Dementia and Dentistry An Overview, by Natalie Wilson

What is Dementia? ICD-10: “as a disorder with deterioration in both memory and thinking which is sufficient to impair personal activities of daily living...patients have deficits in thinking and reasoning in addition to the memory disturbance.” A syndrome - a range of clinical symptoms that combine to form an overall clinical picture Can be over 100 causes

Prevalence Increasing - recognised global time bomb Currently vastly underdiagnosed (up to 55% of those affected) Estimated >1million diagnosed in UK by 2025 1 in 3 will have some form of dementia

Diagnosis 1. Patient exhibits changes in cognition, function and personality for at least a year. 2. Thorough history with family member/carer present 3. Several short cognitive exams carried out by GP 4. Blood testing 5. Specialist memory service referral 6. Further testing National Dementia Commissioning for Quality and Innovation requires A&E admissions for >75y/o to screen for memory problems

Types of Dementia Alzheimer’s Vascular Mixed Lewy Body Frontal Lobe

Alzheimer’s Most common (60%) Chemical changes in nerve cells in the brain - plaques appear Typically presents with short term memory loss and word difficulties Forgetting names, places, events Mood swings and frustration Become withdrawn NICE recommended drug of choice is Donepizil (Aricept) - anti cholinergic

Normal healthy brain vs Alzheimer’s affected brain https://en.wikipedia.org/wiki/Dementia#/media/File:Alzheimer%27s_disease_brain_comparison.jpg

Vascular Dementia Caused by congestion of small blood vessels in the brain - affecting supply of blood to the brain Often diagnosed following a stroke or series of Transient Ischaemic Attacks Linked to cerebrovascular changes in the brain Stepwise deterioration, similar signs as AD Managed with therapeutic interventions as for coronary artery disease Possibly also anti coagulant therapy to prevent clots

MRI of normal brain vs Vascular Dementia http://www.mr-tip.com/serv1.php?type=img&img=Brain%20MRI%20Images%20T1 http://www.medicinenet.com/image-collection/vascular_multi-infarct_dementia_1_picture/picture.htm

Mixed Dementia Combination of Alzheimer’s disease and vascular dementia Changes representing more than one type of dementia occur simultaneously in the brain. In the most common form, the plaques and tangles associated with nerve cells in Alzheimer's disease are present along with blood vessel changes associated with vascular dementia.

Lewy Body Dementia Protein deposits on nerve cells Named after physician who discovered these Often present with sleep disturbance and halucinations Can cause Parkinson’s Disease Symptoms depend on area of brain affected - motor/cognitive Management of symptoms and support of patients

Histology of normal brain tissue vs Lewy body http://www.proteinatlas.org/learn/dictionary/normal/cerebral+cortex/detail+1/magnification+1 http://www.medicinenet.com/image-collection/lewy_body_dementia_picture/picture.htm

Frontal Lobe Dementia Generally affects younger people (60s) than other dementias Frontal and temporal lobes damaged Early features include personality change and problems with executive function Can be aggressive/short tempered Mood swings and sexually inappropriate behaviour Linked to MND MDT support

Dementia and Oral Disease Research suggests less frequent toothbrushing and accumulation of plaque may be early indications of cognitive decline GDP may spot this before family member notices memory loss Systemic inflammation from periodontal disease can affect the brain, disrupt neurons and cause poor memory Carers may ask YOU for advice

Signs for the Dental Team Early Stages: Missing/incorrect appointments Difficulty in decision making Deterioration in OH Repetition of questions Confusion/difficulty grasping new ideas

Middle Stages: Need reminding and help to carry out daily personal care Failure to recognise dental team Failure to remember answers to questions, despite repeatedly asking

Later Stages: Increasing difficulty to attend surgery due to mobility issues May be confined to bed Difficulty in eating/swallowing Weight loss Increasing difficulty in communicating

Dementia and the Dental Team Need to be aware of early signs and how to manage middle and late stages Many potential issues to manage: Communication: language, time, prompts, explanation Consent: Mental Capacity Act 2005 (Eng), PoA/ IMCA Access: mobility/carers, time of day, doms visits Tx planning: simple, maintenance + prevention, dents Cooperation: capacity, anxiety/depression, sedation Drug therapy: oral effects, interactions, metabolism

What can we do? Ensure staff are properly trained in recognising/managing patients with dementia Sensitive conversation with patient and family Can speak to GP Encourage patients to seek diagnosis - early Tx slows progression Be patient and supportive of patient needs Ensure focus is on patient comfort in later stages Ensure caregivers carry out regular oral care Help patients access care services

References www.alzheimercalgary.ca/about...and-dementia/...dementia/mixed- dementia https://www.alzheimers.org.uk/site/scripts/documents_info.php?documen tID=161 Boyle, C; Edwards, J A; Ford L: Dementia and Dentistry. Dental Update, p464, June 2015

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