It is 9:08 p.m., and the RN enters Mrs. Kravel’s (pseudonym) hospital room to hang her intravenous (IV) antibiotic medication. Mrs. Kravel, an 82-year-old Caucasian woman, was admitted 4 days earlier through the emergency department with a diagnosis of urinary tract infection and dehydration. Mrs. Kravel has resided in a local nursing home for the past 2 years, as her husband was no longer able to care for her at home. Diagnosed with probable Alzheimer’s disease 5 years earlier, Mrs. Kravel’s cognitive status has continued to worsen since her admission to the nursing home. She also has had multiple problematic behaviors, including suspiciousness, resistance to care, and sundowning. In the days leading up to her hospital admission, she had experienced multiple falls, and her behaviors had worsened, suggesting delirium and prompting her physician to transfer her to the emergency department for evaluation.
While attempting to engage Mrs. Kravel in some “light” conversation (being mindful of her cognitive impairments), the nurse notices that there appears to be something in Mrs. Kravel’s mouth. On further inspection, the nurse concludes there is still food in Mrs. Kravel’s mouth from dinner. After starting the IV, the nurse attempts to speak to the nursing assistant who was responsible for Mrs. Kravel’s evening care. “She wouldn’t let me anywhere near her mouth,” the nursing assistant explains when questioned by the RN as to why oral care was not performed. “She became combative and started swinging at me,” the nursing assistant continues. “Maybe you can give her something to calm her down so that I can do her oral care?”
In this article, we will examine this all-too-familiar scenario that occurs on a daily basis in both hospitals and nursing homes. The challenges of providing oral care to residents with Alzheimer’s disease or other forms of dementia can be formidable but can be met with caring and competence.
Does Oral Care Matter in Older Adults?
Later that same evening, the RN overhears the nursing assistant describing their earlier exchange about Mrs. Kravel’s lack of oral care. She hears the nursing assistant responsible for Mrs. Kravel’s care say to another nursing assistant, “I don’t know why she’s so concerned about brushing her teeth, she’s 82 years old, and has Alzheimer’s disease. I think brushing her teeth is the least of her worries. What does she think, brushing her teeth is going to cure her?!” Whereas on the surface, this sounds flippant, it is actually a very good question that requires exploration.
It has already been established through multiple studies that oral care affects overall health and well-being. Poor oral care has been associated with a wide range of conditions including—but certainly not limited to—endocarditis and other cardiovascular diseases and development of pneumonia in both intubated individuals on critical care units and non-intubated individuals (U.S. Department of Health & Human Services, 2000). But of what use is oral care to individuals with dementia?
It should be acknowledged that there is at least some validity in what the nursing assistant had said. Although oral care will not cure Ms. Kravel’s dementia, there is at least some evidence that intact dentition, which can facilitate effective chewing, “might stimulate brain functions and protect against the degradation of cognitive functions” (Kikutani et al., 2010, p. 327). These authors concluded that sensory areas of the cortex that are related to oral function are stimulated with oral care, which in turn improve swallowing reflexes, thus preventing aspiration pneumonia. The authors even went as far as to argue that “oral care would contribute to cognitive function as much as donepezil” (p. 328).
A 2008 study by Ellefsen et al. demonstrated that individuals with dementia had significantly more dental caries than individuals of the same age without dementia. In fact, those individuals with a Mini-Mental State Examination (MMSE) score of less than 24 had significantly more caries than those with higher MMSE scores. The authors noted that “prevalence of caries was related to both dementia type and severity of cognitive decline” (p. 65). The study’s findings accentuate the fact that oral care is often neglected in older adults with Alzheimer’s disease and other types of dementia. There has also been some discussion in the literature regarding the association between tooth loss prior to age 35 and the subsequent development of Alzheimer’s disease (Gatz et al., 2006). This represents a classic debate: Did poor oral health contribute to dementia, or did dementia (and the resultant behavioral difficulties) result in poor oral care?
Challenges of Dementia and Oral Care
Despite the fact that the literature makes a strong case for the importance of oral care in older adults with Alzheimer’s disease and other types of dementia, challenges to the provision of oral care persist. Chalmers and Pearson (2005) conducted a comprehensive literature review in which 306 articles addressing oral hygiene in residents with dementia were examined. The results provide a compendium of graded evidence that can be incorporated into oral hygiene practices with older adults with dementia. Unfortunately, behaviors often exhibited by individuals with dementia preclude the ability to apply these evidence-based practices on a consistent basis.
It is important to note that difficulties associated with providing oral care to individuals with dementia are not isolated to the United States. Problems associated with different staff members being responsible for providing oral care to nursing home residents—coupled with a “lack of guidelines and routines for oral hygiene and a lack of guidelines for sharing information between the different professional groups”—were identified by Sonde, Emami, Kiljunen, and Nordenram (2010, p. 92) in a study conducted in Stockholm, Sweden. Similar examples can also be identified in other areas of the world. As the number of older adults with dementia continues to increase worldwide, difficulties associated with oral care will become more prevalent.
