Weight Loss in End-stage Dementia

A Layperson’s Guide: Weight Loss in End-stage Dementia

Evelyn Smith


M. S. in Library Science (1995), University of North Texas

Summary: Most Alzheimer's patients need to be
encouraged to eat while frontal temporal
lobe dementia patients are "plate cleaners".

Several weeks ago, a rapid weight loss of 7.8 pounds (4 kg.) within a single month necessitated placing Mother, who was already confined to a wheelchair, in hospice care when this weight loss was coupled with other aggravating factors, so the reader should note that this blog entry is very much in response to a personal need to learn about weight loss in dementia patients and how it fits into the dying process.   This type of weight loss, however, is very different from the weight loss that occurs during the onset of Alzheimer's and when some patients simply lose interest in eating. Thus, this cathartic summary of sources available Online intends to give other caregivers an overview of what is happening once hospice care has started as well as an understanding of how weight loss fits into the dying process. 

Family members should also be forewarned that the wasting brought about by end-stage dementia is not pleasant to watch, but they can give their loved ones some small measure of comfort if they confer regularly with the hospice and/or nursing home staff.   For example, immediately after Mother was admitted to hospice care, her physician changed her multi-vitamin supplement to provide her with more nutrients.  However, since she had progressively had trouble swallowing this supplement, perhaps because the calcium included in it is granular, the search was on for another vitamin supplement that fit her progressive inability to swallow.  Eventually, all vitamin supplements stopped because it was simply too hard for her to swallow them.

Family members should also be cautioned that the weight loss caused by trouble swallowing as well as the ongoing shut down of the digestive system is a progression that each individual patient experiences differently.   Even so, it is comforting to know what to expect.

Alzheimer's Society & Popular Sources

Dementia information for carers, families and friends of people with severe and end stage dementia. (2007). 2^nd ed. University of Western Sydney.  Palliative Care Dementia Interface: Enhancing Community Capacity Project.  Retrieved from http://catalogue.nla.gov.au/Record/4085461

In late-stage Alzheimer’s patients usually lose weight despite receiving adequate amounts of food and fluids because the progression of the disease causes complex physiological changes.  Patients also lose interest in eating and drinking, often refusing food and drink in the final weeks of the dying process (Dementia information, 2007, para. 21).

Eating in late-stage dementia. (2011, May 18).  Dementia-friendly environments: A guide for residential care.  Victorian Government Health Information.  Retrieved from http://www.health.vic.gov.au/dementia/strategies/assisted-eating.htm

Patients who lose interest in food and/or have trouble swallowing are more likely to lose weight, so caretakers should take the following steps to provide the highest quality of care:

• Provide soft and pureed foods as long as patients can tolerate swallowing them;

• Change food textures as needed;

• Check weight loss regularly and make up for it with fortified foods and vitamin supplements or foods higher in calories.

(Eating in late-stage dementia, 2011, para. 1)

During the most severe stages of dementia, patients will no longer be able to eat.  Even so, care givers should not force patients to eat even as they moisten the mouth and continue to provide oral health care (Eating in late-stage dementia, 2011, para. 2).

Fernandez, F. (2011, March 15).  Final stages of dementia.  Livestrong.com.  Retrieved from http://www.livestrong.com/article/103819-final-stages-dementia/1

Advanced-stage dementia patients have trouble swallowing and choking.  Weight loss occurs, and the skin around the lips becomes very thin.  Additionally, they start to display grasping and sucking reflexes (Fernandez, 2011, para. 3).

Gordon, M. (2011, January 31).  Alzheimer’s disease/ Timeline for final stages in early-onset dementia.  AllExperts. Retrieved from http://en.allexperts.com/q/Alzheimer-s-Disease-1005/2011/1/Timeline-final-stages-early.htm

Signs that the end is nigh include wasting and weight loss, loss of interest in food and drink, sleeping more and responding less, not being able to sit up in a chair, a rise in contracting opportunistic infections, and a corresponding break down of the immune system.

 

Late stage and end-of-life care: Caregiving in the final stages of life.  (n. d.). Helpguide.org. Retrieved from http://www.helpguide.org/elde/alzheimers_disease_dementia_caring_final_stage.htm

As patients lose their appetites and experience a decreased need for food and fluid, care givers should let them choose if they need to eat or drink while moistening the lips with glycerin swabs and lip balm as well as supplying [thickened] water, or juice if they are still physically capable of swallowing (Late stage Help Guide, n. d., p. 15).

