The Challenges of Domiciliary Care...Care home staff request a domiciliary visit for Mr K who is showing signs of stress and distress during oral care: Mr K, 77 years old Medical History

The Challenges of Domiciliary Care

Jonathan Kallow and Emma Moyes

NHS Fife Public Dental Service

Increasing Demand

• Elderly

• Physical disability

• Learning disability, Autism

• Mental illness

• Equity of access

Teeth!

• Emergency Care

• Treatment – Normative vs Realistic

• Equipment

• Environment

• Transport, Transfer

• Shared CareDenture status and need for

prosthodontic treatment among

institutionalized elderly in Denmark

Community Dent Oral Epidemiol 1987 15:

128-133

Communication

• Planning appointments

• Speaking with carers

• Liaising with relatives

• Medical Colleagues

• Social Work

• Capacity Assessment

• DH/DT/EDDN Prescription

• Payment

Training and Accreditation

• Local Mentoring

• NES – AwI and Section 63

• University courses

• Royal Colleges – Diplomas and Membership in Special Care Dentistry (Specialist Training Programme)

• ‘Dementia’ and ‘Palliative and End of Life Care’ Frameworks (NES + Scottish Social Services Council)

Challenges:

Domiciliary Care for the

Elderly

Education and continuous training

must ensure that oral health care

providers have skills in and a

profound understanding of the

biomedical and psychosocial

aspects of care for older people.”

Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of

the WHO Global Oral Health Program. Community Dentistry and Oral Epidemiology

2005; 33: 81-92

Care home staff request a domiciliary visit for Mr K

who is showing signs of stress and distress during

oral care:

Mr K, 77 years old

Medical History : Advanced dementia (mixed Alzheimer's vascular type

diagnosed 2010). IHD, CVA, gastritis and epilepsy. Frailty. Valid DNR

certificate.

Medication: Lamotrigine, omeprazole. asprin and trazodone.

Social History: Care home resident for 4yrs. Ex -military. Close family.

Dental History: Heavily restored dentition. Previous IV sedation. 3/12

topical fluoride applications. Prescribed 2800ppm toothpaste. Soft diet

with frequent sugary snacks.

Consent: Son holds Continuing POA. Certificate of Incapacity for dental

treatment.

Mobility: Wheelchair user, no sitting balance, full body hoist.

Dependency: Fully dependant for all aspects of personal care. Often

exhibits stress and distress during personal care.

Dementia Skills

• People with dementia have the right to health services ..provided by professionals who have had appropriate training on dementia…

• Knowledge and understanding of the causes and signs of stress and distress for the person with dementia

• Approach• Environment• Communication• Promote self-care• Rescue

Jablonski RA, Therrien B, Kolanowski A. No more fighting and biting during mouth care: applying the theoretical constructs of

threat perception to clinical practice. Res Theory Nurs Pract 2011; 25: 163-75

Jablonski R A. Examining oral health in nursing home residents and overcoming mouth care-resistive behaviors. Annals of Long-

Term Care 2010; 18: 21-6

Communicating Oral Pain in Dementia?

• Over 60 percent of assessed participants were considered to have a pain-causing condition. Cohen-Mansfield J, Lipson S. The under detection of pain of dental etiology in persons with dementia. Am J Alzheimer's DisOther Demen 2002; 17: 249-53

• There is little research focused on orofacial pain in older people with dementia. Delwel S, Binnekade TT, Perez RS, Hertogh CM, Scherder EJ, Lobbezoo F. Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues. Clin Oral Investig2016

• See Change, Think Pain.

Examination

Lost LR6 MOD amalgam. Lingual wall

fractured sub gingival. Caries UL3 mesial. No

evidence of swelling or trauma.

Treatment options

Monitor only ?

Attempt restoration with domiciliary kit or bring patient

into surgery with hoist?

Consider IV sedation or GA ?

What were the Challenges ?

Logistical

Special Care Dentistry

Dementia skills

Adults with Incapacity

Multi disciplinary working ( Family / Carers / DCPs / PAMs

/Nursing Staff / Doctors / Anaesthetic team / Ambulance

Transport Crews)

MACENTEE, M. I. Muted dental voices on interprofessional healthcare teams. J Dent, v. 39 Suppl 2, p. S34-40,

2011. ISSN 1879-176X. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/22101120 >.

Thank you

for

Listening