely upon clinical signs and symptoms to exclude other types of dementias, which may be reversible or treatable.

Dementia is a permanent or progressive decline in several dimensions of intellectual function that interferes substantially with activities of daily living.⁷ More than 70 disorders can cause dementia, including depression, drug toxicity, metabolic disorders, and central nervous system infections. Alzheimer's disease is, however, the most common cause by far. The actual prevalence of Alzheimer's disease is difficult to determine, but in a community-based study by Evans and colleagues in East Boston, Mass., 10.3 percent of the people age 65 and older met the criteria of probable Alzheimer's disease.³ The prevalence of the disease increased with the age of the group: 3 percent for people age 65 to 74; 18.7 percent for ages 75 to 84; and 47.2 percent for those age 85 and older. If these results are representative of other communities in the United States, they suggest that there are about 4 million Americans with Alzheimer's disease. If the incidence of the disease continues at the present growth rate of older Americans, there will be 9 to 10 million people with Alzheimer's disease by the year 2030. It is also one of the leading causes of death for elderly individuals.

Clinical Progression: Symptoms and Signs

The most frequent and characteristic early symptom of Alzheimer's disease is the gradual onset of short-term memory loss, such as difficulty remembering names, recent events, and conversations; misplacing items; missing appointments; and repeating questions or answers during conversation. Because these mild memory difficulties are often present in older adults in the absence of disease, many of them worry that they are developing Alzheimer's disease. This age-associated memory impairment is generally believed to be part of normal forgetfulness. Where pathologic changes apparent in Alzheimer's disease begin is still unclear, but they tend to be based on a person's ability to function in society.

The progression of symptoms and signs in Alzheimer's disease varies among individuals; but, to help categorize treatment strategies, the clinical course is usually divided into three stages.⁸ In addition to memory loss, someone in the early stage may be unable to tell what day it is, the time of day, or where they are. Patients may display less sparkle in personality and appear emotionless or less energetic or willing to begin something. In this stage, patients are likely to make errors in judgment, such as making a mistake when driving or getting lost when going to or from familiar places (the home of a relative, a store, or a doctor's office). Finally, patients in this stage may not be able to think of certain words to use when speaking, have difficulty learning new things, and become easily angered.

The middle, or moderate, stage is characterized by continued progressive cognitive losses and may advance from the early stage in as little as a few months or as long as a few years. Patients develop rapid and widespread memory losses and become slower in movement or in speech or unable to communicate. They may hoard common items, such as napkins or pencils, and lose the ability to care for themselves (can no longer dress, bath, cook, or eat on their own). During this stage, patients become increasingly interested in themselves and less interested or sensitive to other people's feelings. In many cases, patients pace continuously during waking hours and may wander off if not supervised. Many Alzheimer patients also develop perceptional problems, such as being unable to recognize their own face in a mirror or images on television, and may display personality changes such as becoming physically violent or displaying verbal outbursts over minor daily situations.

In the severe, or late, stage, patients have great difficulty understanding instructions or simple language. They completely lose the ability to remember and speak, uttering only meaningless phrases or repeating words or phrases over and over again. Typically, they are reluctant to go anywhere "different," such as leaving home or the nursing facility, and they may be unable to recognize even family members or close friends. Most patients are unable to respond appropriately to questions and constantly repeat phrases or invent words or often will respond with the first thing that comes to their minds. In this last stage, patients need total care with activities of daily living such as dressing, bathing, eating, and using the bathroom and commonly have behavior problems such as aggressiveness or anxiousness. Typically the progress of Alzheimer's disease is gradual, and some patients' conditions plateau for a time, but the end stage is coma and death.

Oral Findings

A number of studies^9,10 validate clinicians' observations that Alzheimer patients have poor oral hygiene and increased prevalence of dental and periodontal disease. This is mainly believed to be a result of the individual's inability to perform routine and effective oral hygiene procedures. Other studies^11,12 highlight the importance of salivary function and demonstrate that patients with Alzheimer's disease may be at increased risk for salivary gland dysfunction, which further increases the risk for dental diseases. It is important that the patient receive assistance with oral care from either a caregiver (spouse, sibling, or children) or nursing professional as the disease progresses from the early to the late stage.

