User login
A checklist of approaches for alleviating behavioral problems in dementia
Dementia—“major neurocognitive disorder” in DSM-5—manifests as progressive decline in cognitive function.In tandem with that decline, approximately 80% of nursing home patients with dementia exhibit behavioral disturbances,1 including irritability, insomnia, wandering, and repetitive questioning.1,2 These disturbances can erode their quality of life and can frustrate caregivers and providers.3
Causative pathology
Before designing a therapeutic intervention for cognitively impaired people with behavioral disturbances, a precise diagnosis of the causative pathology must be determined. This affords therapies that specifically address the patient’s problems. Other related and unrelated somatic or mental health concerns should be identified to specify the optimal approach.
Patients in whom dementia is suspected require that a thorough medical, psychiatric, substance use, and family history be taken to identify predisposing factors for their illness2; exhaustive review of the history might reveal drug interactions or polypharmacy that can cause or exacerbate symptoms, including behavioral manifestations. Physical examination, cognitive function testing, laboratory tests, and neuroimaging also help reveal the etiologic diagnosis of the dementia.1,3
Identifying the diagnosis directs the treatment; for example, a behaviorally discontrolled person with a cognitive, stroke-induced encephalopathy requires an entirely different regimen than a comparatively compromised individual with Alzheimer’s disease or frontotemporal dementia. Early detection of dementia also is helpful for managing its cognitive and behavioral problems more effectively.1Once a diagnosis of dementia is established, it might be behavioral symptoms and poor insight that become more worrisome to the patient’s caregivers and providers than cognitive deficits. Your task is then to apply behavioral approaches to management, with consistency, to maximize, at all times, the patient’s safety and comfort.4
How you approach behavioral management is important
Consider these interventions:
- Ensure that you appropriately treat associated depression, pain, and somatic illness—whether related or unrelated to dementia.
- Offer caregivers and staff a plan for attending to supportive measures, including nutrition, hydration, and socialization.
- Provide family and caregivers with disease education, social support, and management tips1,2; be respectful to family members in all interactions.3
- Offer caregivers and staff a plan for attending to supportive measures, including nutrition, hydration, and socialization.
Minimize psychosocial and environmental stressors
- Avoid unnecessary environmental changes, such as rearranging or refurbishing the patient’s living space.1
- As noted, ensure that the patient is comfortable and safe in his (her) surroundings, such as providing wall-mounted handrails and other aids for ambulation.
- Provide access to television, proper lighting, and other indicated life-enhancing devices.1,2
- Consider a pet for the patient; pets can be an important adjunct in providing comfort.
- Provide music to reduce agitation and anxiety.4
- Appeal to institutional administration to provide a higher staff−patient ratio for comfort and security.2,5
- Because social contact is helpful to build a pleasant environment, preserve opportunities for the patient to communicate with others, and facilitate socialization by encouraging friendly interactions.1
- Provide stimulation and diversion with social activities, support programs, and physical exercise—sources of interaction that can promote health and improve sleep.
- Redirection and validation are helpful to divert a patient’s attention from stressful situations and keep him (her) calm.2,5
- Pharmacotherapy should be implemented if psychosocial methods of behavioral management fail or the patient’s behavior becomes threatening.1
- Provide access to television, proper lighting, and other indicated life-enhancing devices.Provide music to reduce agitation and anxiety.Redirection and validation are helpful to divert a patient’s attention from stressful situations and keep him (her) calm.Pharmacotherapy should be implemented if psychosocial methods of behavioral management fail or the patient’s behavior becomes threatening.
Other considerations
- Identify and treat primary and secondary causes of the underlying major neurocognitive disorder.
- Use an integrative, multidisciplinary approach to manage behavioral problems in dementia.
- Utilize a social worker’s expertise to faciliate family, financial, or related social issues and better cooperation. This promotes comfort for patients, families, and staff.
- Physical therapy aids in maintaining physical function, especially preservation of gait, balance, and range of motion. Thus, with greater stability avoiding a fall can be a life-saving event.
- Socialization, mental outlook, and emotional health are improved by occupational therapist interventions.
- Individual psychotherapy helps to improve self-esteem and personal adjustment. Group activities reinforces interpersonal connections.
- Refer the family and caregivers for supportive therapy and education on dementia; such resources help minimize deleterious effects of the patient’s behavioral problems on those key people.
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Tampi RR, Williamson D, Muralee S, et al. Behavioral and psychological symptoms of dementia: part I—epidemiology, neurobiology, heritability, and evaluation. Clinical Geriatrics. 2011;19:41-46.
