Dementia-friendly dental practice

THE number of older people in the UK is growing and will continue to grow – and so too the prevalence of dementia.

The term dementia describes a set of symptoms that affects everyday living, including memory loss and difficulties with thinking, problem-solving or language. It is reported by Alzheimer’s Research UK that there are approximately 944,000, people in the UK who have dementia (517,412 have a formal diagnosis) and that number will soon exceed one million.

It follows that oral healthcare professionals will increasingly see more patients affected by dementia at varying stages, and it is therefore crucial to have a basic understanding of the condition and how these patients can be managed in a primary care environment. Relevant training should be part of a personal development plan for all dental registrants.

Below are some practical tips to help make your practice more dementia-friendly.

Know the early signs of dementia

Dentists can have an important role to play in helping to detect the signs of dementia in patients, possibly leading to an early diagnosis. These include:

• reduced interest in normal activities, e.g. not cleaning teeth
• communication issues
• short-term memory issues (forgetting what happened within the last 24 hours, repetition)
• changes in independence (requires verbal prompts or help with decision making)
• changes in planning and organisational skills (needs someone to book an appointment)
• confusion about time or place (signs of restlessness/disorientation even if attended before)
• sight or vision problems (judging distance, difficulty reading)
• unusual emotional responses, e.g. the patient becomes irritable more easily or appears withdrawn.

Address ongoing dental care soon after diagnosis

Poor oral health has a significant impact on general health and wellbeing in dementia, particularly affecting hydration and nutrition. Planning for a patient’s future oral health can help to maintain their quality of life and reduce their risk of hospital admission.

Patients attending soon after diagnosis will be in the early stages of the disease and can better cope with treatment in familiar practice surroundings. This is an ideal time to discuss treatment options for the best long-term plan to avoid future complications, taking into account personal wishes regarding the prognosis of individual teeth. Prevention is vital. An individual’s needs will change over time and it is essential to review the care plan and gain permission to involve supporting relatives or carers.

At the first appointment after diagnosis:

• establish an individual treatment plan, which can be reviewed and modified in response to changes in medical, social and dental circumstances over time.
• take a pragmatic approach to dental treatment so that their oral health is easy to maintain.
• focus on prevention, giving a tailored preventative regime in line with Delivering Better Oral Health guidance.
• establish a recall interval appropriate to the patient’s risk of, and from, oral disease.

Effective communication

In dealing with dementia patients it’s important to be more aware of non-verbal messages, such as facial expressions and body language. Communication aids can be useful, such as a simplified social story board or pictures to explain procedures and processes. Masks can hinder understanding and may frighten people, so speak clearly and slowly and check that the person understands. Provide written information in an easy read format to aid understanding.

The following tips may improve communication between you and the person living with dementia:

• Explain things calmly and in simple sentences, allowing the person more time to respond.
• Listen carefully and give the patient your full attention.
• Make eye contact and encourage the person to look at you when either of you are talking.
• Try not to interrupt, even if you think you know what they’re saying.
• Minimise distractions, such as loud music or radio.
• To check understanding, repeat what you heard back to the person and ask if it’s accurate, or ask them to repeat what they said.

Informed consent

Every person living with dementia is different on different days, and their disease course is different. How they react can depend on their previous dental experience. Stress and anxiety decreases ability to cope and the individual may only be able to concentrate for short periods. Dementia is a progressive disease so mental capacity will change. A person living with dementia may become less able to express their symptoms, needs and wishes, or take part in decision making.

A person living with dementia may struggle to make sense of information about proposed treatments due to:

• difficulty with cognition (ability to focus/concentrate)
• communication difficulties (making sense of descriptions of treatments/being able to express themselves using language)
• memory difficulties (remembering details and weighing up the options)
• increased anxiety: struggling to understand what is happening or having powerful emotional responses.

Try to understand the issues and find ways, if possible, to overcome them.

Keep careful records including the process for assessing capacity and of working out the best interests for a patient for each relevant decision. Some people living with dementia may have a lasting power of attorney (England and Wales) or welfare power of attorney (Scotland), or enduring power of attorney (Northern Ireland). This can cover personal welfare and decisions about healthcare. Note that in Scotland, if the treating healthcare professional considers that the patient does not have capacity, they have to complete a Section 47 Certificate regardless of whether or not there is welfare power of attorney.

More information about consent and capacity can be found at:

• Making decisions about someone else - Mental Capacity Act (England and Wales)
• Adults with incapacity: forms and guidance (Scotland).

Managing appointments

By getting to know the individual it may be possible to plan dental care to be delivered at their best time of day, and make adjustments that will reduce their levels of stress. These might include playing relaxing music in the waiting room and surgery and lowering the ambient lighting. Reception staff are often the first point of contact and should be trained about how best to communicate with these patients. Virtual pre-treatment familiarisation tours to the practice or a video consultation prior to treatment may help the individual, especially if they have been an infrequent attender in the past.

Dental appointments should be kept within the individual's ability to cope. This can vary, with some who have short attention spans or who are particularly anxious being less able to cooperate.

Remember that people have good days and bad days. The most important aspect is that you see the patient as an individual and not just the symptoms of dementia. Try to find out something personal about them, e.g. what they did for a living or a hobby. Get them to bring in familiar objects (avoid anything valuable) – favourite things and photographs are often helpful – or music to play on a CD or phone.

Focus on the things that the person can still do, rather than what is no longer possible.

During treatment it is helpful to:

• use clear short instructions repeated in the same words.
• find tactful ways to offer help without seeming to take over.
• try not to criticise, and try to avoid situations where the person is set up to fail.
• use objects that have a very distinct and strong colour to help distinguish them.
• remove unnecessary objects from sight.
• name objects when handing them to the person.
• watch out for warning signs, such as anxious or agitated behaviour or restlessness, and take action immediately to help the person feel more calm and reassured.

It is important to recognise that distressed or distressing behaviour represents an unmet need.

Team approach

Use a whole-team approach and promote effective communication so that the dental team can share responsibility of ensuring that the patient living with dementia has a positive experience whilst in the practice. This also means that everyone can be vigilant to make sure that the individual’s safety is maintained, particularly if they attend independently. Sadly, there is a higher risk of abuse in people living with dementia so safeguarding training for all staff is important.

It can be stressful to treat people with dementia so it is also important to build supportive relationships within the team so that issues can be raised and problems shared.

Practice environment

Dental practitioners have a duty under the Equality Act (2010) to make reasonable adjustments in the practice for disabled people with physical or mental conditions. Designing an environment for people living with dementia can result in a well-designed environment for all. The process should involve a review of the whole patient journey – getting to and from the surgery through the practice environment. Large modifications to the design or layout of the practice may sometimes be difficult due to basic architecture and the capital costs required, but some simple changes can make a significant difference to the patient experience.

Things to consider:

• Objects that are shiny, patterned or reflective can cause people with dementia to mistake what they are seeing.
• Features such as lighting, mirrors, shadows, steps and patterned walls and floors might cause problems for some people with dementia.
• If someone with dementia has increased difficulty with reading or processing visual information they may not recognise signs or know where they should put things.
• Practices can be noisy – be aware of how this might affect someone.

Key recommendations to support people living with dementia can be found in comprehensive guidance from the Department of Health and other documents informing the design of medical settings (pdf).

In conclusion…