Late-stage care: Providing care and comfort during the late stage of Alzheimer’s disease. (2011). Alzheimer's Association. Retrieved from http://www.alz.org/national/documents/brochure_latestage.pdf

The Alzheimer’s Association warns care givers that while weight loss is common in end- stage dementia, it can also signal inadequate nutrition,undiagnosed illness, or the side effects of medication (Late-stage care, 2011, p. 6).

Late stages of dementia.  (2013). Alzheimer’s Society.  Retrieved from 
http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=101

Even though most dementia patients lose weight in end- stage dementia, care givers should ensure they are receiving enough food and liquid.   Because muscles in the throat and the patients’ reflexes are not working properly, this causes choking problems that often result in chest infections [aspiration pneumonia].  Thus, as the occasion demands it, physicians [or hospice nurses] may need to periodically refer patients to speech therapists or nutritionists (Late stages, 2013, Alzheimer’s UK, para. 12-14).

Lynne, V. (2013).  Symptoms of advanced-Alzheimer’s.  Hub Pages. Retrieved from

http://virginialynne.hubpages.com/hub/Symptoms-of-Advanced-Alzheimers

Severe weight loss occasioned by the inability to eat and process food is one of the symptoms of advanced dementia (Lynne, 2013, para. 5).   Dealing with these patients necessitates the following suggestions: 1) Make sure patients are seated upright when eating [Mother’s nursing home makes sure she is in an upright position for thirty minutes after meals]; 2) feed them pureed food more slowly than they have previously done so, and 3) and stroke the neck to elicit a swallowing response (Lynne, 2013, para. 6).   Hospice attendants ordinarily encourage end-stage dementia patients to eat and drink, but they also allow them to refuse food and water since as the digestive process starts to shut down, the body cannot take in nourishment, and eating makes them increasingly uncomfortable (Lynne, 2013, para. 16). 

Vaughan, K. (2013, April 30).  Signs & symptoms of end-stage dementia. e-How. Retrieved from http://www.ehow.com/list_5787280_signs-symptoms-end_stage-dementia.html

End-stage dementia results in weight loss caused by 1) feeding apraxia, or loss of the ability to chew and to swallow, 2) depression, 3) weakened motor skills, and 4) increased risk of aspiration (Vaughan, 2013, para. 4).

Volicer, L. (2005).  End-of-life care for people with dementia in residential care settings. Alzheimer’s Association. Retrieved from http://www.alz.org/national/documents/endoflifelitreview.pdf

Volicer notes that forgetting to eat and a lessening of their ability to smell, intensive pacing, and poor-feeding practices causes weight loss in the beginning stages of Alzheimer's. Patients with frontotemporal dementia, by way of contrast, often suffer from hyperphagia, or excessive hunger (Volicer, 2005, p. 13).

As dementia progresses, however, all patients lose the ability to feed themselves without assistance whereupon care givers can hand feed them until the beginning of the dying process starts when the body begins to shut down. 

Observation of mentally-cognitive cancer patients indicates that the dying do not feel hunger and thirst.  Thus, when patients refuse all food and liquids, this will not result in pain or discomfort, and they will usually die a comparatively peaceful death within two weeks (Volicer, 2005, p. 13-14). 

Waller, E. (2001).  Lesson Thirteen—the death and dying process.  Gerontology 130: Working with the frail elderly.  Coastline Community College.  Retrieved from http://cvc3.coastline.edu/modelcvc3courses/elliswaller/lesson13.htm

Waller furnished a death-watch time line for elderly patients:  Older patients ordinarily decrease their food intake from between one to three months prior to death.  From one to two weeks before dying, their exhibit the following symptoms:  1) Refusal of food and drink, 2) decreased blood pressure, 3) increasing or decreasing pulse rate, 4) changes in skin color, 5) increased perspiration,  6) problems breathing, 7) [chest] congestion, 8) sleeping and not responding, and 9) fluctuations in body temperature.  10) Those who can communicate also complain that their body is tired and heavy.