2. Hulme C, Wright J, Crocker T, et al. Non-pharmacological approaches for dementia that informal carers might try or access: a systematic review. Int J Geriatr Psychiatry. 2010;25(7):756-763.
3. Perkins R. Evidence-based practice interventions for managing behavioral and psychological symptoms of dementia in nursing home residents. Ann Longterm Care. 2012;20(12):24.
4. Desai AK, Grossberg GT. Recognition and management of behavioral disturbances in dementia. Prim Care Companion J Clin Psychiatry. 2001;3(3):93-109.
5. Douglas S, James I, Ballard C. Non-pharmacological interventions in dementia. Advances in Psychiatric Treatment. 2004;10(3):171-177.
Dementia—“major neurocognitive disorder” in DSM-5—manifests as progressive decline in cognitive function.In tandem with that decline, approximately 80% of nursing home patients with dementia exhibit behavioral disturbances,1 including irritability, insomnia, wandering, and repetitive questioning.1,2 These disturbances can erode their quality of life and can frustrate caregivers and providers.3
Causative pathology
Before designing a therapeutic intervention for cognitively impaired people with behavioral disturbances, a precise diagnosis of the causative pathology must be determined. This affords therapies that specifically address the patient’s problems. Other related and unrelated somatic or mental health concerns should be identified to specify the optimal approach.
Patients in whom dementia is suspected require that a thorough medical, psychiatric, substance use, and family history be taken to identify predisposing factors for their illness2; exhaustive review of the history might reveal drug interactions or polypharmacy that can cause or exacerbate symptoms, including behavioral manifestations. Physical examination, cognitive function testing, laboratory tests, and neuroimaging also help reveal the etiologic diagnosis of the dementia.1,3
Identifying the diagnosis directs the treatment; for example, a behaviorally discontrolled person with a cognitive, stroke-induced encephalopathy requires an entirely different regimen than a comparatively compromised individual with Alzheimer’s disease or frontotemporal dementia. Early detection of dementia also is helpful for managing its cognitive and behavioral problems more effectively.1Once a diagnosis of dementia is established, it might be behavioral symptoms and poor insight that become more worrisome to the patient’s caregivers and providers than cognitive deficits. Your task is then to apply behavioral approaches to management, with consistency, to maximize, at all times, the patient’s safety and comfort.4
How you approach behavioral management is important
Consider these interventions:
- Ensure that you appropriately treat associated depression, pain, and somatic illness—whether related or unrelated to dementia.
- Offer caregivers and staff a plan for attending to supportive measures, including nutrition, hydration, and socialization.
- Provide family and caregivers with disease education, social support, and management tips1,2; be respectful to family members in all interactions.3
- Offer caregivers and staff a plan for attending to supportive measures, including nutrition, hydration, and socialization.
Minimize psychosocial and environmental stressors
- Avoid unnecessary environmental changes, such as rearranging or refurbishing the patient’s living space.1
- As noted, ensure that the patient is comfortable and safe in his (her) surroundings, such as providing wall-mounted handrails and other aids for ambulation.
- Provide access to television, proper lighting, and other indicated life-enhancing devices.1,2
- Consider a pet for the patient; pets can be an important adjunct in providing comfort.
- Provide music to reduce agitation and anxiety.4
- Appeal to institutional administration to provide a higher staff−patient ratio for comfort and security.2,5
- Because social contact is helpful to build a pleasant environment, preserve opportunities for the patient to communicate with others, and facilitate socialization by encouraging friendly interactions.1
- Provide stimulation and diversion with social activities, support programs, and physical exercise—sources of interaction that can promote health and improve sleep.
- Redirection and validation are helpful to divert a patient’s attention from stressful situations and keep him (her) calm.2,5
- Pharmacotherapy should be implemented if psychosocial methods of behavioral management fail or the patient’s behavior becomes threatening.1
- Provide access to television, proper lighting, and other indicated life-enhancing devices.Provide music to reduce agitation and anxiety.Redirection and validation are helpful to divert a patient’s attention from stressful situations and keep him (her) calm.Pharmacotherapy should be implemented if psychosocial methods of behavioral management fail or the patient’s behavior becomes threatening.
Other considerations
- Identify and treat primary and secondary causes of the underlying major neurocognitive disorder.
- Use an integrative, multidisciplinary approach to manage behavioral problems in dementia.
- Utilize a social worker’s expertise to faciliate family, financial, or related social issues and better cooperation. This promotes comfort for patients, families, and staff.
- Physical therapy aids in maintaining physical function, especially preservation of gait, balance, and range of motion. Thus, with greater stability avoiding a fall can be a life-saving event.
