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Besluitvorming omtrent onvrijwillige mondzorg bij ouderen met dementie
Abstract
Veel ouderen met dementie tonen verzet bij het ontvangen van mondzorg. Wanneer zorg verleend wordt ondanks verzet, is er sprake van onvrijwillige zorg. De Wet zorg en dwang schrijft voor dat de zorg bij verzet gestaakt moet worden, tenzij sprake is van ernstig nadeel. Om inzicht te krijgen in de attitude van zorgverleners ten aanzien van onvrijwillige mondzorg bij ouderen met dementie werd een onderzoek hiernaar uitgevoerd. Een online vragenlijst, die bestond uit algemene vragen, vragen over specifieke casuïstiek en kennisvragen over de Wet zorg en dwang, werd afgenomen bij 392 zorgverleners. In alle casussen werd een discrepantie gezien tussen de beoordeling van het mondgezondheidsprobleem als ernstig nadeel en de bereidheid om onvrijwillige mondzorg te verlenen. Met andere woorden, veel zorgverleners zijn zich bewust van de mogelijke gezondheidsrisico’s die het niet verlenen van mondzorg met zich meebrengt, maar zijn desondanks terughoudend met het verlenen van onvrijwillige mondzorg. Daarnaast heeft een groot deel van de zorgverleners een laag kennisniveau met betrekking tot de Wet zorg en dwang.
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Background
Dementia care at home often involves decisions in which the caregiver must weigh safety concerns with respect for autonomy. These dilemmas can lead to situations where caregivers provide care against the will of persons living with dementia, referred to as involuntary treatment. To prevent this, insight is needed into how family caregivers of persons living with dementia deal with care situations that can lead to involuntary treatment.
Objective
To identify and describe family caregivers’ experiences regarding care decisions for situations that can lead to involuntary treatment use in persons living with dementia at home.
Research design
A qualitative descriptive interview design. Data were analysed using the Qualitative Analysis Guide of Leuven.
Participants and research context
A total of 10 family caregivers providing care for 13 persons living with dementia participated in in-depth semi-structured interviews. Participants were recruited by registered nurses via purposive sampling.
Ethical consideration
The study protocol was approved by the Ethics Committee of the University Hospitals Leuven and the Medical Ethical Test Committee Zuyderland.
Findings
Family caregivers experience the decision-making process concerning care dilemmas that can lead to involuntary treatment as complicated, stressful and exhausting. Although they consider safety and autonomy as important values, they struggle with finding the right balance between them. Due to the progressive and unpredictable nature of dementia, they are constantly seeking solutions while they adapt to new situations. Family caregivers feel responsible and experience social pressure for the safety of persons living with dementia. They may be blamed if something adverse happens to the persons living with dementia, which increases an already stressful situation. Their experience is influenced by characteristics of the care triad (persons living with dementia, professional and family caregivers) such as practical and emotional support, knowledge, and previous experiences.
Discussion and conclusion
To prevent involuntary treatment, professionals need to proactively inform family caregivers, and they need to support each other in dealing with complex care situations.
Pneumonia is a leading cause of death among older adults. The effectiveness of oral care in preventing pneumonia in nursing homes and hospitals has been reported. However, in community-dwelling older adults, the role of denture cleaning in preventing pneumonia remains unknown. We aimed to investigate the association between infrequent denture cleaning and the risk of pneumonia in community-dwelling older adults. This cross-sectional study was based on the self-reported questionnaire targeting towards community-dwelling older adults aged ≥65 years. Responses of 71,227 removable full/partial denture users were included. The incidence of pneumonia within the last one-year and the frequency of denture cleaning (daily/non-daily) were treated as dependent and independent variables, respectively. The odds ratio (OR) and 95% confidence interval (CI) were calculated by the inverse probability weighting (IPW) method based on the logistic regression model. The mean age of the participants was 75.2 ± 6.5 years; 48.3% were male. Overall, 4.6% of the participants did not clean their dentures daily; 2.3% and 3.0% who did and did not clean their dentures daily, respectively, experienced pneumonia. After IPW, infrequent denture cleaning was significantly associated with pneumonia incidence (OR = 1.30, 95% CI = 1.01–1.68)). This study suggests that denture cleaning could prevent pneumonia among community-dwelling older adults.