Vetted & Research-based Sources

, P. N. (2010, October 27).  Palliative care in end stage dementia: Providing the right care for the right patient at the right time in the right place.  American College of Osteopathic Internists.  Retrieved from http://www.acoi.org/2010Convention/BrymanPalliativeCareAndAdvanced.pdf

Bryman identifies one of the symptoms of hospice eligibility as the inability to maintain sufficient fluid and caloric intake  so that a ten percent weight loss has occurred during the previous six months. Other symptoms include 1) serum albumin levels of less than 2.5 g. dL.  [Serum albumin is a globular protein commonly found in blood, the normal range of which is from 3 to 4 dl in adults]; 2) aspiration pneumonia, 3) pyelonephritis, or kidney infections, or other upper Urinary Tract Infections (UTI), 4) septicemia, or infections of the blood, 5) pressure ulcers, and 6) fever that recurs after antibiotic therapy (Bryman, 2010, slide 19).

Grundman, M., Corey-Bloom, J, Jernigan, T., Archibald, S. and Thal L. T.  (1996 June). Neurology, 46(6), 1585-91 (Medline Abstract).  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8649553

In a case study, Alzheimer’s exhibited significantly more brain atrophy in all regions of the brain other than the white regions than their controls did, although the Mesial temporal control region (MTC) remained the only brain region associated with dementia patients.  The study thus concluded that damage to the limbic system that controls swallowing correlates with weight loss in Alzheimer’s patients.

Hughes, J. C, Jolley, D., Jordan, A., and Simpson, E. L. (2007).  Palliative care in dementia: Issues and evidences. Advances in Psychiatric Treatment, 19 (4). doi: 10.1192/apt.bp.106.003442,  Retrieved from http://apt.rcpsych.org/content/13/4/251.full

United States Medicare funding for hospice care depends on the patient’s inability to survive less than six months, so complications caused by rapid weight loss have become just one of the indications that recommend dementia patients for hospice care.  Other Functional Assessment Staging or FAST variables include the following components:   

1) Hospice candidates suffering from dementia are ordinarily non-ambulatory; 2) they can no longer speak, and 3) they are entirely dependent upon others for all their activities of daily living. 4) Moreover, they may suffer from recurrent skin infections and pressure sores, 5) hip fractures, 6) [aspiration] pneumonia, and finally, 7) the need for artificial feeding—or the acceptance upon those who have medical power of attorney that life cannot be substantially prolonged or its quality improved by tubal feeding (Hughes, 2007, para. 16).

During the last stages of dementia, weight loss and the loss of muscle strength reflect reduced food intake, although the degree of weight loss in dementia patients may be greater than the refusal of food alone would indicate.  This is because a low metabolic rate and physical inactivity can bring about a state of physiological homeostasis, so that patients constantly lose weight and body mass, develop skin contractures, easily torn skin, and bed sores—all of which result from muscle atrophy and a poor diet that the trouble they have swallowing causes (Hughes, 2007, para. 16).

Additionally, advanced dementia and the lack of mobility that goes with it produce incontinence that threatens skin integrity and constipation that, in turn, leads either to impaction or overflow incontinence.  Constipation impedes bladder function and causes discomfort, pain, and toxicity whereupon patients may become confused or agitated, and may feel more comfortable being placed lying on their sides (Hughes, 2007, para. 17).

As this cycle continues, patients lose their appetites.   The loss of a need for regular meals causes coordination and sequencing problems involved with swallowing, so patients more easily choke on food and may develop aspiration pneumonia (Hughes, 2007, para. 26). 

Kovach, C. R. (2001).  Late-state dementia care. Marquette Elder Advisor, 2 (3).  Article 7, 48-56. Retrieved from http://scholarship.law.marquette.edu/cgi/viewcontent.cgi?article=1248&context=elders

Weight-loss in late-stage dementia is usually caused by swallowing problems as dementia patients lose the ability to coordinate the complex process involved in swallowing, and they are also less likely motivated to eat (Kovach, 2001, p. 50). As appetite decreases, the inability to swallow may lead to patients aspirate food, which in turn leads to fluid in the lungs (Kovach, 2001, p. 47).  

Pivi, G. A. K., Bertolucci, P. H. F. & Schultze, R.  (2012). Nutrition in severe dementia. Current Gerontology and Geriatrics Research.  doi: 10.1155/2012/983056 Retrieved from http://www.hindawi.com/journals/cggr/2012/983056/

Feeding problems and difficulty swallowing result in continuous weight loss as dementia progresses.  Most patients will eventually experience dysphagia, or the ability to coordinate all the steps in the swallowing process--a stage often associated with aspirate pneumonia (Pivi, 2012, para. 4-6).