Medical Treatment

There is no single drug available for treating the complete range of problems seen in Alzheimer's disease. However, the drug donepezil hydrochloride (Aricept, approved in 1997), offers the best therapy available to slow progressive memory loss. The rationale for the use of Aricept stems from the clinical finding of decreased brain neurotransmitters (primarily acetylcholine) in Alzheimer patients' brains. Aricept and its predecessor, Cognex (Tacrine), approved in 1993, work by increasing the amount of acetylcholine in the brain. Cognex can cause liver damage, and Aricept can cause an irregular heartbeat, especially in patients with heart conditions. Although, neither drug reverses the pathogenesis of Alzheimer's disease, both may delay progression for up to six to 12 months for patients in the early or moderate stages.¹³

In addition to drugs that help acetylcholine-producing cells survive longer and slow or prevent Alzheimer's disease, researchers are systematically investigating numerous other drugs and/or compounds that may be helpful. There are 19 pharmacologic agents in various testing phases; manufacturers are searching for medications that may be helpful in treating Alzheimer patients.¹⁴ Research is centered around the following agents, which may be helpful in preventing the onset of Alzheimer's disease or treating the symptoms at higher doses: Vitamin E, ginkgo biloba, prednisone, estrogen replacement therapy, and aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).¹³

Dental Management

The dental management is similar for patients with Alzheimer's disease and those who have other neurological impairments. Although a number of treatment planning issues could be considered, the following five areas are critical in patients with Alzheimer's disease or neurological impairments:

* Presence or absence of pain;

* Presenting dental condition;

* Stage of disease;

* Caregiver's concerns; and

* Dentist capabilities.

A brief description of each of these areas will follow with the specific recommendations for the practitioner.

Presence or Absence of Pain

All dentists have a good working knowledge of the symptoms commonly present in dental pain. In patients with Alzheimer's disease or other neurological impairments, the ability to communicate pain or the absence of acute signs will often be the norm. For example, it is common for dental symptoms of pain in patients in the moderate or late stages of Alzheimer's disease to be manifested only by a sudden worsening of behavior; moaning or shouting, refusal to do certain things; or increased restlessness (Table 1).

Clinicians who are attempting to determine if there is a treatable cause must use the history of the patients' baseline behavior as an even more important indicator of the patient's possible source of pain. The caregiver (spouse, child, nurse, etc.), whether in the home or nursing facility, is the best person from whom to obtain this history.

If pain of a dental origin in the Alzheimer patient is diagnosed, aggressive treatment to eliminate this pain should take precedence. If pain of a dental origin cannot be diagnosed through a clinical exam alone, a careful workup including dental radiographs should be performed to rule out a possible dental source.

Presenting Dental Condition
Using standard criteria such as the number of teeth remaining, oral debris present, level of oral hygiene, broken or carious teeth, periodontal status (gingival redness, bleeding on probing, mobility of teeth), and previous degree of restorative dentistry provided, a patient can be categorized as having good, fair, or poor dental health. Treatment plans determined for patients who have poor oral health will be much different from those with a fully restored dentition. The presenting dental condition is probably the best indication of a patient's past motivation and desire for continued dental treatment. For example, a patient who had seen a periodontist for 20 years in the moderate stage of Alzheimer's disease would likely continue to maintain her teeth if he or she were able to communicate his or her desires to the dentist.

Stage of Disease

Although presenting dental condition is important, it must not be used alone in determining the extent of dental treatment or whether dental care should be aggressive or postponed. The stage of Alzheimer's disease (early, moderate, or late) is also an important consideration. Because Alzheimer's disease is progressive, patients will eventually lose their ability to provide for their own oral care. In the later stages, dental treatment should focus more on maintenance and less on restorative/rehabilitative care. A case in point can be seen from the previous example. Although a patient may have maintained his or her teeth for more than 20 years, if he or she is in the moderate to late stages of Alzheimer's disease and the presenting dental condition is now severe periodontal disease, extracting the remaining teeth may be the best treatment option.