Background:
The number of people with dementia and natural dentition is growing. As dementia progresses, the degree of self-care decreases and the risk of oral health problems and orofacial pain increases.
Objectives:
To examine and compare the presence of orofacial pain and its potential causes in older people with Mild Cognitive Impairment (MCI) or dementia.
Methods:
In this cross-sectional observational study, the presence of orofacial pain and its potential causes was studied in 348 participants with MCI or dementia with all levels of cognitive impairment in two outpatient memory clinics and ten nursing homes.
Results:
Orofacial pain was reported by 25.7% of the 179 participants who were considered to present a reliable pain self-report (Mini Mental State Examination score ≥ 14 points), while it could not be determined for people with more severe cognitive impairment. The oral health examination of the 348 participants indicated that potential painful conditions such as coronal caries, root caries, tooth root remnants, or ulcers were present in 50.3%. There was a significant correlation between the level of cognitive impairment and the number of teeth, r= .185, p=.003, teeth with coronal caries, r= -.238, p<.001, and the number of tooth root remnants, r=-.229, p=.004, after adjusting for age.
Conclusions:
This study indicated that orofacial pain and its potential causes were frequently present in participants with MCI or dementia. Therefore, a regular oral examination by (oral) healthcare providers in people with MCI or dementia remains imperative, even if no pain is reported. This article is protected by copyright. All rights reserved.
Objectives
The objective of this study is to assess oral health and oral status of elderly patients newly admitted to a nursing home from admission until death. Materials and methodsOral health, oral status, need for dental care, cooperation with dental treatment, and given dental care were assessed by two geriatric dentists in all new long-stay patients (n = 725) admitted to a nursing home between January 2009 and December 2013. All patients were followed from admission until death or until they left the nursing home. ResultsAt admission, dementia patients were significantly older than somatic patients; median [IQR] ages were, respectively, 85 [79–89] and 81 [76–87] (p = 0.001). In addition, edentulous patients were significantly older than patients with remaining teeth, 83 [79–89] versus 80 [74–86] (p = 0.001) years. Thirty percent of the admitted patients died within 12 months after admission. A small minority (20%) of the patients had their own teeth. In this group, poor oral hygiene (72%), caries (70%), and broken teeth (62%) were frequently observed. Edentulous patients were significantly more cooperative with treatment than patients with remaining teeth (64 versus 27%). Finally, significantly less professional dental care was given to edentulous patients when compared to patients with remaining teeth (median 90 [IQR 60–180] versus 165 [75–375] min). Conclusion
When compared to edentulous elderly patients, patients with remaining teeth were younger at admittance, were more often non-cooperative, and had a poorer oral health and higher need for dental care. Clinical relevanceIt is important that health care workers ensure adequate oral health and dental care to frail elderly, especially for elderly with remaining teeth.
Background
To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature.
Methods
A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included.
Ethical considerations
The review is conducted according to the Vancouver Protocol.
Results
There are few studies that study ethical challenges when using coercion in an explicit way. However, promoting the patient’s best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good (beneficence) and inflicting harm (maleficence). In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion.
Conclusion
There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a ‘clinical must’. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress.
Sažetak U ovom prikazu opisali smo slučaj 80-godišnjeg pacijenta koji je bio upućen u Zavod za oralnu me-dicinu Stomatološkog fakulteta u Zagrebu zbog gingivalnog ulkusa prisutnog osam dana. Na kli-ničkom pregledu uočena je eksponirana kost na bezubom alveolarnom grebenu u području mo-lara s desne strane mandibule veličine 0,8 cm u promjeru. Inače, pacijent je svakodnevno uzimao doksazosin jer je imao teškoća s urinarnim traktom te ipatropij-bromid zbog respiratornih tegoba. Donju djelomičnu protezu nije promijenio već šest godina. Na početku je, točnije prva tri dana, bio liječen parodontnim zavojem (Resopack, HagenWerken, Njemačka) uz preporuku da ne nosi pro-tezu, no nakon tri dana klinički pregled nije pokazao poboljšanje stanja. Zato smo se odlučili na li-ječenje topikalnim kortikosteroidom (betametazon) i oralnim antiseptikom (klorheksidin-digluko-nat) tri puta na dan. Nakon tri tjedna lezija je zacijelila. Naveden je popis mogućih čimbenika koji mogu rezultirati nastankom ulkusa gingive.
