Introduction of hygienists in a long-term care facility for patients with Alzheimer's disease, cognitive impairment

This poster was presented at Europerio 7 in Vienna Austria, June 6-9, 2012. The project aims were to: include the dental hygienist within the multidisciplinary team caring for patients with Alzheimer’s disease in order to establish a bridge and continuing collaboration between the teams and the Alzheimer’s Oral Health Service of the Department of Dentistry of Pio Albergo Trivulzio, through the development of a shared protocol in order to pursue the following objectives:

• Improve the appearance of care understood as a structure, staff, and family;
• Improve the quality of life of hospitalized patients;
• Reduce risks factor;
• Reduce acute and related chronic diseases.

This project's aims were to:

• Assess health status and oral hygiene in patients with Alzheimer’s disease or cognitive impairment patients in nursing homes, by insertion of a tool for evaluating the oral cavity (OHAT);
• Assess current knowledge and practices of oral hygiene of service personnel of departments, through questionnaires;
• Raise awareness and educate health workers and caregivers on appropriate strategies and products suitable for a proper oral hygiene through development of a basic protocol and direct training;
• Develop a custom protocol adapted to individual patient needs to be included in the integrated personnel folder;
• Plan and implement interventions aimed at restoring the dentistry of oral health;
• Determine indicators extensible for verification of results;
• Assess the perception of improvement of the assistance provided through the forms of satisfaction with the service, addressed to relatives and medical staff and health.

As part of the multidisciplinary nature of patients suffering from dementia, the Oral Health Service of the Department of Dentistry of the Pio Albergo Trivulzio began in January 2011, a collaboration with the RSA and Alzheimer Fornari Schiaffinati. The purpose was to prevent and possibly restore and maintain the oral health status of these patients. This project has been a successful working group between the three operating units involved, consists of 63 professionals (doctors geriatricians, nurses, OG, OSS, physiotherapists); two nuclei distributed in Alzheimer's; and three (3) students of dental hygiene department of dentistry. The project followed precise steps and timing: • Phase 1: observation phase: development of an information letter and consent to service of attending physicians to geriatric wards with coaching in order to know the reality and the organizational needs of the two nuclei, to know the current and past medical condition, the profile behavioral skills, feeding mode and characteristics of individual patients to identify the most appropriate way doctor/patient. Definition of a location for permanent storage of mobile units (trucks and self-priming portable scaler). • Phase 2: the first phase operational management visit: oral assessment and compiling medical records (via module OHAT). Develop a basic protocol (simplified, the same for everyone, extended family and medical staff). • Step 3: education in health care: basic protocol adherence through training on appropriate strategies and products suitable for a proper daily oral hygiene. • Step 4: reassessment of all patients, development of custom protocols, reporting to doctors of geriatric patients who needed a dental examination and oral hygiene sessions, inclusion of the clinical nursing integrated within the folder of each patient. • Step 5: Recognition of indicators extensible through the collaboration of the Department of Microbiology and verification of results. • Step 6: Delivery of service satisfaction forms of oral hygiene, addressed to relatives and medical team.Results Through this multidisciplinary collaborative project, we examined and evaluated 70 of the 80 Alzheimer patients RSA residents in the two nuclei. Because of the deaths in these intervening months, the number of patients examined was down to 65 out of 78, of which 10 were male and 55 were female. • 65% of these patients are aged between 70 and 90 years • 27% are over 90 years • 8% are under 70 years

Figure 1 - Distribution of patients by age and gender

100% of patients suffering from various degrees of dementia with BPSD and: • 70% of patients suffering from heart disease and hypertension • 40% of patients are diabetic • 35% of patients suffering from COPD 100% of patients were considered as not independent in performing the necessary maneuvers of oral hygiene.

Table 1 - Summary of pathologies Odontostomatological division: • Edentulous without dentures or with a single prosthesis: 26; Edentulous with two prosthesis: 7; Patients with less than 8 teeth: 7; Patients with more than 10 teeth: 14; and Patients with dentures and / or prosthesis: 11.

