Longitudinal study on oral health in subjects with Alzheimer's disease

Nutritional patterns in elderly patients with dementia of Alzheimer type

Body weight and some nutritional serum parameters (albumin, urea nitrogen, creatinine, glycemia, hemoglobin, total cholesterol, triglycerides, potassium) were analyzed in 44 subjects aged over 60 in order to evaluate weight loss and its possible link with the progression of dementia. Patients were consecutively admitted to our Day Hospital with the complaint of psychogeriatric symptoms. They all were living at home, no one presented risk factors for malnutrition and their cognitive impairment did not exceed the 4th degree of GDS (Global Deterioration Scale). Subjects were divided into two groups on the basis of diagnosis at discharge: (i) Possible or probable dementia of Alzheimer type (30 subjects, mean age 72.1 +/- 5.9 years), (ii) Age-associated memory impairment (14 subjects, mean age 73.6 +/- 6.2 years). One year later, a second control of body weight and nutritional parameters was performed. Differences between these latter measures versus the initial values were not significant when analyzed in the total group of demented patients or in the subgroups with different degree of cognitive impairment and physical activity. A possible hypothesis to explain the absence of differences among groups is that the caregivers were very carefully looking after all the patients examined.

Pathophysiology of age-related diseases

A Symposium regarding the Pathophysiology of Successful and Unsuccessful Ageing was held in Palermo, Italy on 7-8 April 2009. Three lectures from that Symposium by G. Campisi, L. Ginaldi and F. Licastro are here summarized. Ageing is a complex process which negatively impacts on the development of various bodily systems and its ability to function. A long life in a healthy, vigorous, youthful body has always been one of humanity's greatest dreams. Thus, a better understanding of the pathophysiology of age-related diseases is urgently required to improve our understanding of maintaining good health in the elderly and to program possible therapeutic intervention.

The role of cognitive ability in socio-economic inequalities in oral health

Studies have postulated a role for cognitive ability in socio-economic inequalities in general health. This role has not been examined for oral health inequalities. We examined whether cognitive ability was associated with oral health, and whether it influenced the relationship between oral health and socio-economic position. Data were from the Third National Health and Nutrition Examination Survey (1988-1994), for participants aged 20-59 years. Oral health was indicated by extent of gingival bleeding, extent of loss of periodontal attachment, and tooth loss. Simple reaction time test, symbol digit substitution test, and serial digit learning test indicated cognitive ability. Education and poverty-income ratio were used as markers of socio-economic position. Participants with poorer cognitive ability had poorer oral health for all indicators. The association between oral health and socio-economic position attenuated after adjustment for cognitive ability. Cognitive ability explained part, but not all, of the socio-economic inequalities in oral health.

Oral health and cognitive function in the Third National Health and Nutrition Examination Survey (NHANES III)

OBJECTIVES

To investigate the association between oral health and cognitive function in early-, mid-, and late-adult life.

METHODS

A secondary analysis was carried out of a large, well-characterized community sample (NHANES III). Analyzed variables included three measures of oral health (gingival bleeding, loss of periodontal attachment, loss of teeth) and three measures of cognitive function: the Symbol Digit Substitution Test (SDST), the Serial Digit Learning Test (SDLT) (both in 5138 participants aged 20-59 years), and a Story Recall test (in 1555 participants aged >or=70 years). Other covariates in linear regression models included age, gender, ethnicity, education and poverty, and cardiovascular risk factors.

RESULTS

Worse scores on all three measures of oral health status were significantly associated with poorer performance on all three measures of cognitive function after adjustment for age. Education was an important confounding factor. However, after full adjustment for all other covariates, gingival bleeding (%) and loss of periodontal attachment (%) remained associated with relative impairment on SDST score (B coefficients both = 0.003), and gingival bleeding was associated with relative impairment on SDLT (B = 0.017). No effect modification by age was observed.

CONCLUSIONS

Poor oral health is associated with worse cognitive function throughout adult life. This may, in part, be accounted for by early life education and social status. However, the possibility of direct causal pathways requires further investigation.

Tooth loss, dementia and neuropathology in the Nun study

BACKGROUND

Numerous studies have linked dementia to the subsequent deterioration of oral health. Few investigators, however, have examined oral disease as a potential risk factor in the development of dementia. The authors conducted a study to investigate a potential association between a history of oral disease and the development of dementia.