- Socialization, mental outlook, and emotional health are improved by occupational therapist interventions.
- Individual psychotherapy helps to improve self-esteem and personal adjustment. Group activities reinforces interpersonal connections.
- Refer the family and caregivers for supportive therapy and education on dementia; such resources help minimize deleterious effects of the patient’s behavioral problems on those key people.
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Dementia—“major neurocognitive disorder” in DSM-5—manifests as progressive decline in cognitive function.In tandem with that decline, approximately 80% of nursing home patients with dementia exhibit behavioral disturbances,1 including irritability, insomnia, wandering, and repetitive questioning.1,2 These disturbances can erode their quality of life and can frustrate caregivers and providers.3
Causative pathology
Before designing a therapeutic intervention for cognitively impaired people with behavioral disturbances, a precise diagnosis of the causative pathology must be determined. This affords therapies that specifically address the patient’s problems. Other related and unrelated somatic or mental health concerns should be identified to specify the optimal approach.
Patients in whom dementia is suspected require that a thorough medical, psychiatric, substance use, and family history be taken to identify predisposing factors for their illness2; exhaustive review of the history might reveal drug interactions or polypharmacy that can cause or exacerbate symptoms, including behavioral manifestations. Physical examination, cognitive function testing, laboratory tests, and neuroimaging also help reveal the etiologic diagnosis of the dementia.1,3
Identifying the diagnosis directs the treatment; for example, a behaviorally discontrolled person with a cognitive, stroke-induced encephalopathy requires an entirely different regimen than a comparatively compromised individual with Alzheimer’s disease or frontotemporal dementia. Early detection of dementia also is helpful for managing its cognitive and behavioral problems more effectively.1Once a diagnosis of dementia is established, it might be behavioral symptoms and poor insight that become more worrisome to the patient’s caregivers and providers than cognitive deficits. Your task is then to apply behavioral approaches to management, with consistency, to maximize, at all times, the patient’s safety and comfort.4
How you approach behavioral management is important
Consider these interventions:
- Ensure that you appropriately treat associated depression, pain, and somatic illness—whether related or unrelated to dementia.
- Offer caregivers and staff a plan for attending to supportive measures, including nutrition, hydration, and socialization.
- Provide family and caregivers with disease education, social support, and management tips1,2; be respectful to family members in all interactions.3
- Offer caregivers and staff a plan for attending to supportive measures, including nutrition, hydration, and socialization.
Minimize psychosocial and environmental stressors
- Avoid unnecessary environmental changes, such as rearranging or refurbishing the patient’s living space.1
- As noted, ensure that the patient is comfortable and safe in his (her) surroundings, such as providing wall-mounted handrails and other aids for ambulation.
- Provide access to television, proper lighting, and other indicated life-enhancing devices.1,2
- Consider a pet for the patient; pets can be an important adjunct in providing comfort.
- Provide music to reduce agitation and anxiety.4
- Appeal to institutional administration to provide a higher staff−patient ratio for comfort and security.2,5
- Because social contact is helpful to build a pleasant environment, preserve opportunities for the patient to communicate with others, and facilitate socialization by encouraging friendly interactions.1
- Provide stimulation and diversion with social activities, support programs, and physical exercise—sources of interaction that can promote health and improve sleep.
- Redirection and validation are helpful to divert a patient’s attention from stressful situations and keep him (her) calm.2,5
- Pharmacotherapy should be implemented if psychosocial methods of behavioral management fail or the patient’s behavior becomes threatening.1
- Provide access to television, proper lighting, and other indicated life-enhancing devices.Provide music to reduce agitation and anxiety.Redirection and validation are helpful to divert a patient’s attention from stressful situations and keep him (her) calm.Pharmacotherapy should be implemented if psychosocial methods of behavioral management fail or the patient’s behavior becomes threatening.
Other considerations
- Identify and treat primary and secondary causes of the underlying major neurocognitive disorder.
- Use an integrative, multidisciplinary approach to manage behavioral problems in dementia.
- Utilize a social worker’s expertise to faciliate family, financial, or related social issues and better cooperation. This promotes comfort for patients, families, and staff.
- Physical therapy aids in maintaining physical function, especially preservation of gait, balance, and range of motion. Thus, with greater stability avoiding a fall can be a life-saving event.
- Socialization, mental outlook, and emotional health are improved by occupational therapist interventions.
- Individual psychotherapy helps to improve self-esteem and personal adjustment. Group activities reinforces interpersonal connections.
- Refer the family and caregivers for supportive therapy and education on dementia; such resources help minimize deleterious effects of the patient’s behavioral problems on those key people.