Cachexia, or wasting away, and weight loss are common symptoms of end-stage dementia patients (Pivi, 2012, para. 13), and this weight loss correlates with higher rates of infection.  As this degenerative process increases, so do skin infections and ulcers, and body temperature eventually declines (Pivi, 2012, para. 13-15).  Pivi et al theorize that the continuing atrophy of the mesial temporal cortex corresponds with this drop in weight since the last stages of dementia also bring about a lowering of the Body Mass Index (BMI) in advanced dementia (Pivi, 2012, para. 18).

Sachs, G, A., Shega, J. W., & Cox-Hayley, D. (2004, October).  Barriers to excellent end-of-life care for patients with dementia.  Journal of General Internal Medicine, 19(1), 1057-1063.  doi:  10.1111/j.1525-1497.2004.30329.x.  Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492583/

Sachs and his fellow researchers review the symptoms of end-stage dementia—a period preceded by the loss of all or most of the activities of daily living, any meaningful conversation, and a non-ambulatory status, weight loss of ten percent or more, recurrent infections, pressure sores, and possible hip fractures and/or [aspirant] pneumonia (Sachs, 2004, para. 18).  

Tsai, S. & Arnold, R. (n. d.).  #150 Prognostication in dementia.  End of Life/Palliative Education Resource Center.  Retrieved from http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_150.htm

Factors predicting a shortened-survival rate for patients with dementia include “male gender, old age, diabetes mellitus, CHF, COPD, cancer, cardiac dysrhythmias, peripheral edema, aspiration, bowel incontinence, recent weight loss, dehydration, fever, pressure sores, seizures, shortness of breath, dysphagia [or difficulty swallowing], low oral intake, not being awake most of the day, low Body Mass Index, and need for continuous oxygen” (Tsai, n. d., para. 2).  Six months after dementia patients are admitted to hospice care, over half have either succumbed to pneumonia compared with 13 percent of mentally cognitive hospice patients or have died from complications resulting from hip fractures compared with 12 percent of hospice patients not experiencing dementia (Tsai, n. d., para. 3).

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Postscript: A Personal Note

March 30, 2014

So how much weight does a patient lose during the end stage of dementia?  The answer obviously depends on the individual patient, but a wasting away isn't all that uncommon for all stages of Alzheimer's if medical intervention doesn't occur.  However, please let me cite my mother's case as an example:  Since inactivity and a craving for food experienced by frontotemporal dementia patients had originally caused Mother to gain approximately 40 pounds, or 64 kilograms, she differed from most Alzheimer's patients, who show no interest in food.  Mother originally stood five feet eight inches tall (173 cm.), and she weighed approximately 140 pounds (65 kg.)  at the time she started to lose her memory.  Since she had always been fashionably thin most of her adult life--she weighed 120 pounds (54 kg.) when she was wed in 1946.  Thus, she would have been pleased that a mortician was able to dress her in a size 14 Misses suit that was kept back for her funeral with only a little adjustment, for she had lost around 30 pounds (14 kg.) within the space of ten months, which is hard to do when confined to a reclining geriatric wheelchair. 

Fortunately, after Mother's initial weigh loss, after being placed in hospice care, her weight loss was gradual until the last week of her life when from Friday through Wednesday she refused all food, and from Tuesday onward she was unable even to swallow any liquid no matter how hard she tried.  Her food had been pureed for over three years and her water thickened as well.

The medical links furnished on this Web page represent the opinions of their authors, so they complement—not substitute—for a physician’s advice.

Therapeutic, Restorative and Preventive Dental Care for Patients with Alzheimer's and Other Dementias

What a Caretaker Needs to Know about

 Caring for a Dementia Patient’s Teeth

   

 Evelyn Smith

M.S. in Library Science, University of North Texas (2012)

While much advice about how to care for the teeth and gums of Alzheimer's and dementia patients is sparse, the sampling of references below  emphasizes preventive and therapeutic care, most particularly stressing attention to the gums since receding gums speed up the development of dental decay because this process exposes the roots of the gums  Snacking also needs to be restricted since patients who are beginning to have difficulty swallowing pocket food in the mouth rather than swallowing it.  This possibility also suggests that a caretaker needs to brush the patient's teeth following a meal.