METHODS

Longitudinal dental records supplemented data collected from 10 annual cognitive assessments of 144 Milwaukee participants in the Nun Study, a longitudinal study of aging and Alzheimer disease, who were 75 to 98 years old. Neuropathologic findings at autopsy were available for 118 participants who died.

RESULTS

A low number of teeth increased the risk of higher prevalence and incidence of dementia.

CONCLUSION

Participants with the fewest teeth had the highest risk of prevalence and incidence of dementia.

CLINICAL IMPLICATIONS

Edentulism or very few (one to nine) teeth may be predictors of dementia late in life.

Caries prevalence in older persons with and without dementia

OBJECTIVES

To examine the prevalence of coronal and root caries in a memory clinic-based population of elderly patients with and without a diagnosis of dementia and to examine the influence of age, sex, social relations, social position, and functional ability.

DESIGN

Cross-sectional.

SETTING

Patients referred with possible cognitive dysfunction were recruited from two university hospital dementia clinics.

PARTICIPANTS

In total, 106 dentate persons participated in the study. Mean age was 82, 69 were women, and 87 had a diagnosis of dementia.

MEASUREMENTS

Data from interviews and a clinical examination were collected. The diagnosis of dementia was made at the dementia clinics according to the criteria of International Classification of Diseases, Tenth Revision. Active coronal and root caries was assessed using previously defined diagnostic criteria from the National Institute of Dental and Craniofacial Research.

RESULTS

The mean number of coronal and root surfaces with caries was statistically significantly higher in subjects with a diagnosis of dementia (7.0 vs 2.7, P<.05). Subjects with a diagnosis of Alzheimer's disease had a significantly higher mean number of root surfaces with caries (4.9, P<.05) than subjects with other dementia diagnoses (2.3) and those without dementia (1.7). People with Alzheimer's disease also had significantly more mean total caries than subjects without dementia (7.8 vs 2.7, P<.05). Participants with a Mini-Mental State Examination (MMSE) score less than 24 had significantly more caries than participants with a MMSE-score of 24 or higher (7.6 vs 4.3, P<.05).

CONCLUSION

Patients with newly diagnosed dementia already had a high level of active dental caries when they were referred to the memory clinic. The high caries prevalence was related to dementia type and severity.

Cognitive function and dental care utilization among community-dwelling older adults

OBJECTIVES

We sought to investigate the relationship between varying levels of cognitive function and dental care utilization.

METHODS

Using data obtained from the National Health and Nutrition Examination Survey (1999-2002), we performed weighted descriptive and multivariate logistic regression analyses on 1984 individuals with at least 1 tooth and who were 60 years and older.

RESULTS

Multivariate analyses suggested that level of cognitive function was associated with dental care utilization. At a higher level of cognitive functioning, individuals were more likely to have had more frequent dental visits. In addition, a higher level of socioeconomic status, healthy lifestyle, and worse self-rated oral health-related symptoms were more likely to indicate a higher frequency of dental care utilization. By contrast, poorer oral health status as determined by clinical examinations was negatively associated with frequency of dental visits.

CONCLUSIONS

The results suggest that community-dwelling older adults with low cognitive function are at risk for less frequent use of dental care. Oral health serves as a mediating factor between cognitive function and dental care utilization. There is a great need to improve oral health awareness and education among older adults, caregivers, and health care professionals.

The epidemiology, consequences and management of periodontal disease in older adults

BACKGROUND

This review summarizes the literature on periodontal disease (PD) in older adults. The authors focused on significant sequelae of PD and therapy in this population.

TYPES OF STUDIES REVIEWED

The authors conducted a search on PubMed for human studies using the terms "periodontal disease OR periodontitis" and "older adults." They retrieved 649 articles and excluded studies that had poor experimental design. For each topic of the review, they selected one to three of the most recent studies or reviews for inclusion and cited classic articles where appropriate.

RESULTS

PD is a common oral chronic inflammatory disease often found in older adults. In older patients, PD may lead to root caries, impaired eating and socialization. It also may increase patients' risk of developing systemic diseases such as diabetes mellitus, lung disease, heart disease and stroke. Treatment is not limited by chronological age but depends on the patient's medical and emotional status and the availability of financial resources.

CLINICAL IMPLICATIONS

General dentists usually can treat the majority of older people with mild or moderate PD. For older adults who are medically compromised and dependent, the literature supports treatment that prevents PD progression.