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Tampi RR, Williamson D, Muralee S, et al. Behavioral and psychological symptoms of dementia: part I—epidemiology, neurobiology, heritability, and evaluation. Clinical Geriatrics. 2011;19:41-46.
2. Hulme C, Wright J, Crocker T, et al. Non-pharmacological approaches for dementia that informal carers might try or access: a systematic review. Int J Geriatr Psychiatry. 2010;25(7):756-763.
3. Perkins R. Evidence-based practice interventions for managing behavioral and psychological symptoms of dementia in nursing home residents. Ann Longterm Care. 2012;20(12):24.
4. Desai AK, Grossberg GT. Recognition and management of behavioral disturbances in dementia. Prim Care Companion J Clin Psychiatry. 2001;3(3):93-109.
5. Douglas S, James I, Ballard C. Non-pharmacological interventions in dementia. Advances in Psychiatric Treatment. 2004;10(3):171-177.
1. Tampi RR, Williamson D, Muralee S, et al. Behavioral and psychological symptoms of dementia: part I—epidemiology, neurobiology, heritability, and evaluation. Clinical Geriatrics. 2011;19:41-46.
2. Hulme C, Wright J, Crocker T, et al. Non-pharmacological approaches for dementia that informal carers might try or access: a systematic review. Int J Geriatr Psychiatry. 2010;25(7):756-763.
3. Perkins R. Evidence-based practice interventions for managing behavioral and psychological symptoms of dementia in nursing home residents. Ann Longterm Care. 2012;20(12):24.
4. Desai AK, Grossberg GT. Recognition and management of behavioral disturbances in dementia. Prim Care Companion J Clin Psychiatry. 2001;3(3):93-109.
5. Douglas S, James I, Ballard C. Non-pharmacological interventions in dementia. Advances in Psychiatric Treatment. 2004;10(3):171-177.
Poor oral hygiene in the mentally ill: Be aware of the problem, and intervene
Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.1 Poor oral hygiene is a significant problem because it results in dental pathology that has an adverse influence on the whole body.
Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.2 In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.3 Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.4
Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.5 The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental erosions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leukoplakia, and oral papilloma or other cancers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.5
Alcohol consumption increases the risk of oral cancer. Long-term alcohol use suppresses bone marrow function, causing leukopenia and resulting in immunosuppression and an increased incidence of dental infections.6 Excessive alcohol consumption also can cause thrombocytopenia and bleeding, which can complicate dental procedures.
Smoking cigarettes increases the incidence of periodontal disease, especially necrotizing gingivitis and candidiasis.7 Ninety percent of patients with schizophrenia smoke—compared with up to 70% of patients with other psychiatric disorders, and 19% of the general population.7,8 Physiologic aspects of schizophrenia reinforce the smoking habit.7
Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obesity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.
Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that periodontal disease will progress.9 Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque formation.10 Depression, anxiety, and substance abuse can lead to temporomandibular disorders that cause pain and restrict jaw movement.11 Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.
Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.
Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.11 Misdiagnosis can result in extractions or procedures without an appropriate indication and failure to alleviate the pain.
Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candidiasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyskinesia, dystonia) may cause tooth damage and make managing dentures difficult.6
What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting substances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of dental caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.
From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.
A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physician, facilitates health care and works to offer the patient access to global medical services.
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Mental Illness Fellowship of Australia Inc. Overview of the oral health of people affected by mental illness. http:// www.wfmh.com/links/external-contacts/mental-illness-fellowship-of-australia. Accessed June 18, 2014.
2. Kisely S, Quek LH, Pais J, et al. Advanced dental disease in people with severe mental illness: systematic review and meta-analysis. Br J Psychiatry. 2011;199(3):187-193.
3. Dental caries (tooth decay) in adults (age 20 to 64). National Institute of Dental and Craniofacial Research. http:// www.nidcr.nih.gov/DataStatistics/FindDataByTopic/ DentalCaries/DentalCariesAdults20to64.htm. Updated January 6, 2014. Accessed June 18, 2014.
4. Peridontal disease in adults (age 20 to 64). National Institute of Dental and Craniofacial Research. http://www.nidcr. nih.gov/DataStatistics/FindDataByTopic/GumDisease/ PeriodontaldiseaseAdults20to64.htm. Updated January 6, 2014. Accessed June 18, 2014.
5. Maloney WJ. The significance of illicit drug use to dental practice. http://www.webmedcentral.com/wmcpdf/ Article_WMC00455.pdf. Published July 28, 2010. Accessed June 18, 2014.
6. Oral health care for people with mental problems: guidelines and recommendations. British Society for Disability and Oral Health. http://www.bsdh.org.uk/guidelines/ mental.pdf. Updated January 2000. Accessed June 18, 2014.