Elderly individuals with extensive tooth loss preferentially consume soft, easier to chew foods which have a low nutrient density. The purpose of this study was to suggest that every complete denture wearer has to be periodically counseled by a registered Dietician and Dentist for check up to avoid malnutrition and disease. Fourteen patients were selected for this study. Seven of them with four or five teeth remaining without any functional units and seven patients who were known cases of complete denture wearers with ill-fitting or worn out dentures. The results of the study analyzed the change in eating pattern and hence the nutritional status of two groups of edentulous subjects; Group I (patients who underwent a recent transition from partially edentulous state to a completely edentulous state), and Group II (known complete denture wearers for five to ten years). Clinical examination of Group I showed an improvement, by, the decrease in percentages in both the paleness of the conjunctiva and nails of the selected patients. In Group II, there was a significant change in anthropometry and iron intake and the clinical examination showed positive changes in the patient's normal appearance, eyes and nails. Paired sample statistics between both the groups evaluated significant changes in energy, iron and vitamin C intakes in the dietary assessment chart. The general questionnaire assessment showed an improvement in the eating pattern of both the groups, which, may definitely account for a positive change in the nutritional status of the participants later. This study emphasizes that every complete denture wearer needs to be periodically counseled by a registered dietician and dentist for checkup to avoid malnutrition and disease.
to assess nurses' knowledge and practices concerning oral care on surgical and medical wards in a district general hospital in Ireland.
a survey of all qualified nurses on three medical and three surgical wards was carried out. Two hundred questionnaires were distributed and 50 were returned with 43 of these rendered useable.
the majority of nurses (90%) viewed oral care as an important aspect of nursing care. However, nurses lacked adequate knowledge of oral care practices, and experienced problems attending to oral care as a result of time constraints, lack of oral care packs, patients being confused or uncooperative, lack of toothpaste and toothbrush, limited education and low status attached to oral care. Although most nurses (over 70%) had received education on oral care, this was of short duration. Sixty-four per cent did not use an assessment tool to measure the condition of the patient's oral cavity, while 73% believed that an assessment tool would be important to measure a baseline of the condition of the patient's oral cavity.
although oral care is an essential component of quality nursing care, it appears to be given low priority by some nurses. This study indicates the need for educational updates for qualified nurses, adequate supply of oral care equipment and promotion of formal assessment tools usage in the hospital setting.
Background and objective
Pain assessment tools for cognitively impaired older people, unable to self‐report pain, are commonly founded upon observation of pain behavior, like facial expressions, vocalizations, and body movements. The scientific basis for claiming that body movements may indicate pain has not formerly been investigated in a systematic review. The objective was to explore research evidence for body movements being pain indicators in older people with cognitive impairment.
Data bases and data treatment
MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library were searched systematically. Two researchers independently identified and consented on studies to be included. PRISMA statement for reporting systematic reviews was followed. Mixed Methods Appraisal Tool was used for critical evaluation of study quality.
Results
2096 records from the literature searches were identified, and 17 quantitative and 8 qualitative studies were included in the review, the studies mainly related to older people with dementia. Quality scores ranged from 50 to 100%. We combined 62 items of body movements into 13 similar or synonymous items, and criteria for evidence were defined. Strong evidence was found for restlessness (agitation), rubbing, guarding, rigidity and physical aggression as the behaviors frequently responded (increased or decreased) to pain provoking activities, painful procedures, and/or pain medication.
Conclusions
Among 13 categories of body movements, we found five with strong and five with moderate evidence of validity. As few items were typically included in many studies reflecting criterion validity, all should be included in future studies of patients with different characteristics, location, and duration of pain.
This article is protected by copyright. All rights reserved.
Objectives:
To get insight into restraint use in older adults receiving home care and, more specifically, into the definition, prevalence and types of restraint, as well as the reasons for restraint use and the people involved in the decision-making process.
Design:
Systematic review.
Data sources:
Four databases (i.e. Pubmed, CINAHL, Embase, Cochrane Library) were systematically searched from inception to end of April 2017.
