In the dental practice
Sometimes people with dementia "disappear" from the practice, without the dentist noticing. The patient cancels (too) late, does not come to an appointment (forgetting, problems with transport, problems with supervision?), Does not respond to a call and does not make a new appointment. Especially when a patient is less able to take care of himself, it is important that he continues to visit the dentist.
With a demented patient who does come, the contact and the dental treatment are different every time, even if you know the patient well. You must therefore look closely at the situation and the behavior of that moment and adjust your own behavior accordingly. It helps if you hear from the family or counsel how things are going or what it has been like lately. Prepare the visit of a demented patient well. Points of attention for assisting the chair are given in the following table under 'Assisting the chair'.
Preparation of a visit to a dentist for a patient with dementia
|Keep in touch||
– Make a practical plan for maintaining contact with vulnerable elderly people: extra reminder call, SMS or app, telephone?
– Ask if you can write down a telephone number of someone from the area, in case the patient can no longer properly arrange his appointments
– Realize that no-show in the elderly can be a sign of decline; call at a no-show always to find out the reason and make a new appointment; if it appears that someone can no longer come, you can immediately find another solution; this way you will not lose sight of the patient
|Make an appointment||– Schedule the appointment at the end of the day if necessary; ensure peace in practice|
– Collect all information before the patient arrives
– Check whether the patient has swallowing problems
– Ask family / counseling how the patient was lately (before being treated) (ill, not feeling well, behavioral problems)
– Ask whether you have been able to stop taking medication before treatment (anticoagulation) or, conversely, use it for treatment (antibiotics, possible pre-medication); possibly ask the (family) doctor before you start
|Everything ready||– Prepare everything in advance|
Assisting the chair
– Make contact
– Match your communication to the person and what happens in the conversation
|General||– Consult with the patient or attendant how you can help remind him of the dental appointment: mail, e-mail, text message or app, telephone (the day before and / or the morning of the appointment) to the patient or attendant|
|To the seat|
– Take the time before treatment starts; attention to the patient creates tranquility
– Switch off the radio; only turn on music when the patient or counselor has indicated that he / she likes music
– Assume eye level
– Talk calmly, slowly and clearly, and with a low voice; it can help to lower your mouth cap when talking to your demented patient; He can then see your facial expression and understand you better
– If your patient does not respond immediately to your question, give him some time instead of repeating the question or asking it in another way
– Watch how your patient responds to physical contact (stroking hands)
– Make sure that you retain the attention of the person suffering from dementia
– Ensure that your patient can continue to see you; do not approach your patient from behind; Sometimes it is unpleasant for the person suffering from dementia if you stand or sit diagonally behind him to perform oral care
|Focus on the patient||– Focus your attention fully on the patient, so that the dentist can work quickly and effectively|
– Join the living world of the person suffering from dementia; don't argue with it; come up with creative solutions; respect the patient and his limits
– Take as a starting point that nothing should be done; estimate whether it helps if you give your patient more time, or if this is a moment where you can better "continue to", of course without forcing
– As an assistant, be alert to the stop signal or signs of unrest in the patient; the dentist must be able to concentrate on the mouth;
– Indicate when the dentist must stop; sometimes it is useful to use a code word for this, so as not to worry the patient
– Take your time; almost works backwards.
– Monitor how long (minutes, seconds) the dentist can still work; report this to the dentist so that he can determine whether or not he can still carry out a treatment
– Let the patient know that the treatment stops (for a moment) and that he can swallow, say something, move
Information for family members
Family members will generally help the demented more and more. Also with his oral care. Discuss the importance of good oral care and a visit to the dentist, also in the future. Ask what the caregiver thinks it is to help his neighbor with oral care or to take over this care. Ask him how he approaches that, whether he experiences bottlenecks. Give instruction on how oral care can best be performed at another person. Refer to supporting material.
Information for carers
Oral care is not the most pleasant part of the care for their psychogeriatric patients by most carers. Due to time constraints, oral care does not always get the attention and time it takes. Moreover, caregivers often lack knowledge about oral care and how to deal with the immune behavior of people with dementia during oral care. Defensive behavior is behavior that makes it difficult or prevents good oral care. Knowledge about this has been collected in recent years. A step-by-step plan and a list of tips are now available. In addition, training courses have been set up. Many institutions use the cleaning instruction cards.
In general practice
In the beginning it is not clear whether a patient is demented, but you can notice things. For example, a patient calls a few times in a short time with the same question (repeat prescription; forget medication, what now?). Or forget his appointment more than once. These signals are important to note for your colleagues and for the doctor. Other signs may be that the patient reports that he has forgotten to take his medication. In the initial phase of dementia, the patient may notice that he has forgotten medication; he is aware of it. Give advice and make a note in the file. In the diagnosis phase and the first time afterwards, people are often sad when they realize what is going on. Then you can catch them, offer a listening ear.