7. Lohr JB, Flynn K. Smoking and schizophrenia. Schizophr Res. 1992;8(2):93-102.
8. Centers for Disease Control and Prevention (CDC). Vital signs: current cigarette smoking among adults aged ≥18 years–United States, 2005-2010. MMWR Morb Mortal Wkly Rep. 2011;60(35):1207-1212.
9. Yoffee L. The link between oral health and medical illness. http://www.everydayhealth.com/dental-health/oral-conditions/oral-health-and-other-diseases.aspx. Updated November 9, 2012. Accessed June 18, 2014.
10. Demmer RT, Desvarieux M. Periodontal infections and cardiovascular disease: the heart of the matter. J Am Dent Assoc. 2006;137(suppl 2):14S-20S; quiz 38S.
11. Mental illness and the dental patient. American Dental Hygienists’ Association. http://www.adha.org/ce-course-10. Accessed June 18, 2014.
Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.1 Poor oral hygiene is a significant problem because it results in dental pathology that has an adverse influence on the whole body.
Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.2 In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.3 Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.4
Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.5 The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental erosions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leukoplakia, and oral papilloma or other cancers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.5
Alcohol consumption increases the risk of oral cancer. Long-term alcohol use suppresses bone marrow function, causing leukopenia and resulting in immunosuppression and an increased incidence of dental infections.6 Excessive alcohol consumption also can cause thrombocytopenia and bleeding, which can complicate dental procedures.
Smoking cigarettes increases the incidence of periodontal disease, especially necrotizing gingivitis and candidiasis.7 Ninety percent of patients with schizophrenia smoke—compared with up to 70% of patients with other psychiatric disorders, and 19% of the general population.7,8 Physiologic aspects of schizophrenia reinforce the smoking habit.7
Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obesity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.
Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that periodontal disease will progress.9 Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque formation.10 Depression, anxiety, and substance abuse can lead to temporomandibular disorders that cause pain and restrict jaw movement.11 Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.
Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.
Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.11 Misdiagnosis can result in extractions or procedures without an appropriate indication and failure to alleviate the pain.
Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candidiasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyskinesia, dystonia) may cause tooth damage and make managing dentures difficult.6
What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting substances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of dental caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.
From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.
A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physician, facilitates health care and works to offer the patient access to global medical services.
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.1 Poor oral hygiene is a significant problem because it results in dental pathology that has an adverse influence on the whole body.
Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.2 In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.3 Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.4
Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.5 The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental erosions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leukoplakia, and oral papilloma or other cancers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.5
Alcohol consumption increases the risk of oral cancer. Long-term alcohol use suppresses bone marrow function, causing leukopenia and resulting in immunosuppression and an increased incidence of dental infections.6 Excessive alcohol consumption also can cause thrombocytopenia and bleeding, which can complicate dental procedures.
Smoking cigarettes increases the incidence of periodontal disease, especially necrotizing gingivitis and candidiasis.7 Ninety percent of patients with schizophrenia smoke—compared with up to 70% of patients with other psychiatric disorders, and 19% of the general population.7,8 Physiologic aspects of schizophrenia reinforce the smoking habit.7
Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obesity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.
Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that periodontal disease will progress.9 Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque formation.10 Depression, anxiety, and substance abuse can lead to temporomandibular disorders that cause pain and restrict jaw movement.11 Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.
Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.
Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.11 Misdiagnosis can result in extractions or procedures without an appropriate indication and failure to alleviate the pain.
Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candidiasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyskinesia, dystonia) may cause tooth damage and make managing dentures difficult.6
What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting substances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of dental caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.
From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.
A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physician, facilitates health care and works to offer the patient access to global medical services.
Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Mental Illness Fellowship of Australia Inc. Overview of the oral health of people affected by mental illness. http:// www.wfmh.com/links/external-contacts/mental-illness-fellowship-of-australia. Accessed June 18, 2014.
2. Kisely S, Quek LH, Pais J, et al. Advanced dental disease in people with severe mental illness: systematic review and meta-analysis. Br J Psychiatry. 2011;199(3):187-193.
3. Dental caries (tooth decay) in adults (age 20 to 64). National Institute of Dental and Craniofacial Research. http:// www.nidcr.nih.gov/DataStatistics/FindDataByTopic/ DentalCaries/DentalCariesAdults20to64.htm. Updated January 6, 2014. Accessed June 18, 2014.
4. Peridontal disease in adults (age 20 to 64). National Institute of Dental and Craniofacial Research. http://www.nidcr. nih.gov/DataStatistics/FindDataByTopic/GumDisease/ PeriodontaldiseaseAdults20to64.htm. Updated January 6, 2014. Accessed June 18, 2014.