Dental Health and Cognitive Impairment in an English National Survey Population

OBJECTIVES

To investigate the association between dental health and cognitive impairment and to examine the extent to which dental status accounts for the association between cognitive impairment and low body mass index (BMI) in a national survey sample.

DESIGN

A secondary analysis of data from the Health Survey for England 2000.

SETTING

A nationally representative cross-sectional population survey.

PARTICIPANTS

Two thousand four hundred sixty-three adults aged 65 and older living in private households and 1,569 adults aged 65 and older living in care homes.

MEASUREMENTS

Data collected by interview (self-reported or by proxy) included age, sex, level of education, disability, BMI, dental status, and cognitive function (Abbreviated Mental Test Score).

RESULTS

Less than half of the community sample (40.4%) and 67.9% of the care home sample were edentulous; lack of teeth was significantly associated with cognitive impairment (odds ratio=3.59, 95% confidence interval=2.36-5.47). This association remained strong after adjustment for other covariates only in the community sample. Cognitive impairment was associated with lower BMI in both samples, but dental status did not explain this.

CONCLUSION

Poor dentition is associated with cognitive impairment. Nutritional status in people with cognitive impairment is recognized to be at risk. Although dental health did not account for the association between cognitive impairment and low BMI in this sample, other possible nutritional consequences require further evaluation.

Alzheimer's disease

BACKGROUND

The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental treatment of patients with Alzheimer's disease (AD).

STUDIES REVIEWED

The authors conducted MEDLINE searches for 2000 through 2005 using the terms "Alzheimer's disease," "geriatric," "epidemiology," "pathophysiology," "treatment" and "dentistry." Reports selected for further review included those published in English in peer-reviewed journals. The authors gave preference to articles reporting randomized, controlled trials.

RESULTS

AD is a progressive and fatal neurodegenerative disorder characterized by cognitive dysfunctions, particularly in learning and memory, and the emergence of behavioral abnormalities. Deficiencies in the cells responsible for storage and processing of information underlie the cognitive, functional and behavioral changes seen in patients with the disorder.

CLINICAL IMPLICATIONS

As the elderly population grows, increasing numbers of Americans with AD will require dental treatment. The prevalence of dental disease likely will be extensive, because of diminished salivary flow and patients' inability to perform appropriate oral hygiene techniques. Preventive dental education for the caregiver and use of saliva substitutes and anticaries agents by the patient are indicated.

Oral health status in individuals with dementia living in special facilities

AIM

The aim of this review was to retrieve data describing the oral health status of individuals with dementia living in special facilities.

MATERIALS AND METHODS

A literature search on the MEDLINE database (Entrez PubMed) was performed. The literature search yielded 208 papers, of which seven publications were selected for evaluation.

RESULTS

From the available studies poorer oral hygiene, decreased saliva flow rates and a higher caries incidence were reported in individuals with dementia living in special facilities when compared with healthy individuals. Oral health problems were more pronounced in the severe stage of the disease.

CONCLUSIONS

There is limited scientific data describing the oral health status of individuals with dementia living in special facilities. However, available data indicate that individuals with dementia living in special facilities have more oral health problems than individuals without dementia.

Oral hygiene care for residents with dementia: a literature review

AIM

This paper presents a literature review of oral hygiene care for adults with dementia in residential aged care facilities, including evidence for: (1) prevalence, incidence, experiences and increments of oral diseases; (2) use of assessment tools to evaluate residents' oral health; (3) preventive oral hygiene care strategies; and (4) provision of dental treatment.

BACKGROUND

The impact of dementia on residential care is ever-increasing and regular oral hygiene care provision is challenging for cognitively impaired residents. Although an abundance of oral hygiene care recommendations for older people have been published, the supporting evidence has not been clearly delineated.

METHODS

A review was conducted of English language publications (1980-2002), using a two-step approach (keyword electronic database search, supplemented with secondary search of cited references). All 306 selected articles were critically reviewed and systematically categorized.

RESULTS

Evidence confirmed clinicians' observations of poor oral health in older residents with dementia. Possible risk factors identified were: salivary dysfunction, polypharmacy, medical conditions, swallowing and dietary problems, functional dependence, oral hygiene care assistance and poor use of dental care. One comprehensive, reliable and validated oral assessment screening tool for residents with dementia had been published. Expert opinion indicated that oral assessment screening by staff and a dentist would be ideal at admission and regularly thereafter. Clinicians and researchers suggested that oral hygiene care strategies were effective in preventing oral diseases and appropriate for residents with dementia.

