Current research aims at improving early detection and treatment of cognitive impairment (CI), particularly in patients at high risk for progression to dementia. It is important to treat signs and symptoms as early as possible to normalize quality of life. In older cognitively impaired patients, dentists and physicians should consider polypharmacy, uncontrolled cardiovascular risk factors, depression, metabolic or endocrine derangements, delirium due to intercurrent illness, and dementia, all of which may increase risk for CI and other negative outcomes. An interdisciplinary team approach is a necessity for a responsible and safe treatment sequence.
Key points
- •
Variations in cognitive impairment in patients cause behavioral changes in patients which may then affect the ability to provide and maintain dental care.
- •
The proper diagnosis for cognitive impairment and knowledge of available medical treatment modalities allow for a better understanding of the systemic interactions with the dental care.
- •
Practitioners should be well aware of the process of informed consent since cognitively impaired patients are unable to consent to or approve oral care.
- •
Dental maintenance and management after treatment should continue on within an interdisciplinary approach.
Introduction
Cognitive impairment (CI) in older adults is a broad term for a variety of functions and activities that effect memory recall, learning, concentration, or decision-making skills occurring in the elderly.
There are several degrees and levels of CI, ranging from mild CI (MCI) to dementia. Although at one point all were grouped into a single condition as part of the natural aging process, research shows each as unique, with different causes, symptoms, and treatment.
It is now estimated that the over–65-year-old age group constitutes approximately 15% of the US population. , Despite the increase in multiple chronic conditions (MCCs) with age, most people with MCCs now are individuals younger than 65 years old. To some investigators, the high rate of CI among younger adults with MCCs may be a somewhat unexpected finding. This could be a result, however, of lower rates of other chronic conditions or factors, such as lack of sleep, side effects of medication, and use of illicit drugs, and may not be associated with future risk of dementia. Whatever the cause, being cognitively impaired may affect someone’s ability to self-manage other chronic conditions. In 2017, the US Centers for Disease Control and Prevention reported that those individuals younger than age 65 were more likely to report asthma, CI, depression, smoking, obesity, poorer access to health care, disability, and worse quality of life than those adults age 65 or older with MCCs. Based on these reports, it was estimated that the future risk of CI is approximately 28.6% for the greater than 65-year-old category compared with 57.2% in the less than 65-year-old category. These estimates for the less than 65-year-old cohort paint a picture that many more CI issues may have to be addressed in the future than currently are addressed today.
Age remains the greatest risk factor for CI, and, as the baby boomer generation passes age 65, the number of people living with CI is expected to jump dramatically. An estimated 5.1 million Americans age 65 years or older currently may have Alzheimer disease, the most well-known form of CI; this number may rise to 13.2 million by 2050. CI is costly. People with CI report more than 3 times as many hospital stays as individuals who are hospitalized for some other condition. Alzheimer disease and related dementias alone are estimated to be the third most expensive disease to treat in the United States.
As the impairment develops, a person may notice changes in their cognitive function but still have success accomplishing everyday activities and living independently. More severe types of impairment can affect a person’s ability to control bodily movements and manual dexterity and understand the meaning or importance of something as well as affecting speech and writing abilities. Therefore, when treating older adults, it is important to understand that oral health issues relevant to the healthy aging population are different than those who are aging with impairments or disabilities because providers have to bear in mind that oral health needs to be managed and maintained in concert with a patient’s impairments.
Cognition and daily living
Professionals who work in aging often want to know whether an older person needs any help with activities of daily living (ADLs) and instrumental ADLs (IADLs). As discussed in Joseph M. Calabrese and Kadambari Rawal’ article,“ Demographics and Oral Health Care Utilization for Older Adults ,” in this issue., they represent key life tasks that people need to manage in order to live at home and be fully independent.