5. Maloney WJ. The significance of illicit drug use to dental practice. http://www.webmedcentral.com/wmcpdf/ Article_WMC00455.pdf. Published July 28, 2010. Accessed June 18, 2014.
6. Oral health care for people with mental problems: guidelines and recommendations. British Society for Disability and Oral Health. http://www.bsdh.org.uk/guidelines/ mental.pdf. Updated January 2000. Accessed June 18, 2014.
7. Lohr JB, Flynn K. Smoking and schizophrenia. Schizophr Res. 1992;8(2):93-102.
8. Centers for Disease Control and Prevention (CDC). Vital signs: current cigarette smoking among adults aged ≥18 years–United States, 2005-2010. MMWR Morb Mortal Wkly Rep. 2011;60(35):1207-1212.
9. Yoffee L. The link between oral health and medical illness. http://www.everydayhealth.com/dental-health/oral-conditions/oral-health-and-other-diseases.aspx. Updated November 9, 2012. Accessed June 18, 2014.
10. Demmer RT, Desvarieux M. Periodontal infections and cardiovascular disease: the heart of the matter. J Am Dent Assoc. 2006;137(suppl 2):14S-20S; quiz 38S.
11. Mental illness and the dental patient. American Dental Hygienists’ Association. http://www.adha.org/ce-course-10. Accessed June 18, 2014.
1. Mental Illness Fellowship of Australia Inc. Overview of the oral health of people affected by mental illness. http:// www.wfmh.com/links/external-contacts/mental-illness-fellowship-of-australia. Accessed June 18, 2014.
2. Kisely S, Quek LH, Pais J, et al. Advanced dental disease in people with severe mental illness: systematic review and meta-analysis. Br J Psychiatry. 2011;199(3):187-193.
3. Dental caries (tooth decay) in adults (age 20 to 64). National Institute of Dental and Craniofacial Research. http:// www.nidcr.nih.gov/DataStatistics/FindDataByTopic/ DentalCaries/DentalCariesAdults20to64.htm. Updated January 6, 2014. Accessed June 18, 2014.
4. Peridontal disease in adults (age 20 to 64). National Institute of Dental and Craniofacial Research. http://www.nidcr. nih.gov/DataStatistics/FindDataByTopic/GumDisease/ PeriodontaldiseaseAdults20to64.htm. Updated January 6, 2014. Accessed June 18, 2014.
5. Maloney WJ. The significance of illicit drug use to dental practice. http://www.webmedcentral.com/wmcpdf/ Article_WMC00455.pdf. Published July 28, 2010. Accessed June 18, 2014.
6. Oral health care for people with mental problems: guidelines and recommendations. British Society for Disability and Oral Health. http://www.bsdh.org.uk/guidelines/ mental.pdf. Updated January 2000. Accessed June 18, 2014.
7. Lohr JB, Flynn K. Smoking and schizophrenia. Schizophr Res. 1992;8(2):93-102.
8. Centers for Disease Control and Prevention (CDC). Vital signs: current cigarette smoking among adults aged ≥18 years–United States, 2005-2010. MMWR Morb Mortal Wkly Rep. 2011;60(35):1207-1212.
9. Yoffee L. The link between oral health and medical illness. http://www.everydayhealth.com/dental-health/oral-conditions/oral-health-and-other-diseases.aspx. Updated November 9, 2012. Accessed June 18, 2014.
10. Demmer RT, Desvarieux M. Periodontal infections and cardiovascular disease: the heart of the matter. J Am Dent Assoc. 2006;137(suppl 2):14S-20S; quiz 38S.
11. Mental illness and the dental patient. American Dental Hygienists’ Association. http://www.adha.org/ce-course-10. Accessed June 18, 2014.
Apply your psychiatric skills to managing rheumatoid arthritis
Joint disease is the most common cause of disability and the source of considerable psychological distress. In the United States, 50 million adults complain of joint pain; in 2007, 1.5 million people suffered from rheumatoid arthritis (RA). A chronic inflammatory autoimmune disease of joints, RA can involve almost all organs.1
The link to mental illness
Mental illness in RA patients often is underdiagnosed and undertreated. These missed opportunities contribute to poor compliance with medical therapy, suboptimal therapeutic response, greater disability, and diminished quality of life.2
Limited mobility, chronic pain, sleep disturbance, fatigue, and immunological factors predispose RA patients to depression and anxiety.3 The proinflammatory cytokines, tumor necrosis factor-α (TNF-α), interleukin 1 (IL-1), IL-6, and interferon-g have a role in inducing affective symptoms. There also is a relationship between an elevated IL-17 level and anxiety.