In the case of further dementia, the patient may have taken the medication, but cannot remember it. Then you have to weigh the risks. You often consult your doctor or pharmacist for safe advice. Of course you note the situation. It is important to give a signal to the doctor or the case manager about the unsafe situation surrounding medication use. Table offers tips for dealing with common situations.
Points of interest for your contact with people with dementia
– Make contact
– Match your communication to the person and what happens in the conversation
|Signals||– Be alert to signals of forgetfulness, character and behavioral change, and make a note of this in the file|
|during office hours|
– If a family or caregiver has come: first make contact with the person suffering from dementia; Imagine and welcome him ("You are … nice that you are here. And that … has come with you. Sit down. The doctor will call you in soon")
– Assess the patient's performance during contact: is he now confused, or does he have a clear moment
– If necessary, say that you would also like to ask the person who came with you; with the information you get from the family / caregiver, you complete your picture of the situation
|The patient arrives on the wrong day / time||
– Explain to the patient that he has the appointment on a different day or time
– See how the patient responds: does he realize that he has made a mistake? for example, he says, "but today is Thursday," or does he get angry because you made a mistake (that may also be the case); stay friendly, don't argue
– Discuss what you can do at the moment, for example see if the patient can go to the doctor
– Make a note in the file
|The patient did not come to his appointment||
– Call the patient, depending on the work agreements in practice, and tell him that you missed him on his appointment; the patient's response can give you information about his sense of time, for example if the patient says "today is Tuesday" (while it is Thursday)
– Make a note in the file; sometimes a patient often misses an appointment; that also says something
|Patient on the telephone|
|Story is incorrect||– The patient tells a story that has no line, cannot indicate the order of events, tells things that are not correct; provide correct information if necessary; if that is not really necessary at that time, do not do it, because it can increase the confusion and uncertainty of the patient|
– Ask on; if the patient does not give clear answers, ask him if someone is with him and if you can also ask that person a few questions over the phone
– Consultation with family / informal care can provide clarity in a certain situation; if you still do not get a clear picture, consult the doctor; sometimes the doctor calls back to get a better picture of the situation
– In practice you often know the patient and you know about the situation; that makes a correct assessment easier, but it can also be a pitfall: you can underestimate a situation
– Take it for granted if you do not know the patient, or if there is no family caregiver
– For some patients there is an agreement that consultations or visits can only be requested by the district care
– A demented patient can call with a story that is not about health problems; apparently he wants to say something, but he does not realize that his story does not belong to the general practice
– Stay calm and friendly
– Then explain that you can listen for a while, even if the patient is not calling about health problems; you can usually finish the conversation after a few minutes by wishing him goodbye or, if you have made a follow-up appointment, by saying "goodbye" or "see you next week"
|Family / caregiver on the phone|
|Story of family and patient||
– A family member usually calls for moderately severe dementia people; clarify their story and their question, possibly state their concern; say it's good that they call
– Also ask, if possible, the patient on the telephone
The person suffering from dementia often receives a case manager as coordinator of care, a source of information and support. Note the contact details of the case manager.
When dementia worsens, other health problems often also increase. Patients often start to feel more insecure, the risk of falling increases, they sometimes lose weight. For the informal caregiver, the care becomes heavier. The doctor will consult the case manager more often.
In the pharmacy
As an assistant you work a lot with the elderly. Also with the elderly who are cognitively deteriorating. In the pharmacy you can be alert to various signals thereof.
You sometimes notice that patients do not understand your information or remember it properly. You will notice this especially if you ask to repeat the information or to tell them how they will use the medication at home. Sometimes patients say they have not received their medication. Or they have lost their medication and come, more than once, to ask for new medication. Others call about their medication a few times a day. Or they come several times within a week to collect their medication. Sometimes patients come with the baxter roll (a roll with transparent bags of medication per intake moment) and ask where they should start. Occasionally they have started in the middle of a role and now do not know how to proceed. The behavior of people with dementia can change. As a result, they can sometimes behave improperly.
Discuss with your patient how you can make it easier to use his medicines (baxter roll, medicine box, filled by the pharmacy). Discuss your observations with your colleagues and the pharmacist.
It is useful to have the medication evaluated. The pharmacist can consult with the doctor about a simplified medication schedule, for example by using combination preparations. The doctor can also call home care in consultation with the patient. In addition, electronic aids can be deployed: a warning signal at the times that medication must be taken, a medication dispenser with remote monitoring.
Antipsychotics in dementia
Antipsychotics are used especially in institutions for people with dementia. Often to reduce anxiety and nocturnal wandering, or to treat a delirium (acute confusion with a physical cause). Dementia sufferers who live at home rarely use antipsychotics. Most antipsychotics are not developed for this purpose, nor for use with this target group. They also have serious disadvantages, such as choking, choking, and a greater chance of falling. Antipsychotics can lower the quality of life because the users are less active, can do things independently and are less able to participate in activities. Many institutions are investigating whether the use of these drugs in dementia patients can be reduced. It often turns out to be possible (http://www.zorgvoorbeter.nl/ouderenzorg/vrijheidsbeperking-psychofarmaca.html).