A Creative and Comprehensive Approach
Meeting the oral care needs of older adults with dementia is a complex issue and requires not only a comprehensive approach but a creative one as well. The sections that follow will help guide the development of an oral care program, whether working with older adults with dementia in skilled nursing, assisted living, adult day care, or community settings. Readers are encouraged to critically evaluate the following areas of their facility’s oral care practices as part of their comprehensive oral care program.
Policies and Organizational Culture
Nurses should ask the following policy and organizational questions:
- What current policies exist in the facility specific to the oral care needs of older adults with dementia?
- How often is this oral care to be provided? Who is responsible for doing it?
- What quality assurance mechanisms are in place to ensure that oral care is provided in a manner consistent with policy?
- How are evidence-based practices specific to oral care in older adults with dementia incorporated into existing policies? If no policies exist, they should be developed.
- When policies are being developed or revised, are nursing assistants, licensed practical nurses, and staff RNs invited to join the discussion to offer their experience and insights?
Clear Roles of Caregivers
Caregiver roles can be explored through questions such as:
- Are nursing assistants, personal care assistants, or other unlicensed assistive personnel responsible for the provision of oral care within the facility?
- Who is responsible for screening the oral cavity? With what frequency should screenings be completed? When abnormalities are identified during the oral cavity screening, what processes are implemented? Who is responsible for following through with these processes?
- How often is the resident/client able to see a dentist?
The following questions can launch a conversation about the family’s role and knowledge:
- Does the facility currently provide education to families regarding the oral care needs of their loved one?
- Have family members been asked to share with the nursing staff those practices and techniques they used at home to get their loved one to participate in oral care?
Many times, family members who have taken care of residents at home prior to admission to a nursing home or assisted living facility may have identified unique approaches to getting the care recipient to cooperate. If the family caregiver visits every day, perhaps he or she can incorporate oral care into the visit. Many times, family members like to feel as though they are contributing to the care of their loved one. By inviting them to assist with oral care, the resident gets the oral care he or she needs while the family member feels useful and helpful in their loved one’s care.
Next, staff members’ knowledge and training can be examined:
- How are staff members educated regarding the importance of oral care?
- Is oral care both emphasized in orientation and evident in day-to-day unit activities?
- What happens if the staff nurse realizes that the unlicensed assistive personnel did not provide oral care?
- Do they use the discovery that oral care was not provided as an opportunity to punish the nursing assistant, or do they transform it into a teaching moment?
If a resident with dementia is resisting oral care, the possibility of oral pain as a cause of resistance should be considered. Many myths surrounding pain in older adults persist, including the notion that pain is a normal part of aging, failure to verbalize pain indicates the pain does not exist, and that pain cannot be successfully treated in older adults due to risk of addiction. Pain in older adults can be assessed using objective measures such as the Pain Assessment in Advanced Dementia scale (Horgas & Miller, 2008).
Inspection of Oral Cavities and Visiting the Dentist
Unfortunately, inspection of oral cavities is not done on a routine basis in older adults with dementia (Jablonski, 2011). Bad breath is generally attributed to poor oral hygiene, but the cause can also be something more ominous. Loose or broken teeth can harbor pathogenic bacteria, resulting in infections of the oral cavity which, if not properly identified and treated, can lead to regional infection or advance to septicemia. Oral cancers may also be identified through inspection of oral cavities.
Older adults with dementia should have the same number of scheduled dentist visits as any other adult. Unfortunately, individuals of lower socioeconomic status, such as those receiving Medicaid (which includes a large portion of skilled nursing facility residents), have limited access to dentists for routine oral care. The federal regulations governing skilled nursing facilities only require the facility arrange for routine dental services to the extent covered by the state plan. That is, whatever the state’s Medicaid coverage for oral care is, that is the extent of dental care and services the facility is required to provide (Centers for Medicare & Medicaid Services, 2011). Although on the surface this sounds sufficient to meet the oral care needs of many nursing home residents, it is woefully inadequate. Many dentists refuse to see Medicaid recipients because of the low levels of Medicaid reimbursement. Individuals who have private insurance covering their long-term care stay are at an increased advantage when it comes to being able to access dental care and services.
Making a Routine and Providing Human Resources
Oral care should be a routine part of care practices. I have been a long-term care consultant for more than a decade, and whenever I reviewed the staffing patterns at a skilled nursing facility, many times, basic arithmetic told me that oral care was not a priority in the facility. Observing that one nursing assistant was responsible for providing care and services to 8 residents on the day shift and 10 to 12 residents on the evening shift—which encompassed assisting residents with meals, bathing, repositioning to prevent skin breakdown, and incontinence care—it wasn’t difficult to deduce that consistent oral care was not taking place. Staff who are curious about whether proper oral care is taking place in their facility can visit the central supply clerk to find out how often toothpaste and toothbrushes are ordered. In my consultant role, this simple inquiry allowed me to determine how much oral care actually takes place in the facility.