Regularly checkups may need to be increased from two to four or more times a year as the patients lose the ability to brush and floss as well as to explain that they are  in pain. Eventually, caretakers will also need to find a dentist that specializes in the care of dementia patients and who makes visits to nursing homes or home visits.

Relatives of residents living in nursing homes need not only to talk regularly with the dental hygienist who professionally clean the residents’ teeth, but they also need to make sure that  the attendants who actually brush them daily are doing an adequate job of it.   For example, while a dental hygienist might recommend exchanging a manual toothbrush for an electric toothbrush, a talk with an aide might help a family member discover that the soft bristles of a battery-powered child’s brush might be more effective in late-stage Alzheimer’s than the harder-bristles of an adult electric toothbrush. 

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Addendum: The Yogurt Cure

January 30, 2014

Noticing my mother’s breathe had a sour smell yesterday, I checked; and sure enough, a layer of brown gunk covered her teeth, verifying my suspicions that the aides weren’t regularly brushing them.  I quickly set about to remedy the situation by brushing away this film during a single session with her child's battery-powered toothbrush.  At this point, I  resolved to brush her teeth daily myself instead of relying on the nursing home staff to do so.  However, when I mentioned the problem to her ward’s on-duty nurse, she suggested that I buy a bottle of mouth wash, so an aide could swab Mother's teeth in addition to brushing them--provided that Mother opened her mouth sufficiently to allow the aide to do so without clamping down on the toothbrush.  When picking up the mouth wash at a local pharmacy, the cashier also recommended that a daily serving of non-flavored yogurt be added to Mother’s diet since it contributed to oral hygiene.  Sure enough, PubMed  has published abstracts that suggest that the regular consumption of yogurt without any added flavors or fruit might be beneficial in patients that are incapable or unwilling to properly brush and floss their own teeth.

Caglar, E, Kargul, B, Tanboga, I. (2005, May). Bacteriotherapy and probiotics' role on oral health. Oral Diseases, 11(3):131-7.   [Abstract only].  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15888102

“Probiotic approaches” or what researchers also call “whole bacteria replacement therapy” or “bacteriotherapy” has become “an alternative and preventive way to combat infections by using harmless bacteria to displace pathogenic microorganisms”.

Varghese, L., Varughese, J.M.,  &Varghese. N.O. (2013).  Inhibitory effect of yogurt extract on dental enamel demineralisation - an in vitro study. Oral Health & Preventive Dentistry, 11(4), 369=74. doi: 10.3290/j.ohpd.a30604. [Abstract only].  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24046825

A study of 80 intact, cavity-free human premolars tested four demineralizing solutions that researchers allowed to stay on four groups of premolars for 96 hours.  After this time elapsed, researchers selected selected five teeth from each group for microscopic study.  Results revealed that “probiotic yogurt extract is effective in reducing demineralisation of enamel under experimental conditions.”

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Bibliography of Commercial and Alzheimer’s Association and Society-based Sources

Alzheimer’s care and dental health.  (2011, October 25).  The Dementia Zone.  Alzheimer’s Care Consultants.  Retrieved from

http://blog.alzheimerscareconsultants.com/alzheimers-blog/bid/103056/Alzheimer-s-Care-and-Dental-Health

Dental care should not stop when a neurologist diagnoses patients with dementia, and although dental problems are not a direct cause of dementia, they can cause difficult behavior and speed up mental and physical decline.  Hence, caregivers need to recognize that 1) brushing and flossing are multistep processes that in time will prove too difficult for the patient to accomplish first without supervision and later at all; 2)  caregivers need to set realistic goals for caring for a patient’s teeth, depending upon his or her stage of dementia; 3) caregivers also need to recognize that the only outward sign of a mouth infection might be difficult behavior;  and 4) since patients can no longer  adequately communicate discomfort, regularly checkups at least twice a year are very necessary. Finally, caregivers need to regularly check dentures to see if they are fitting properly as well as cleaning off the plaque that encrusts them.

De Marco, B. (2009, December 10).  Alzheimer’s disease—brushing the teeth with the Oral B.  Retrieved from http://www.alzheimersreadingroom.com/2010/09/alzheimers-and-oral-hygiene.html

De Marco recommends using an [Oral B] electric toothbrush since 1) patients and caretakers can use the same system as the toothbrush heads are interchangeable; 2) an electric toothbrush handle is easier to grasp that a standard manual toothbrush; 3) an electric toothbrush ensures more efficient care for the gums and the space between the teeth, and 4) caring for the teeth with an electric toothbrush might be turned into a game (De Marco, 2009, para. 3-9).