CONCLUSION

These literature review findings supported the use of oral assessment screening tools by staff and efficacious preventive oral hygiene care strategies/products for adults with dementia in residential care facilities. Further research with this population is needed to develop and validate oral assessment tools and staff education programmes, trial preventive oral hygiene care strategies/products and trial dementia-focused behaviour management and communication strategies.

Tooth loss and caries prevalence in very old Swedish people: the relationship to cognitive function and functional ability

OBJECTIVE

To analyse whether cognitive function and functional ability are related to oral health among community-dwelling older people over the age of 80 years.

BACKGROUND

This cross-sectional study is based on the Kungsholmen Elders Oral Health Survey (KEOHS). The study included oral examinations carried out in two local clinics by standardised examiners and interviews using structured questionnaires.

MATERIALS AND METHODS

Altogether 159 individuals were included in this study. Coronal caries and root caries were assessed using the National Institute of Dental and Craniofacial Research (NIDCR) diagnostic criteria. Cognitive function was assessed by the Mini-Mental State Examination (MMSE) index and functional ability was assessed by a global measure of self-reported changes.

RESULTS

Older adults with a low MMSE score (< or = 23) tended to have a higher risk of coronal caries than those with higher scores. Participants with mild cognitive decline (MMSE = 24-26) and with a decrease in functional ability had a significantly higher risk of root caries. These associations changed little when adjusted by the covariates. In addition, people with a low MMSE (0-23) had a four times higher risk of not using dental services regularly. This result was unchanged after adjusting for the variables studied.

CONCLUSIONS

This study revealed associations between the cognitive and functional status of the individual and aspects of oral health, that may contribute to a deeper understanding of the background of oral health status in older adults.

Oral hygiene care for adults with dementia in residential aged care facilities

OBJECTIVE

The objective of this systematic review was to report on the best available evidence relating to oral hygiene for adults with dementia in residential aged care facilities, including: INCLUSION CRITERIA: This review considered any randomised or non-randomised controlled studies, cohort studies, case-control studies, multiple time series studies, uncontrolled studies, descriptive studies and opinions of respected authorities (including theses and other publications) related to residents with dementia living in residential aged care facilities in Australia and overseas; community-dwelling adults with dementia; and special needs adult populations (for preventive oral hygiene care strategies and interventions).The review considered studies and publications designed to:1 quantify the oral health status of older adults living in residential aged care facilities;2 quantify the oral health status of adults with dementia living in the community and in residential aged care facilities;3 evaluate tools used to assess the oral health of residents by staff and carers working in residential aged care facilities;4 evaluate preventive oral hygiene care strategies and interventions used in special needs adult populations (including adults with dementia); and5 evaluate oral health care training and oral hygiene care provision, staff and carers working in residential aged care facilities.Dental outcome measures of interest were those relating to the prevalence, incidence, experiences and increments of oral diseases and conditions including: denture problems, coronal and root caries, periodontal diseases (plaque accumulation, gingivitis, loss-of-attachment), oral mucosal conditions, xerostomia and salivary gland hypofunction, tooth loss, difficulty chewing, behavioural problems and pain/discomfort. Related characteristics and outcomes of interest included: medical conditions, medications, cognitive status, functional status, nutritional status and sociodemographics.

SEARCH STRATEGY

The aim of the search was to locate relevant English-language studies and publications appearing between 1980 and 2002. The search utilised a two-step approach, involving an initial search of electronic databases using combinations of key words followed by a second extensive search carried out using the identified key words. This was supplemented with a secondary search of the references cited in the identified studies. Electronic database searched were: Cinahl, Embase, Psycinfo, Medline and Current Contents.

METHODOLOGICAL QUALITY

All selected studies were critically appraised by two reviewers prior to inclusion in the review.