Evidence-Based Approaches to Overcoming Behaviors that Prevent Oral Care
Many approaches have been used to elicit cooperation of older adults with dementia in oral care practices. Behavioral approaches such as chaining (sometimes referred to as task segmentation), the practice by which behavior is achieved through a series of steps comprising the desired behavior; mirroring, demonstrating the behavior in an attempt to get the resident to copy it; and rescuing (i.e., when the resident becomes upset with one caregiver, a substitute caregiver takes over, giving the resident the impression that the substitute caregiver has “rescued” the resident from the person who is causing them frustration) have all been used with varying degrees of success (Weitzel et al., 2011).
Managing Oral Hygiene Using Threat Reduction (MOUTh) has been one of the newest and most promising evidence-based techniques identified thus far to assist caregivers in helping older adults with dementia achieve adequate oral care. This 15-step process, developed by a team of researchers from The Pennsylvania State University and led by Rita Jablonski, represents a combination of common sense, behavioral approaches, appropriate communication techniques, distractions/bridging, and touch (Jablonski et al., 2011). The techniques, which include several of the previously mentioned approaches, coupled with judicious use of gentle touch, avoidance of “elderspeak” (the tendency of some staff to speak to older adults with dementia using “baby talk”), and other approaches, provide the caregiver with a wealth of strategies designed to reduce the challenge of providing oral care. Additional studies of these techniques are currently underway and may result in a compendium of best practices to use when providing oral care to older adults with dementia.
The problem of how to provide effective oral care to older adults with dementia is not new. Individuals who work with this population understand all too well the challenges associated with providing oral care to individuals who lack understanding of what it is the caregiver is trying to do. Unfortunately, based on the literature reviewed in this article, it would appear that the tools available to clinicians have either lacked efficacy or may not have been disseminated widely. Additionally, institutional settings, inadequate staffing, and unrealistic care expectations have given oral care a back seat to other more “visible” care needs. Institutions that provide care for older adults with dementia are encouraged to objectively look at their current policies and procedures, as well as staff training and individual staff approaches, to meeting the oral care needs of older adults with dementia. Incorporation of evidence-based practices can enhance the overall health and well-being of this population.
- Centers for Medicare & Medicaid Services. (2011, January7). State operations manual: Appendix PP–Guidance to surveyors for long term care facilities (revision 70). Retrieved from https://www.cms.gov/manuals/Downloads/som107ap_pp_guide-lines_ltcf.pdf
- Chalmers, J. & Pearson, A. (2005). Oral hygiene care for residents with dementia: A literature review. Journal of Advanced Nursing, 52, 410–419. doi:10.1111/j.1365-2648.2005.03605.x [CrossRef]
- Ellefsen, B., Holm-Pedersen, P., Morse, D.E., Schroll, M., Andersen, B.B. & Waldemar, G. (2008). Caries prevalence in older persons with and without dementia. Journal of the American Geriatrics Society, 56, 59–67. doi:10.1111/j.1532-5415.2007.01495.x [CrossRef]
- Gatz, M., Mortimer, J.A., Fratiglioni, L., Johasson, B., Berg, S., Reynolds, C.A. & Pedersen, N.L. (2006). Potentially modifiable risk factors for dementia in identical twins. Alzheimer’s & Dementia, 2, 110–117. doi:10.1016/j.jalz.2006.01.002 [CrossRef]
- Horgas, A.L. & Miller, L. (2008). Pain assessment in people with dementia. American Journal of Nursing, 108(7), 62–70. doi:10.1097/01.NAJ.0000325648.01797.fc [CrossRef]
- Jablonski, R.A. (2011, July). Mouth care: Reducing resistant behaviors. Long-Term Living, 54. Retrieved from http://www.ltlmagazine.com/article/mouth-care-reducing-resistant-behaviors
- Jablonski, R.A., Therrien, B., Mahoney, E.K., Kolanowski, A., Gabello, M. & Brock, A. (2011). An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: A pilot study. Special Care in Dentistry, 31(3), 77–87. doi:10.1111/j.1754-4505.2011.00190.x [CrossRef] . doi:10.1111/j.1754-4505.2011.00190.x [CrossRef]
- Kikutani, T., Yoneyama, T., Nishiwaki, K., Tamura, F., Yoshida, M. & Sasaki, H. (2010). Effect of oral care on cognitive function in patients with dementia. Geriatrics & Gerontology International, 10, 327–328. doi:10.1111/j.1447-0594.2010.00637.x [CrossRef]
- Sonde, L., Emami, A., Kiljunen, H. & Nordenram, G. (2010). Care providers’ perceptions of the importance of oral care and its performance within everyday caregiving for nursing home residents with dementia. Scandinavian Journal of Caring Sciences, 25, 92–99. doi:10.1111/j.1471-6712.2010.00795.x [CrossRef]
- U.S. Department of Health and Human Services. (2000). Oral health in America: A report of the Surgeon General. Retrieved from http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf
- Weitzel, T., Robinson, S., Barnes, M.R., Berry, T.A., Holmes, J.M., Mercer, S. & Kirkbride, G.L. (2011). The special needs of the hospitalized patient with dementia. Medsurg Nursing, 20, 13–18.