Dental care. (2009). Alzheimer’s Association.  New York City Chapter.  Retrieved from http://www.alznyc.org/caregivers/dental.asp

Since caregivers need to increasingly assume the responsibility for providing dental care for a patient with Alzheimer’s, the New York City Chapter of the Alzheimer’s Association furnishes a detailed guide for doing so (Alzheimer’s Association, 2009, para. 2).  Regular dental checkups thus might need to increase from two to four times a year, so a dentist can take care of problems as soon as they are discovered.   Additionally, caregivers need to find a dentist qualified to work with elderly patients, and if at all possible choose a dentist that offers home care and/or who visits nursing homes.  The dentist also needs a list of all the medications patients are taking [since dentist often put patients to sleep to facilitate cleaning or to fill cavities or extract teeth if  they cannot otherwise cooperate or tolerate the procedures] (Alzheimer’s Association, 2009, para. 3).

Dental care, however, needs to concentrate on prevention which recognizes the relationship between diet and mental health—eliminating sugary foods and between the meal sacks and substituting fruits and vegetables for cookies and candy--and maintaining “good oral hygiene”: 1) brushing at least twice daily for two minutes, making sure that the teeth are adequately brushed after the evening meal and the dispensing of liquid medication; 2) using a fluoride toothpaste;  3) encouraging patients to brush as long as they are able to do so, possibly using a bicycle grip handled toothbrush; 4) postponing brushing teeth  until patients are willing to cooperate  once aides or caretakers take over this task; 5) introducing an electric [or battery-powered] toothbrush to clean the teeth in a way that does not disturb sensitive patients; 6) using mouth rinses that contain no alcohol (Alzheimer’s Association, 2009, para. 4 & 5).

Dental care and dementia. (2013). Alzheimer’s Society.  Retrieved from 
http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=138

Dental pain and infection from periodontal disease and tooth decay can worsen the confusion associated with Alzheimer’s.  Gum disease results in inflamed and bleeding gums while receding gums reduce gum tissue, causing the roots of the teeth to be exposed.  Plaque caused by food debris and bacteria leads to gum disease if sufficient cleaning does not remove it where the teeth met the gums. Thus, the Alzheimer’s Society recommends that patients rinse the mouth with an antiseptic and disinfectant mouth wash (Alzheimer’s Society, 2013, para. 2 & 3).   However, the author fails to address what caretakers should do when dementia patients no longer understand the concept of rinsing.

Since tooth decay and the action of plaque on the teeth occur when the patient eats sugary foods, foods,  caregivers need to restrict such  treats to meals; for example, high-energy food supplements contain high levels of sucrose.  Gum recession also increases the chance of tooth decay (Alzheimer’s Society, 2013, para. 4 & 5).  

During the early stages of dementia, most patients can most probably still clean their own teeth, at first without supervision and only needing an occasional reminder to do so, but as manual dexterity decreases, an electric toothbrush or a manual toothbrush with an adaptive handle may help them maintain independence.  However, during the later stages of dementia, caregivers will need to assume this responsibility (Alzheimer’s Society, 2013, para. 5 & 6).  

Additionally, antidepressants, anti-psychotic, and sedative medications dry the mouth, causing problems with dentures and causing an increase build-up of bacteria and food debris in the mouth since saliva has a cleansing effect on teeth while at the same time the liquid syrup-based medication that the patient may be administered instead of swallowing a capsule or pill aggravates tooth decay (Alzheimer’s Society, 2013, para. 7 & 8).

Accordingly, it is crucial to schedule regular checkups for since caretakers increasingly may have to infer that patients are in pain by observing outward behavior (Alzheimer’s Society, 2013, para. 9 & 12).

During the early stages of dementia, however, advanced restorative treatment is still possible particularly if patients can still brush their teeth themselves. So this is the time to prevent further gum decay [perhaps by accustoming patients to using an electric toothbrush] (Alzheimer’s Society, 2013, para. 22).  In the middle stages of dementia, however, the focus needs to shift from restoration to prevention since some uncooperative patients may need to be sedated (Alzheimer’s Society, 2013, para. 23).  During the final stages of dementia, caregivers will need to concentrate on maintaining “oral comfort” and emergency treatment; Caregivers also need to clean plaque that can build up on dentures and to replace ill-fitting dentures (Alzheimer’s Society, 2013, para. 24-27). 