Research substantiates a relationship between RA and depression.3 The prevalence of affective illness is approximately 6% among the general population, and 13% to 30% among RA patients.4 In arthritic populations, 52% exhibit depression and anxiety; joint discomfort contributes to insomnia in 25% to 42% of cases.4
Arthritic pain persists despite suppressed inflammation, which suggests involvement of the CNS.5 Increased levels of IL-6 and TNF-α can cause insomnia and affect pain perception.6 Decreased conditioned pain modulation, a lower pain threshold, and pressure pain intolerance lead to increased pain awareness and heightened discomfort.
How can you help your patient who has RA?
Because the focus of care in RA is on the disease’s physical attributes, psychiatric symptoms sometimes receive less attention.7 And because arthritic symptoms overlap with anorexia, weight loss, fatigue, pain, and insomnia, affective illness can go unrecognized.
Depression rating scales can overestimate affective illness, but a history and follow-up questionnaire can facilitate an accurate diagnosis of depression and help determine the need for, and type of, intervention.
Selective serotonin reuptake inhibitors (SSRIs) are considered first‐line treatment of depression associated with RA.7 Although SSRIs for RA can be administered to the maximum recommended dosage, titration is advised in accordance with patient response and tolerance.
Tricyclic antidepressants are not as well tolerated in RA, especially in older patients; however, they have more of an analgesic effect, even at lower dosages.
Joint disease activity and mood are associated with sleep disturbance, and vice versa.5 Insomnia calls for patient education about sleep hygiene, avoiding caffeine and other stimulants, and an individualized appraisal of options for pharmacotherapy.
Alleviating RA pain is important for psychosocial health.8 Although the medical team’s emphasis should be on controlling inflammation to minimize joint damage and pain, be sure to address your RA patients’ mood symptoms to improve the quality of their life.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Centers for Disease Control and Prevention. Arthritis-related statistics. http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm. Updated August 1, 2011. Accessed January 4, 2013.
2. Shih M, Hootman JM, Strine TW, et al. Serious psychological distress in U.S. adults with arthritis. J Gen Intern Med. 2006;21(11):1160-1166.
3. Sato E, Nishimura K, Nakajima A, et al. Major depressive disorder in patients with rheumatoid arthritis. Mod Rheumatol. 2013;23(2):237-244.
4. Wolfe F, Michaud K, Li T. Sleep disturbance in patients with rheumatoid arthritis: evaluation by medical outcomes study and visual analog sleep scales. J Rheumatol. 2006;33(10):1942-1951.
5. Fragiadaki K, Tektonidou MG, Konsta M, et al. Sleep disturbances and interleukin 6 receptor inhibition in rheumatoid arthritis. J Rheumatol. 2012;39(1):60-62.
6. Lee YC, Lu B, Edwards RR, et al. The role of sleep problems in central pain processing in rheumatoid arthritis. Arthritis Rheum. 2013;65(1):59-68.
7. Dickens C, Creed F. The burden of depression in patients with rheumatoid arthritis. Rheumatology (Oxford). 2001; 40(12):1327-1330.
8. Courvoisier DS, Agoritsas T, Glauser J, et al. Pain as an important predictor of psychosocial health in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64(2):190-196.
Joint disease is the most common cause of disability and the source of considerable psychological distress. In the United States, 50 million adults complain of joint pain; in 2007, 1.5 million people suffered from rheumatoid arthritis (RA). A chronic inflammatory autoimmune disease of joints, RA can involve almost all organs.1
The link to mental illness
Mental illness in RA patients often is underdiagnosed and undertreated. These missed opportunities contribute to poor compliance with medical therapy, suboptimal therapeutic response, greater disability, and diminished quality of life.2
Limited mobility, chronic pain, sleep disturbance, fatigue, and immunological factors predispose RA patients to depression and anxiety.3 The proinflammatory cytokines, tumor necrosis factor-α (TNF-α), interleukin 1 (IL-1), IL-6, and interferon-g have a role in inducing affective symptoms. There also is a relationship between an elevated IL-17 level and anxiety.
Research substantiates a relationship between RA and depression.3 The prevalence of affective illness is approximately 6% among the general population, and 13% to 30% among RA patients.4 In arthritic populations, 52% exhibit depression and anxiety; joint discomfort contributes to insomnia in 25% to 42% of cases.4
Arthritic pain persists despite suppressed inflammation, which suggests involvement of the CNS.5 Increased levels of IL-6 and TNF-α can cause insomnia and affect pain perception.6 Decreased conditioned pain modulation, a lower pain threshold, and pressure pain intolerance lead to increased pain awareness and heightened discomfort.
