Residents with Cognitive Impairments

Another group of health conditions that often necessitate nursing home care or assistance with personal care are cognitive impairments, including Alzheimer’s disease and other forms of dementia, as well as cognitive deficiencies related to strokes or physical trauma.

Cognitive impairments vary widely in both the nature of the impairments and their severity, and these can affect a patient’s oral health in a number of ways. Communication problems are one of the barriers, which can prevent patients from notifying caregivers of mouth pain or from requesting assistance with oral care. Memory impairments can also prevent patients from keeping to a routine or even being aware of whether they have performed oral care recently. Furthermore, Cognitive impairments sometimes lead to resistance to care and combative behavior in patients who don’t understand what caregivers are doing to help them and have feelings of fear or aggression.²⁰

Depending on the severity and specific manifestations of each patient’s situation, the level of possible independence and the ability to participate in one’s oral hygiene routine will differ from patient to patient. As far as it is possible, accommodation and encouragement should be offered for independence and participation in self-care. However, the plan of care should also include adequate assistance to achieve thorough and frequent oral care. This plan will have to be updated and modified over time, especially when considering the progressive nature of many forms of dementia.

Providing care for residents that exhibit combative or fearful behavior can be especially challenging for nursing staff as well as family caregivers.²¹ There are different approaches that can make providing adequate care possible in situations where resistance or confusion had previously frustrated caregivers and left patients without adequate care and prone to dental decay, periodontal infections, and unobserved pathologies and symptoms.²²

Patients may be confused about what is happening and grab or play with toothbrushes or dental care aids. Some effective methods to try with these patients include:

• Distracting the resident by giving them something else to hold.

• Reassuring them by holding their hand or rubbing their back.

• Speaking to them or singing during care.

• Handing them the toothbrush as this can jog their memory and they begin to brush their own teeth.

Patients may also bite down on the toothbrush or dental care aid when confused instead of allowing the caregiver to perform care. Massaging the jaw will sometimes prompt them to open their mouth, or simply moving the brush around in the vestibule and asking them to open will sometimes elicit the desired reaction. Another method is similar to using a bite block in a dental office—when the patient bites down on a safe object such as the plastic of a second toothbrush or another item that isn’t small enough to choke on or will not damage their teeth—a toothbrush can then be inserted between the teeth that are propped open by the object they are biting on. This allows the caregiver to brush the lingual and occlusal surfaces of the teeth, which can often be neglected in patients with this automatic biting response.

Aggressive or combative behavior is one of the most difficult situations to address. Caregivers want to provide care, but patients may resist or show aggression toward the caregiver, causing them to avoid providing care and leaving the patient without the necessary oral hygiene.²³ It is important not to give up and to try various approaches in order to follow through and ensure care is provided. This includes finding optimal times for certain patients that may be more cooperative at certain times of day (such as after eating breakfast) or in certain settings (such as when in the bathtub or shower). It may also require trying different caregivers, as some patients respond differently to different individuals. Having a second person reassure the patient or hold their hands, or creating a distraction like television or singing, is also effective with some patients. Most importantly, oral care should not be avoided, but rather different approaches should be tried to find the methods that work best for each patient.

Important Reminders for Caregivers:

• For residents with dementia or confusion, provide oral care at least twice each day, especially after the last meal or oral medication.²⁴

• For residents that forget, are unable, or are resistant to care, follow best practices to ensure optimal cooperation and oral hygiene.

• Be observant of resident discomfort or problems in the mouth since residents may not be able to perceive or report pain.

• Promote as much resident independence as possible.