Difficulties with ADLs and IADLs often correspond to how much help, supervision, and hands-on care an older person needs to obtain in order to be comfortable, functional, and safe. This assessment can determine the cost of care at a facility, whether someone is considered safe to live at home, or even whether a person is eligible for long-term care services. For each ADL, people can vary from needing just a little help (such as a reminder or a person to stand-by assist) to full dependency, which requires others to do a task for them. ,
Why activities of daily living and independent activities of daily living matter
Generally, older adults need to be able to manage ADLs and IADLs in order to live independently without the assistance of another person. Periodic assessment of ADLs and IADLs as part of the ongoing assessment of an older person’s function typically reveals problems with physical health, cognitive health, or both. Identifying functional difficulties can help medical and dental practitioners diagnose and manage important overall health and oral problems.
Identification of functional difficulties also is crucial because medical providers want to make sure older adults are getting the help and support they need to compensate for or overcome the functional difficulties. In doing so, any family caregivers who might be struggling to assist a relative who needs help can become aware of addressing these issues with the health care team.
More importantly, if a person is not fully independent with ADLs and IADLs, then the oral health provider should ask the nursing home staff, visiting nurse, caretaker, or family member to include some information about the amount of assistance they require. These individuals serve as resources and can help the oral health team to facilitate the formulation of a dental treatment plan as well as a maintenance program that becomes more realistic and achievable.
Geriatric evaluation overview
Geriatric assessments provide a valuable basis for evaluating treatment decisions and the prediction of treatment tolerance in the elderly. Geriatric assessments in the dental setting may be more comprehensive than assessments done on other patients and usually cover the domains of general medical health as well as cognitive, social, and physical functions. They also should include evaluation of caregiver and environmental concerns, with an emphasis on the optimization of dependent or independent function. A typical geriatric assessment in a dental setting should include the following components:
- •
Communication
- •
Physical
- •
Mobility
- •
Mental
- •
Nutritional
- •
Dental
- •
Social
- •
Medical
To aid practitioners, there are multiple performance-based screening tools designed for measuring cognitive issues in older adults, such as
- •
Mini-Mental State Examination (MMSE)—the most common tool used
- •
Lawton IADL scale—analyzes functional ability; has a scale range of 0 to 9
- •
Katz ADL scale—has a scale range of 0 to 6
- •
Stanford Health Assessment Questionnaire 8-item Disability Index (HAQ 8-item DI)—the complete version of HAQ has 5 subscales and 1 of the subscales is the disability scale, which has been used frequently as an independent questionnaire.
All components of the geriatric assessment should be reviewed briefly at every dental visit, because they change more frequently in the cognitively impaired or frail elderly and can identify barriers to maintaining good oral health.
Mild cognitive impairment
Cognitive decline is a common and often feared aspect of aging. MCI is defined as the “symptomatic pre-dementia stage” on the continuum from normal cognition to dementia, characterized by objective impairment in cognition that is not severe enough to require help with usual ADLs. , Unlike other types of CI that affect speech and bodily control, with MCI, only 1 function is declining—memory. A roadblock to earlier diagnosis and potential treatment is the lack of consistency with screening for MCI. Universal screening would be ideal but is limited ( Box 1 ).
- •
The person, family member, or others express concerns about changes in the patient’s memory or thinking.
- •
Provider observe problems/changes in the patient’s memory or thinking.
- •
The patient is age 80 or older, because the risk of dementia increases rapidly after this age.
- •
Other risk factors that could indicate the need for dementia screening include low education, history of type 2 diabetes mellitus, stroke, depression, and trouble managing money or medications.
- •
Various dementia screening methods are available and can be used.
- •
Patients who specifically express a concerm likely want to know what the underlying problem is.
At present time, there are no pharmacologic treatments proved to slow or cure progression of MCI to dementia; nonetheless, there is evidence that lifestyle modifications, including diet, exercise, and cognitive stimulation, may be effective in postponing or managing early MCI symptoms. A person with MCI is at increased risk for developing more severe types of impairment like dementia or Alzheimer dementia.
Although patients with MCI are at greater risk of developing dementia compared with the general population, there currently is substantial variation in risk estimates (from <5% to 20% annual conversion rates), depending on the population studied. Risk typically increases with age, and men appear to be at higher risk than women.