RESULTS

In regards to relevance, incidence, experiences, and increments of oral diseases and conditions, possible risk factors identified included: saliva dysfunction, polypharmacy, comorbid medical conditions, swallowing and dietary problems, increased functional dependence, need for assistance with oral hygiene care, and poor access and utilisation of dental care.Evidence on the use of assessment tools by carers to evaluate residents' oral health showed that successful assessment of residents with and without dementia by nursing staff requires appropriate staff training by a dental professional. Coupled with appropriate training, an oral assessment screening tool designed for residents with dementia has been successfully used by nursing and care staff to identify residents requiring further review by dental professionals. Expert opinion in the field indicates that oral assessment screenings by a staff member and then by a dentist would ideally be undertaken upon admission to a facility, and regularly thereafter by staff and/or dentists as required.Clinicians and researchers suggested that oral hygiene care strategies to prevent oral diseases and conditions were found to be effective in preventing oral diseases, and thus are relevant for use in the resident with dementia.In regards to the provision of dental treatment and ongoing management of oral diseases and conditions, the use of adjunctive and preventive aids were found to be effective when introduced in conjunction with a staff training program:Expert opinion suggests that behaviour management techniques will increase the potential of performing oral hygiene care interventions.

CONCLUSIONS

This review suggests that the training of staff in the form of a comprehensive practically oriented program addressing areas such as oral diseases, oral screening assessment, and hands-on demonstration of oral hygiene techniques and products is likely to have a positive impact on the management of oral hygiene care within residential aged care facilities. The review also identified that regular brushing with fluoride toothpaste, use of therapeutic fluoride products and application of therapeutic chlorhexidine gluconate products are validated by research as effective for the general population and some populations with special needs.

Oral diseases and conditions in community-living older adults with and without dementia

This study compared the prevalence and experiences of oral diseases and conditions, as well as tooth loss and retained root status, in community-dwelling older adults with and without dementia. Dental examinations were conducted at baseline and at one-year for randomly selected samples of 116 dentate community-living older adults with dementia and a comparable group of 116 adults without dementia. Participants with dementia had significantly higher experiences of oral diseases and conditions at baseline and one-year compared with participants without dementia: decreased use of dentures; increased prevalence of denture-related oral mucosal lesions; increased plaque accumulation; increased prevalence and experiences of coronal and root caries; and increased numbers of decayed retained tooth roots. These higher experiences of oral diseases and conditions were related to dementia severity, not to specific dementia diagnoses. Participants with dementia already had a compromised oral health status when admitted into institutional long-term care between baseline and one-year; of concern were the high plaque levels on the natural teeth of the group of institutionalized participants with dementia.

Caries incidence and increments in community-living older adults with and without dementia

OBJECTIVES

The Oral Health of Older Adults with Dementia was instigated in the late 1990s to quantify and compare coronal and root caries incidence and increments in community-living older Australians with and without dementia.

METHODS

A longitudinal design was used to conduct dental inspections at baseline and one-year, for two groups of randomly selected community-living older adults--one group of 116 people with dementia and a comparison group of 116 people without dementia.

RESULTS

At one-year there were 103 dementia and 113 (112 dentate) non-dementia participants. Coronal and root surface caries incidence was higher for dementia participants (p < 0.05). Dementia participants had higher coronal and root caries adjusted caries increments (ADJCI) (p < 0.01). Both coronal and root ADJCI were evident in half of dementia participants, compared with one-quarter of non-dementia participants. Dementia participants with higher coronal ADJCI were those who had visited the dentist since baseline, who were taking neuroleptics with high anticholinergic adverse effects, and whose carer had high carer burden score (p < 0.01). Dementia participants with higher root ADJCI were those needing assistance with oral hygiene care and whose carers had difficulties with oral hygiene care (p < 0.05). Baseline characteristics predictive in linear regression for: (1) coronal caries increments among all participants were--dementia participants, those with cognitive testing scores indicative of moderate-severe dementia, those with private health insurance; (2) root caries increments among all participants were--dementia participants, and those who had > or = 1 decayed/filled root surface at baseline. Among dementia participants, being male was the baseline characteristic predictive in logistic regression for coronal caries increments, and having > or = 1 decayed coronal surface was the baseline characteristic predictive for root caries increments.

CONCLUSIONS

Coronal and root caries incidence and increments were significantly higher in the community-living older adults with dementia over the one-year follow-up period. Dementia participants had high levels of coronal and root caries increments; characteristics related to high caries increments included sex (males), dementia severity (moderate-severe), high carer burden, oral hygiene care difficulties, use of neuroleptic medication (with high anticholinergic adverse effects) and previous experience of caries.