Dental health care for Alzheimer’s patients. (n. d.).  Delta Dental.  Retrieved from http://www.deltadentalins.com/oral_health/alzheimers.html

Delta Dental recommends that Alzheimer’s patients or their caretakers 1) brush teeth twice daily, noting that an electric toothbrush may be a good choice if the patient can stand the vibrating bristles;  2) floss once daily, using a special pick or stick rather than dental floss if patients clench their teeth; 3) cleanse the mouth and dentures after each meal, clearing the mouth of any remaining food since patients might not be immediately swallowing everything they put in the mouth; 4) visually inspect the teeth and gums monthly, looking for signs of gum diseases; and 5) schedule regular dental appointments (n. d., para. 2). 

Keith, C. (2012, November 8).  Alzheimer’s Disease/Grinding of teeth in Alzheimer’s.  AllExperts.  Retrieved from http://blog.alzheimerscareconsultants.com/alzheimers-blog/bid/103056/Alzheimer-s-Care-and-Dental-Health

Brain damage in late-stage Alzheimer’s may affect the impulses to the brain that stimulate teeth grinding.  Caregivers may thus need to ask a physician to prescribe sedatives or muscle relaxants; however, a baby’s teething ring briefly chilled in the freezer or a large pacify might also help.  Note: Nursing homes, however, may restrict the use of these low-tech, non-medicinal cures to inhibit tooth grinding because dementia patients might choke on parts that possibly might come loose, and these devices might be perceived of as undignified.

Kennard, C. (2006, September 5).  Dental care in dementia.  About.com. Retrieved from

http://alzheimers.about.com/od/treatmentoptions/a/dental.htm

This British study contrasts the early stages of dementia where patients may have to be reminded to brush, and caretakers may need to check if patients are still able to grasp a toothbrush with late-stage dementia where patients are no longer able to care for their own teeth, and caregivers may need to brush them (Kennard, 2006, para. 1 & 2). At this point, checking the  mouth for damaged teeth, swollen gums, tongue-biting and oral cancer becomes particular important as the patients’ inability to describe any dental symptoms worsens (Kennard, 2006, para. 3).  Signs of dental problems include rubbing or touching the mouth or jaw, moaning or shouting, head rolling or nodding, flinching when someone touches the face, refusing cold or cold drinks, restlessness, poor sleep, irritation, and aggression, and if the patient has dentures, refusing to wear them (Kennard, 2006, para. 4).  Caregivers may be reluctant to schedule dental appointments over anxiety that patients will not cooperate or become upset on the way to the dentist’s office (Kennard, 2006, para. 5). 

Pursley, B.  (2010, September 3). Alzheimer's and oral hygiene.  Alzheimer’s Reading Room.  Retrieved from http://www.alzheimersreadingroom.com/2010/09/alzheimers-and-oral-hygiene.html

Pursley, a registered nurse, gives a first-hand account of how she cared for her mother’s teeth and the problems she faced as a caretaker when trying to give her mother the best care possible.  Brushing her mother’s teeth with an electric toothbrush originally wasn’t difficult, although in time her mother bit Pursley’s hands when she tried to floss between her teeth (2010, para. 1).   However, ten years after the mother was first diagnosed with dementia, when Pursley took her mother to the dentist, he found a broken tooth with a slight infection and five teeth with cavities.  After he recommended that all her mother’s teeth be pulled, Pursley contacted a dental hygienist who counseled against this procedure since if a rotten tooth is dead  patients do not experience any pain, and it takes six months for cavities to show up on an x-ray.  Accordingly, Pursley took the advice that she needed to pay attention to her mother’s facial expressions and how she reacted to hot and cold liquids before taking such a drastic step since late-stage dementia patients usually decline after being administered complete anesthesia, and some never wake up after the procedure. 

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Research-based Surveys & Studies on Dental Care for Dementia Patients

Ellefsen, B., Holm-Pedersen, P., Morse, D. E., Schroll, M., Andersen, B. B., and Waldemar, G. (2008, January).  Caries prevalence in older persons with and without dementia.  Journal of the American Geriatrics Society, 56(1), 59-67.  Abstract only.  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18028345

Dental problems strongly correlate with the severity of dementia. The mean number of coronal and root surfaces with cavities is considerably higher after the diagnosis of dementia while Alzheimer’s patients have a significantly high mean number of root surfaces with caries than subjects who have not been diagnosed with dementia.  