There are many different mental status tests that can be used to place Alzheimer patients into early, moderate, or late stages. The most widely used is the Folstein Mini-Mental Status Exam¹⁵ (Figure 1). With 10 items and a maximum possible score of 30 points, a person would be considered mildly impaired (early stage Alzheimer's disease) with a score of 18 to 24. If the score is less than 18, this would reflect moderate to severe impairment (moderate to severe Alzheimer's disease).

Basic guidelines for providing dental care can be linked to a person's stage of impairment (or Alzheimer's disease) and can be seen in Table 2.¹⁶ The recommendations in this table underscore the importance of good maintenance, frequent recalls, and the role of a caregiver.

Caregiver Concerns

Anyone who provides care to an impaired person, such as an Alzheimer patient, can be called a caregiver. In most cases, the spouse of the affected person serves in this role, although anyone can serve as a caregiver (daughter, son, family member, neighbor, nurse, home health worker, or friend). This person serves as the primary decision maker for patients in the moderate to late stage of Alzheimer's disease and is usually the single most important factor in determining if dental treatment will be sought or in deciding the extent of care.

Initially, caregivers have minimal involvement in dental care. As the disease progresses, however, their roles becomes increasingly important -- ranging from being the legal authority for obtaining an informed consent for treatment, to giving the medical and dental history, participating in the treatment plan, and being the key to a successful home care preventive dentistry program.¹⁷ Dentists need to be aware of the importance of the primary caregiver and train him or her to care for the patient's mouth in the early stage with the expectation of eventually assuming this role completely as the person with Alzheimer's disease loses this ability.

Dentists should also understand the importance in obtaining consent from the caregiver prior to providing dental care. As their disease progresses, Alzheimer patients are no longer capable of giving their own consent for treatment. When this happens, the caregiver may chose to obtain legal decision making power, called guardianship. This process may take one to six months to complete, and not all caregivers go through this process. When caregivers are the legal guardians, no dental treatment should be given without first obtaining written consent from the legal guardian. For those Alzheimer patients who do not yet have legal guardians, it is prudent to discuss treatment options with the primary caregiver present. In all cases, clear communication about dental treatment options and extent of dental care should occur between the dentist and primary caregiver prior to the delivery of care.

Another role caregivers may play is in the actual delivery of dental care. In most cases, caregivers are encouraged to accompany Alzheimer patients into the treatment operatory and sit next to the patient during treatment. Most caregivers tend to alleviate patient stress and anxiety and provide a distraction for the patients, as well as to hold their hand(s) if needed.

A final benefit of having the caregiver present is to witness the dental need of the patient as well as the treatment provided. With this approach, the caregiver becomes a member of the dental treatment team and an advocate of continued dental care for the patient.

Dentist's Capabilities

There are essential equipment items and some special products that can make the treatment of Alzheimer's disease and neurologically impaired patients easier. In addition, advanced training in sedation techniques, and/or obtaining hospital training and privileges, may be needed to treat the very difficult or late-stage Alzheimer patient.

Extraoral mouth props such as the molt prop (Hu-Freidy) and a pair of lead gloves and an extra lead apron are essential equipment items that not all dentists have but which are needed when providing dental care to these type of patients. The extraoral mouth prop maintains the oral opening and helps to control head position. Dental professionals should be very careful not to place their fingers in the mouth of an Alzheimer patient, and extraoral mouth props will eliminate the need to do so.

Although panoramic films are not contraindicated, they may be impossible to obtain because of the limited amount of cooperation the Alzheimer patient has in holding his or her head still during the time of exposure. Another technique, using an extra lead apron and a pair of lead gloves worn by the operator, can be used while holding X-rays in the Alzheimer patients' mouths during radiographic exposures. Using this technique, single exposure bite-wing and periapical films can be made.