Stimulated parotid salivary flow rate in patients with Down syndrome

Saliva is essential for oral defense against infections. Decreased salivary secretion may result in increased dental caries, oral mucosal changes, an altered sense of taste, difficulty in swallowing, and oral pain. A review of the literature reveals sporadic and contradictory reports on the use of sialometry and sialochemistry to explain the role of saliva in the oral health and well-being of subjects with Down syndrome. The present study documents parotid gland saliva secretion at different ages in a group of subjects with Down syndrome. Saliva was collected from 39 patients 11 to 62 years old, by means of a parotid salivary gland cup and under standardized conditions of stimulated secretion. The rate of salivary secretion in the entire group of patients with Down syndrome was lower than that of healthy controls and lower in the older study group compared with the younger group. Institutionalized subjects or those living in hostel-like apartments had a lower secretion rate than those living at home. No difference in salivary flow was found between those patients with Down syndrome with normal thyroid output and those with hypothyroidism who were receiving replacement therapy. In a four-way ANOVA with flow as the dependent variable and Down syndrome, hypothyroidism, institutionalization, and age as factors, Down syndrome was found to be the only variable significantly related to flow (p = 0.017). Our findings indicate that stimulated parotid salivary hypofunction in Down syndrome subjects is mainly related to their genetic disorder.

Systemic diseases and their treatments in the elderly: impact on oral health

The lifespan of the US population is increasing, with the elderly desiring successful aging. This goal is jeopardized as multiple systemic conditions and their treatments become more prevalent with age, causing impaired systemic and oral health and influencing an older person's quality of life. To obtain successful aging, a compression of morbidity must be obtained through prevention and management of disease. This paper describes the most common systemic diseases causing morbidity and mortality in persons aged 65+ years: diseases of the heart, malignant neoplasms, cerebrovascular diseases, chronic obstructive pulmonary disease, pneumonia, influenza, diabetes mellitus, trauma, Alzheimer's disease, renal diseases, septicemia, and liver diseases. Disease prevalence and the impact of medications and other therapeutic measures used to treat these conditions are discussed. Oral sequelae are reviewed with guidelines for early detection of these deleterious consequences, considerations for oral treatment, and patient management. An understanding of the impact of systemic diseases and treatment on oral health is imperative for dental practitioners to appropriately treat and manage older patients with these conditions. With a focus on early detection and prevention, oral health care providers can improve the quality of life of this population and aid in the attainment of successful aging.

Conducting geriatric dental research with cognitively impaired adults

A growth in research focusing on the oral health of older adults has been evident in recent years. However, there are new and complex challenges for geriatric dental researchers studying the increasingly functionally dependent and cognitively impaired older adult population. Many geriatric dental studies have under-reported oral disease prevalence and incidence by excluding adults who are cognitively impaired and/or behaviourally difficult. To ensure representative samples of older adult populations are studied, traditional oral epidemiological protocols in studies with cognitively impaired adults, require additional components detailing: (1) communication and behaviour management strategies for cognitively impaired adults; and (2) methodologies to facilitate the completion of dental examinations. A description of such additional protocol components is presented, along with a discussion of the use of cognitive testing tools by dental researchers.

Dementia and oral health

Older adults are the most rapidly growing segment of the population, and the prevalence of dementia in this cohort is increasing as well. Diagnostic and management strategies for dementia are improving. With significantly more dentate older adults, there will be an increased need in the future for dental care services for the geriatric population with dementia. Research reports demonstrate impaired oral health even in community-dwelling adults with moderate dementia. Therefore, oral health care providers will be increasingly challenged with preserving oral and nutritional health in these patients in order to diminish pain and pathology and to maintain the dignity and quality of life of a person with dementia.

Challenges in geriatric oral health research methodology concerning caregivers of cognitively impaired elderly adults

Little is known about oral health care behaviors of community-dwelling, cognitively impaired elderly (CIE) persons. Few studies have been conducted regarding the actual provision of oral care for CIE persons or the attitudes and concerns about oral health among their caregivers. The CIE person's ability to perform self-care decreases over time, and the role of the caregiver in daily oral care becomes increasingly important. The purpose of this pilot study was to explore the attitudes toward oral health and identify related concerns among caregivers who care for community-dwelling CIE persons. Caregivers were surveyed by means of a self-administered, mailed questionnaire. To maintain confidentiality, an intermediary was used for recruitment and data collection. Overall, 148 caregivers were invited by an intermediary to participate in the survey; only 21 (14%) consented to participate and returned the questionnaire. This paper discusses some of the numerous methodological challenges identified when an attempt was made to survey care-givers' attitudes toward and barriers to providing oral care for a dependent CIE.