Friedlander, A. H., Norman, D. C., Mahler, M. E., Norman, K. M., & Yagiela, J. A. (2006, September).  Journal of the American Dental Association [JADA]. 137 (9), 1240-1251.  Abstract only.  Retrieved from http://jada.ada.org/content/137/9/1240.abstract

Dental disease in dementia patients will likely be extensive because of diminished saliva flow and the patients’ inability to brush and floss their own teeth.  Caregivers therefore need to learn about the use of saliva substitutes and anti-caries agents.

Gitto, C. A., Moroni, M. J., Terezhalmy, G. T., and Sandu, S. (1985).  The patient with Alzheimer’s disease.  Berlin: Quintessence International. [Abstract Only]/ Retrieved from Europe Pub Med Central, http://europepmc.org/abstract/MED/12066662/reload=0;jsessionid=pSkVVEB0lbA8qMOFEf7M.4

Alzheimer’s hinders the ability to convey symptoms of dental pain or dysfunction while a gradual and increasing loss of memory affects the capacity to tolerate therapeutic interventions.  Therefore, caregivers need to develop timely, preventive, and therapeutic strategies that respond to the patients’ willingness to undergo dental care. 

Jones, J. A., Lavallee, N., Alman, J., Sinclair, C. and Garcia, R. I. (1993), Caries incidence in patients with dementia. Gerontology, 10: 76–82. doi: 10.1111/j.1741-2358.1993.tb00086.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1741-2358.1993.tb00086.x/abstract

A study that followed a group of 23 male veterans with moderate and advanced Alzheimer’s contrasted a control group with dementia patients matched for age, number of teeth, and education whereupon it discovered significant statistical difference in teeth and root decay between those veterans who still could care for their own teeth and those who have lost this ability.

Mancini, M., Grappasonni, I, Scori, S., Amenta, F. (2010, June 7).  Oral health in Alzheimer’s disease: A review.  Current Alzheimer’s Research.  7(4), 368-73.  Abstract only. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20043813

As oral health declines, dental pathologies increase in patients diagnosed with Alzheimer’s because patients loose the intelligence that will allow them to care for their teeth and/or dentures themselves.  Thus, dental interventions increasingly need to concentrate on decreasing pain and oral disease and contributing to oral and nutritional health.  Dental treatments in the early stages of dementia, by way of contrast, should aim at producing a stable condition that will help ensure a high quality of oral health throughout the duration of the disease.

Niessen, L. C. and Jones, J. A. (1987), Professional Dental Care for Patients with Dementia. Gerontology, 6: 67–71. doi: 10.1111/j.1741-2358.1987.tb00391.x.  Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1741-2358.1987.tb00391.x/abstract

With the goals of restoring and maintaining oral health and preventing future oral disease, dental professionals need to develop a special skills set to treat patients with dementia: 1) planning a treatment program with caregivers and 2) developing the rapport to communicate with patients who can no longer adequately respond verbally. Dental function should be restored as quickly as possible and an intensive preventive program should be put in place.

Srisilapanan, P. and Jai-Ua, C. (2013, March).  Oral health status of dementia patients in Chiang Mai Neurological Hospital.  Journal of the Medical Association of Th[ailand—Chotmaihet thangphaet.  56(3), 351-357. Abstract only. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23539941

This Thai study discovered that 52.40 percent of all dementia patients with the average age of 75.5 years still had at least 20 functional teeth while the mean of decayed, missing, or filled teeth was 14.9 percent.  The biggest problem these patients face was periodical disease (64.7 percent).  The severity of the patient’s dementia also correlated with an increase in cavities. 

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Postscript:  A Personal Note

I would personally like to thank Ledet Dental for Mother's dental care, a service that provides dental care for nursing home patients throughout the North Central Texas area, for their five years of faithful dental care when she could no longer make a trip to the dentist's office.  Not only did Ledet Dental provide skilled dental care, but they always kept me well-informed as well.  Moreover, Mother always seemed to enjoy the attention she received during their visits, and until the last few months of her life, she always had a beautiful smile. 
  

The links furnished on this Web page represent the opinions of their authors, so they complement—not substitute—for a dentist’s advice.