Review methods:
The study encompassed qualitative and quantitative research on restraint use in older adults receiving home care that reported definitions of restraint, prevalence of use, types of restraint, reasons for use or the people involved. We considered publications written in English, French, Dutch and German. One reviewer performed the search and made the initial selection based on titles and abstracts. The final selection was made by two reviewers working independently; they also assessed study quality. We used an integrated design to synthesise the findings.
Results:
Eight studies were reviewed (one qualitative, seven quantitative) ranging in quality from moderate to high. The review indicated there was no single, clear definition of restraint. The prevalence of restraint use ranged from 5% to 24.7%, with various types of restraint being used. Families played an important role in the decision-making process and application of restraints; general practitioners were less involved. Specific reasons, other than safety for using restraints in home care were noted (e.g. delay to nursing home admission; to provide respite for an informal caregiver).
Conclusions:
Contrary to the current socio demographical evolutions resulting in an increasing demand of restraint use in home care, research on this subject is still scarce and recent. The limited evidence however points to the challenging complexity and specificity of home care regarding restraint use. Given these serious challenges for clinical practice, more research about restraint use in home care is urgently needed.
Oral health is closely related to systemic health. Periodontitis, a chronic inflammatory disease which is highly prevalent worldwide, interacts with a variety of noncommunicable diseases (NCDs). It is a risk factor in the complex pathogenesis of diabetes mellitus and cardiovascular disease and plays a role in the development of endocarditis and recurrent pneumonia in elderly people. However, the available data may be interpreted in different ways, and more and better-designed studies are still needed to answer relevant questions about the causal role of periodontitis in NCDs. What is clear is that periodontitis contributes to the systemic inflammatory burden. As periodontitis shares many common risk factors with NCDs, close collaboration between physicians and dentists is needed to increase the chance of early detection and improve the prevention and control of these conditions.
Denture stomatitis, a common disorder affecting denture wearers, is characterized as inflammation and erythema of the oral mucosal areas covered by the denture. Despite its commonality, the etiology of denture stomatitis is not completely understood. A search of the literature was conducted in the PubMed electronic database (through November 2009) to identify relevant articles for inclusion in a review updating information on the epidemiology and etiology of denture stomatitis and the potential role of denture materials in this disorder. Epidemiological studies report prevalence of denture stomatitis among denture wearers to range from 15% to over 70%. Studies have been conducted among various population samples, and this appears to influence prevalence rates. In general, where reported, incidence of denture stomatitis is higher among elderly denture users and among women. Etiological factors include poor denture hygiene, continual and nighttime wearing of removable dentures, accumulation of denture plaque, and bacterial and yeast contamination of denture surface. In addition, poor-fitting dentures can increase mucosal trauma. All of these factors appear to increase the ability of Candida albicans to colonize both the denture and oral mucosal surfaces, where it acts as an opportunistic pathogen. Antifungal treatment can eradicate C. albicans contamination and relieve stomatitis symptoms, but unless dentures are decontaminated and their cleanliness maintained, stomatitis will recur when antifungal therapy is discontinued. New developments related to denture materials are focusing on means to reduce development of adherent biofilms. These may have value in reducing bacterial and yeast colonization, and could lead to reductions in denture stomatitis with appropriate denture hygiene.
Although the prevalence of dementia increases with age from ages 65 to 85, whether this increase continues after age 90 is unclear. Most studies reporting on dementia prevalence do not have sufficient participants to estimate prevalence for specific ages and sexes above age 90. Here, we estimate age- and sex-specific prevalence of all-cause dementia in the oldest-old, those aged 90 and older.
Participants are 911 elderly from The 90+ Study, a population-based study of aging and dementia in people aged 90 and above. Dementia was diagnosed using in-person examinations as well as telephone and informant questionnaires.
The overall prevalence of all-cause dementia was higher in women (45%, 95% CI = 41.5-49.0) than men (28%, 95% CI = 21.7-34.2). Among women, prevalence increased with age after age 90, essentially doubling every 5 years. A lower prevalence of dementia was significantly associated with higher education in women but not in men.
In a very large sample of participants aged 90 and older, prevalence of all-cause dementia doubled every 5 years for women but not men.
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