A number of specially adapted products are available for patients with disabilities, and two are particularly useful in neurologically impaired or Alzheimer patients. For caregivers, a foam mouth prop called the Open-wide Plus (Specialized Care Co., Edison, N.J.), is designed for caregivers to use to keep the mouth open during oral hygiene. The prop has a unique design of high-density foam that is safe and comfortable for the patient. It is disposable, although one mouth prop can last for 50 to 100 uses, is dishwasher safe, and is inexpensive.

A specialized toothbrush, called the Collis Curve (Collis Curve, Inc., Minneapolis, Minn.) has been designed with three rows of bristles that, when placed correctly, can clean the lingual, facial, and occlusal surfaces at the same time. The technique required with this brush is a simplified scrub motion, and most caregivers find this brush simpler to use than either conventional or electric brushes.

Other conventional products may be helpful for the caregiver in maintaining oral hygiene. For cleaning between the teeth, an interproximal cleaner such as a proxybrush (Butler, Crest, Colgate) may be easier to use by caregivers than floss or even floss-holding devices since proxybrushes do not require fingers to be placed intraorally.

For most practitioners, oral sedation will be the preferred method to manage the anxiety or uncontrolled, undesirable behaviors seen in Alzheimer patients. Dentists should use oral sedatives only after reviewing the patient's medication and medical history or in consultation with the patient's physician. This will allow the dentist to determine the best sedative and most appropriate agent for each patient. Dentists need to remember that oral sedatives can be unpredictable, and what works for one person may not work for another. Given this shortcoming, Table 3 summarizes the oral sedation recommendations for neurologically impaired or Alzheimer patients.¹⁶ Monitoring, training, and licensure all will impact the utilization of oral sedation in clinical practice.

Intravenous conscious sedation may be the best alternative available to treat uncooperative Alzheimer or neurologically impaired patients in the moderate to late stages if trained personnel and monitoring equipment are available. Advantages include the most rapid onset of action, ability to titrate the drug to effect, predictable blood levels, shorter duration of effects, and immediate access to treat complications.¹⁸ The disadvantages are obvious in that venipuncture is necessary, venipuncture complications can occur, more intensive monitoring is required, reversal of intravenous agents is not instantaneous, and more expensive malpractice insurance may be required. In addition, complications associated with intravenous sedation can also occur, such as respiratory depression, cardiac rhythm disturbances, and possible nausea or gastrointestinal disturbances.

For some Alzheimer patients, deeper sedation may be required. For these patients, dental treatment can be accomplished in the dental office under intravenous sedation utilizing trained anesthesiologists or by utilizing general anesthesia in the operating room in a hospital. Another alternative may include the use of surgical centers or ambulatory care facilities where deep sedation or general anesthesia may be administered. In these settings, Alzheimer patients who cannot be controlled using one of the previous techniques may be seen. In every setting, privileges to see patients must be granted to the dentist who is providing the treatment and is based on previous training, education, and experience.

Summary

With the number of adults reaching older ages, the number of Americans who develop Alzheimer's disease and other neurological impairments will also increase. The dental management of these patients requires a great deal of understanding and patience coupled with background knowledge of the disease and proficiency in providing behavior modification techniques. This paper discusses five major areas that dental practitioners should consider prior to caring for patients with Alzheimer's disease or other neurological impairments.

Author/

Robert G. Henry, DMD, MPH, is the director of geriatric dental service at the Department of Veterans Affairs Medical Center in Lexington, Ky.

References/

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18. Malamed S, Sedation: A Guide for Patient Management, 3rd ed. Mosby, St Louis, 1995.

To request a printed copy of this article, please contact: Robert G. Henry, DMD, MPH, VA Medical Center, (160) Dental Service, Leestown Drive Div., 2250 Leestown Drive, VAMC, Lexington, KY 40502.