Dental management of Alzheimer patients. A predictive test of dental cooperation in individualized treatment planning

The aim of the study was to investigate a possible relationship in Alzheimer patients between the stage of dementia, cognitive and functional capacity, and behavior as a dental patient. A special index for assessing behavior in the dental setting was used. The 40 participants were inmates of a nursing home and fulfilled the criteria for Alzheimer's disease in accordance with DSM-III-R. A deficiency in the dental behavior index (DBI) of 50% or less did not correlate with cognitive, functional, or graphic capacity. These subjects were generally aware of earlier regular dental treatment and behaved as if dental visits were familiar to them, although their cognitive, functional, and graphic capacities were more impaired than disclosed by the dental behavior index. A deficiency in the dental behavior index of 50% or more was more correlated with the other capacity assessments. Finding a proper treatment level for an Alzheimer patient is a delicate task in which it is essential to balance awareness of various aspects of impairment and realistic anticipation of benefit. The dental behavior index can be an appropriate instrument in this complex process.

Oral health of persons with and without dementia attending a geriatric clinic

This study of 230 hospital geriatric clinic patients compared the oral health of individuals with dementias with that of persons with no dementing illnesses. Data collected included dental examinations, subject questionnaires and review of hospital records. There were few differences among groups of patients based on categorization into groups of those diagnosed with (1) no dementia, (2) dementia of the Alzheimer's type, and (3) other dementias. However, there were significant differences based on degree of cognitive impairment regardless of dementia diagnosis. Those with severe dementia had poorer gingival health and oral hygiene, but better self-perceived mouth health. There are numerous limitations and inherent difficulties in studies involving persons with dementia, and overcoming these in the future will likely require long-term, interdisciplinary approaches.

Alzheimer's disease, oral function and nutritional status

OBJECTIVES

To study differences in nutritional, dental status and oral function between institutionalised patients with Alzheimer's disease and cognitively healthy elderly people living in the community.

DESIGN

Comparison was made between two groups. Alzheimer's disease sufferers and healthy controls, using established criteria for anthropometric, mental and dental state.

SETTING

An institution and residential area in Stockholm, Sweden.

SUBJECTS

Forty patients with Alzheimer's disease living in a nursing home and 40 age- and gender-matched control subjects living independently.

INTERVENTION

Dental status and anthropometric variables.

RESULTS

Overnutrition was less frequent among the demented than the controls and more demented were undernourished. Dental status was similar in the two groups with few edentulous subjects but only 2 of 7 edentulous subjects with Alzheimer's disease wore dentures. Having natural teeth and many functional oral zones is important for food consistency choice, but not for nutritional status. In the Alzheimer group, the stage of dementia has a strong association to the ability to eat unaided and an association with dental status.

CONCLUSION

There are differences in nutritional status between Alzheimer's patients in institutions and cognitively healthy elderly living at home. The choice of food consistency is correlated to dental status but nutritional status is not shown to be influenced by dental status. However, the ability to eat unaided is strongly correlated to cognitive status.

The perceived importance of appearance and oral function, comfort and health for severely demented persons rated by relatives, nursing staff and hospital dentists

Dental health is an aspect of the quality of life. Oral treatment goals for, the severely demented and the benefits of oral treatment are complex issues. Severely demented people can neither express their wishes nor make rational decisions about oral care. Acting "in the best interests" of a demented person who refuses or does not understand the purpose of treatment depends on what perspective and treatment priorities the advocate has. For oral treatment of a demented person the advocate may be a relative, a member of the ward staff or a hospital dentist. In a structured interview, the relatives of demented patients in a Stockholm hospital and members of the nursing staff were asked to rate the importance of goals for dental care. These ratings were also recorded for hospital dentists. In this study there was agreement on the importance of freedom from oral pain and fear of aspiration. Nursing personnel gave priority to aspects of good care such as being able to chew and enjoy eating. Relatives were also concerned with social behaviour and communication such as fresh breath, normal speech, and normal appearance. The ratings by the hospital dentists were generally lower which might reflect professional awareness of the limitations of treatment success implied by cognitive impairment.