Table 2 - Breakdown of patients according to the dental state

This suggests that: 51% of patients were fully edentulous; 51% of patients do not keep a proper masticatory function; 49% of patients retained adequate masticatory function.

According to the score obtained by the oral health assessment form (OHAT), we can separate patients in the following way: 92% of the patients presented moderate alterations of oral health; 8% of the patients have severe abnormalities of the oral health.

Table 3 - Breakdown of patients by the score OHATDiscussion Poor oral hygiene is predominant in patients with teeth or edentulous patients with prosthesis, followed by alterations of the lips, tongue, gums and mucous membranes due to xerostomia, denture plaque and incongruous. Edentulous patients without prosthesis and the main changes concern the lips and tongue due to xerostomia and inadequate hygiene of the language. 50% of patients were reported to the doctors of the two cores to undergo a dental examination and professional oral hygiene sessions. Whereas, the prosthetic rehabilitation of patients fully edentulous turned out to be difficult from a practical point of view , due to the improbable adaptation by patients themselves to the new device, and, therefore, these patients will have a score based OHAT equal to 4 (2 due to edentulism and 2 due to no prosthesis), we hypothesize that: • Following appropriate treatment of oral hygiene and use of suitable products to increase the lubrication of the mucous membranes, the number of patients with moderate alterations of oral health, (maximum score of between 2 and 4), are reduced from 60 to 35, corresponding to 54% of patients; • Following the interventions required for dentistry, restoring implants and care of teeth, and further compromises regarding the necessary care of oral hygiene, the number of patients with oral health (score 0), would rise from 0 to 30, corresponding to 46% of patients; Consequently the number of patients with severely impaired oral health would be reduced to 0. To verify the effectiveness of our intervention, we performed microbiological investigations on two patients sampled through sampling of plaque in two fixed points. Step 1: language, while the posterior third, point 2: buccal mucosa, lower right), in the first visit, and later distance of three weeks, period of time in which they were made: • A session of professional oral hygiene; • Two meetings for education and the daily oral hygiene care of the patient.

Table 4 - Patient OC1 - Changes in the amount of microorganisms after 3 weeks

Before and AfterConclusions This paper has tried to "photograph" a social-welfare, RSA, in which a multidisciplinary team is required to provide treatment and prevention of health problems to a subgroup of elderly patients with Alzheimer's disease and/or dementia. More specifically, this paper has tried to highlight the importance of including dental hygienists within the care team, with the aim to assess and restore the oral health of these patients in the overall care of the individual.

Through this project we have been able to confirm the data reported in the literature on the prevalence of poor oral hygiene in patients with dementia, as residents in nursing homes. Furthermore, the reduction of the scores obtained from oral forms of assessment (OHAT), and through the introduction of a protocol of oral hygiene, whose effectiveness has been confirmed by a microbiological point of view, allows us to take a step towards the achieving oral health. Another result obtained through this project is the creation and insertion of a clinical evaluation of oral health of patients within the nursing integrated folder of each patient. This is certainly an innovative element within the structure that allows teams to continue work improving the welfare aspect in the overall patient care. Even from this perspective, it is essential that a dental hygienist be present, with the task of updating the directory, intercepting oral problems, and planning oral interventions, with reports to geriatricians and dentists.

In conclusion, this project, which can be extended to other departments within the facility, is highlighting the role of social and clinical dental hygienist in RSA. This multidisciplinary team allows and provides a bridge between geriatrics and dentistry, is a source of motivation and constant updates for health workers and supervision of maintenance of oral health of patients, that is otherwise not achievable.

Dott. SSA Laura Antonia Marino is the President of Unione Nationale Igieniste Dentali (UNID).

Introduction of hygienists in a long-term care facility for patients with Alzheimer's disease, cognitive impairment

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