Critical features that may elucidate a cause are onset, trajectory, time course, and nature of the cognitive symptoms ( Box 2 ). Very rapid cognitive decline (eg, weeks to months) is not typical of MCI due to Alzheimer disease and should raise concerns for other causes, such as neoplasm, metabolic disorders, or prion disease. Patients and informants (such as family members) may report conflicting views regarding the presence and severity of cognitive symptoms, either from lack of insight or because cognitive decline can be emotionally charged and symptom report may be minimized to avoid difficult or disrespectful discussions.
- 1.
Concern regarding a change in cognition from the patient, knowledgeable informant, or from a skilled clinician observing the patient
- 2.
Objective evidence of impairment (from cognitive testing) in 1 or more cognitive domains, including memory, executive function, attention, language, or visuospatial skills
- 3.
Preservation of independence in functional abilities (although individuals may be less efficient and make more errors at performing ADLs/IADLs than in the past)
- 4.
No evidence of a significant impairment in social or occupational functioning (ie not demented)
Dementia
Dementia is more severe than MCI, but initial symptoms appear in the same gradual and progressive manner. Approximately 5 million Americans are living with an age-related form of dementia, and it has been reported that approximately one-quarter are undiagnosed for quite some time. There are several types of dementia :
- •
Vascular dementia is caused by an impaired blood supply to the brain and may be brought on by stroke.
- •
Dementia with Lewy bodies is linked to Alzheimer disease and Parkinson disease. It typically results from the death of nerve cells and loss of tissue in the brain.
- •
Frontotemporal dementia is a group of disorders triggered by gradual nerve cell loss in the brain’s frontal and temporal lobes.
These are a small sample of many forms of dementia seen in the elderly.
Alzheimer disease
Alzheimer disease is the most serious, and common, form of dementia. It is a progressive disease, with symptoms developing gradually before they intensify over time. In its late stages, the disease can make it difficult for a person to handle daily tasks, think clearly, control bodily movements, and live independently. , Alzheimer disease accounts for 60% to 80% of dementia cases and is the sixth leading cause of death in the United States. At the initial stage of the disease, forgetfulness and mild confusion are seen ( Box 3 ). Over time, recent memories also start erasing. Advanced stage symptoms vary from person to person, because there is no cure for Alzheimer disease.
- 1.
Memory impairment present
- 2.
Progressive decline in cognition over months to years (very rapid decline may suggest prion disease, neoplasm, or metabolic disorders)
- 3.
Lack of parkinsonism and visual hallucinations (suggestive of dementia with Lewy bodies)
- 4.
Lack of vascular risk factors and extensive cerebrovascular disease on brain imaging (suggestive of vascular CI)
- 5.
Lack of prominent behavioral or language disorders (suggestive of frontotemporal lobar degeneration)
Alzheimer disease has a complex etiology and is associated with genetic, lifestyle, and environmental factors that affect the brain cells over time ( Box 4 ). The loss of memory, especially for learning and retaining new information, reflects impaired function in the hippocampus and other medial temporal lobe structures, which are sites of early pathologic change.
Background
- •
Very common (more than 3 million cases per year in the United States)
- •
Often requires laboratory test or imaging
- •
Treatments can help manage condition, no known cure
- •
Can last several years or be lifelong
-
Factors known to increase the risk of developing the condition
- •
Age
- •
Family history and genetics
- •
Down syndrome
- •
Head injuries
- •
Past head trauma
- •
MCI
- •
-
Alzheimer disease causes shrinkage (atrophy) of the posterior part of the brain
- •
Amyloid plaques (abnormal deposits of protein) that damage and destroy brain cells
- •
Neurofibrillary tangles—brain cells require the normal structure and functioning of a protein called tau. In Alzheimer disease, threads of tau protein twist into abnormal tangles inside brain cells, leading to the death of brain cells.
- •
Stay updated, free dental videos. Join our Telegram channel
VIDEdental - Online dental courses
