Special Care Flashcards
What are three criteria for valid consent?
1) informed
2) given freely
3) capable patient
What is the acronym for what qualifies as incapacity?
AMCUR
What does the A in AMCUR mean?
ACTING
What does the M in AMCUR mean?
MAKING a decision
What does the C in AMCUR mean?
COMMUNICATING a decision
What does the U in AMCUR mean?
Understanding a decision
What does the R in AMCUR mean?
RETAINING memory of the decision or consistency
In the adults with incapacity act 2000, who are the 5 criteria of incapacity relevant to?
in relation to any particular matter due to mental disorder or an inability to communicate
Can a patient be rendered “incapable” without medical diagnosis of a condition?
no
How do you assess incapacity?
- know the definition (AMCUR)
- apply it to the patient
- use the definition as a framework
How do you check a patient has understood and has the capacity to consent?
- open questions
- chunk and check
- teach back
What act applies if a person lacks capacity to consent to dental treatment?
Adults with incapacity (Scotland) Act 2000
At what age is capacity no longer a responsibility of a parent?
16 in scotland
Is capacity “all or nothing”?
No, it is action or decision specific
What are the 5 key principles of capacity?
1) BENEFIT
2) LEAST restrictive of freedom
3) the person’s past and present WISHES should be taken into account
4) CONSULT relevant others
5) encourage RESIDUAL capacity
What is the definition of dementia?
general term for loss of memory , language, problem solving and other thinking abilities that are severe enough to interfere with daily life
Is dementia a natural part of ageing?
no
What is the likelihood of developing dementia in people >65?
1 in 3 people >65 will develop dementia
What is the prevalence of dementia in people >80?
1 in 6 people have dementia
What are 8 risk factors for dementia?
1) age
2) gender
3) ethnicity
4) genetics
5) down syndrome
6) medical factors
7) lifestyle factors
8) head injuries
What 5 medical factors can increase the risk of dementia?
1) type II diabetes
2) hypertension
3) high cholesterol
4) obesity
5) depression
What are 3 examples of lifestyle factors that can increase dementia risk?
1) smoking
2) alcohol
3) diet
What specific form of dementia can be associated with head injuries in sports?
chronic traumatic encephalopathy
How can people reduce the risk factors for dementia?
1) be physically active
2) stop smoking
3) eat healthily
4) healthy weight
5) reduce alcohol consumption
6) keep mentally active
7) be social
What are 5 different types of dementia?
1) Alzheimer’s disease
2) Vascular
3) Mixed
4) Lewy-Body
5) Fronto-temporal
What percentage of dementia does Alzheimer’s disease account for?
62%
How does Alzheimer’s disease present?
presents as short term memory loss and word finding difficulties
What are the biological changes seen in Alzheimer’s disease?
- amyloid plaques
- tangles - tau protein
- loss of connections between neurons
- decrease in acetylcholine
- brain becomes smaller and shrivelled
What infections can be connected to Alzheimer’s?
1) oral herpes
2) pneumonia
3) spirochete bacteria
Is there an association between periodontal disease and Alzheimer’s?
yes. gingivitis more common among patients with Alzheimer’s
What proportion of dementia does vascular dementia account for?
17%
What is vascular dementia caused by?
reduced blood flow to the brain.
Often diagnosed after a stroke or series of TIAs
What proportion of dementia does mixed dementia account for?
10%
What proportion of dementia does Lewi-Body dementia account for?
4% cases
What are Lewy bodies?
small deposits of protein in nerve cells
What kind of problems can be caused with Lewy body dementia?
- problems with thinking, movement, behaviour and mood
- unpredictable changes in attention/alertness
- visual hallucinations
- disturbed sleep
What can Lewy body dementia sometimes be associated with?
Parkinson’s disease
What kind of population does fronto-temporal dementia tend to affect?
generally effects people slightly younger
symptoms in 6th decade
In what decade of life do symptoms of fronts-temporal dementia generally present?
6th decade
What are the early features of fronts-temporal dementia?
personality change
challenging behaviour as distribution
How can fronto-temporal dementia present?
short temperedness, aggression, mood swings and sexually inappropriate behaviour
How is dementia diagnosed?
- attendance at GP
-taking personal and MH - physical exam and other appropriate investigations (bloods, urine, ECG)
- review of medication that may be adversely affecting cognitive function
- check mental abilities
What does the MMSE assess and what does it stand for?
-Mini mental state exam
- short and long term memory
- attention span
- concentration
- language and communication skills
- ability to plan
- ability to understand instructions
What kind of referral can be done for a suspected dementia patient?
- refer to a specialist dementia diagnostic service - memory clinic, old age psychiatry, geriatrician
What are the treatment options for dementia?
- no cure
- talking therapies/counselling
- reducing cardiac risks may halt deterioration of vascular type dementias
- NSAIDs may slow progression
- drug treatment for Alzheimer’s
- alternative therapies
What are the four licensed drugs for Alzheimer’s disease?
1) donepezil (mild to mod)
2) galantamine (mild to mod)
3) rivastigmine (mild to mod)
4) memantine (blocks effects of glutamate)
What do the symptoms of dementia depend on?
- every person experiences dementia differently
- depends on how and what parts of the brain are affected
What are the three stages of progression of dementia?
1) early
2) middle
3) late
What are the characteristics of early stage dementia?
- changes in ability/behaviour may be minor
- often misattributed to stress/bereavement/normal ageing
- loss of short term memory
- confusion, poor judgement, unwilling to make decisions
- anxiety, agitation
- inability to manage everyday tasks
- communication problems
How can the dental team recognise early dementia?
- forgotten appointments
- difficulty making decisions
- deterioration in OH
- forgotten conversations
- repetition
- confusion in grasping new ideas
What are the characteristics of middle stage dementia?
- more support needed in day to day life - reminders to eat/wash/dress/go to the toilet
- increasingly forgetful and may fail to recognise people
- distress, anger, mood changes
- risk of wandering/getting lost
- may behave inappropriately e.g. go out in pyjamas
- may experience hallucinations, throw-back memories
What dental aspects may we notice in patients with middle stage dementia?
confusion/agitation
may not recognise dental team
repeatedly ask same question
What may be required in relation to appointments for dementia patients?
- helpful to bring someone with them
- what time of day is best?
- longer appointments
- assess capacity/consent
What aspects of treatment planning are important in dementia patients?
- OH
- reliance on others
- polypharmacy
- dentures
- plan for future
- simple treatment plans
- prevention !
consent
How does dementia impact cooperation for treatment?
- declines as dementia progresses
- early stages - behavioural management
- sedation, GA
- take into account age, frailty and co-morbidities
- evidence to suggest dementia can worsen following GA
What are the characteristics of late stage dementia?
- increasingly dependent on others for their care
- inability to recognise familiar objects, surroundings or people (may be some flashes of recognition)
- increased physical frailty - eventually confined to wheelchair or bed
- difficulty eating or swallowing
In what dental scenario could you be treating a late stage dementia patient in?
- emergency treatment
How can you tell if a dementia patient has dental problems?
- refusal to eat (particularly hard or cold foods)
- frequent pulling at face or mouth
- leaving previously worn denture out
- increased restlessness