How can you help your patient who has RA?
Because the focus of care in RA is on the disease’s physical attributes, psychiatric symptoms sometimes receive less attention.7 And because arthritic symptoms overlap with anorexia, weight loss, fatigue, pain, and insomnia, affective illness can go unrecognized.
Depression rating scales can overestimate affective illness, but a history and follow-up questionnaire can facilitate an accurate diagnosis of depression and help determine the need for, and type of, intervention.
Selective serotonin reuptake inhibitors (SSRIs) are considered first‐line treatment of depression associated with RA.7 Although SSRIs for RA can be administered to the maximum recommended dosage, titration is advised in accordance with patient response and tolerance.
Tricyclic antidepressants are not as well tolerated in RA, especially in older patients; however, they have more of an analgesic effect, even at lower dosages.
Joint disease activity and mood are associated with sleep disturbance, and vice versa.5 Insomnia calls for patient education about sleep hygiene, avoiding caffeine and other stimulants, and an individualized appraisal of options for pharmacotherapy.
Alleviating RA pain is important for psychosocial health.8 Although the medical team’s emphasis should be on controlling inflammation to minimize joint damage and pain, be sure to address your RA patients’ mood symptoms to improve the quality of their life.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Joint disease is the most common cause of disability and the source of considerable psychological distress. In the United States, 50 million adults complain of joint pain; in 2007, 1.5 million people suffered from rheumatoid arthritis (RA). A chronic inflammatory autoimmune disease of joints, RA can involve almost all organs.1
The link to mental illness
Mental illness in RA patients often is underdiagnosed and undertreated. These missed opportunities contribute to poor compliance with medical therapy, suboptimal therapeutic response, greater disability, and diminished quality of life.2
Limited mobility, chronic pain, sleep disturbance, fatigue, and immunological factors predispose RA patients to depression and anxiety.3 The proinflammatory cytokines, tumor necrosis factor-α (TNF-α), interleukin 1 (IL-1), IL-6, and interferon-g have a role in inducing affective symptoms. There also is a relationship between an elevated IL-17 level and anxiety.
Research substantiates a relationship between RA and depression.3 The prevalence of affective illness is approximately 6% among the general population, and 13% to 30% among RA patients.4 In arthritic populations, 52% exhibit depression and anxiety; joint discomfort contributes to insomnia in 25% to 42% of cases.4
Arthritic pain persists despite suppressed inflammation, which suggests involvement of the CNS.5 Increased levels of IL-6 and TNF-α can cause insomnia and affect pain perception.6 Decreased conditioned pain modulation, a lower pain threshold, and pressure pain intolerance lead to increased pain awareness and heightened discomfort.
How can you help your patient who has RA?
Because the focus of care in RA is on the disease’s physical attributes, psychiatric symptoms sometimes receive less attention.7 And because arthritic symptoms overlap with anorexia, weight loss, fatigue, pain, and insomnia, affective illness can go unrecognized.
Depression rating scales can overestimate affective illness, but a history and follow-up questionnaire can facilitate an accurate diagnosis of depression and help determine the need for, and type of, intervention.
Selective serotonin reuptake inhibitors (SSRIs) are considered first‐line treatment of depression associated with RA.7 Although SSRIs for RA can be administered to the maximum recommended dosage, titration is advised in accordance with patient response and tolerance.
Tricyclic antidepressants are not as well tolerated in RA, especially in older patients; however, they have more of an analgesic effect, even at lower dosages.
Joint disease activity and mood are associated with sleep disturbance, and vice versa.5 Insomnia calls for patient education about sleep hygiene, avoiding caffeine and other stimulants, and an individualized appraisal of options for pharmacotherapy.
Alleviating RA pain is important for psychosocial health.8 Although the medical team’s emphasis should be on controlling inflammation to minimize joint damage and pain, be sure to address your RA patients’ mood symptoms to improve the quality of their life.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Centers for Disease Control and Prevention. Arthritis-related statistics. http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm. Updated August 1, 2011. Accessed January 4, 2013.
2. Shih M, Hootman JM, Strine TW, et al. Serious psychological distress in U.S. adults with arthritis. J Gen Intern Med. 2006;21(11):1160-1166.
3. Sato E, Nishimura K, Nakajima A, et al. Major depressive disorder in patients with rheumatoid arthritis. Mod Rheumatol. 2013;23(2):237-244.
4. Wolfe F, Michaud K, Li T. Sleep disturbance in patients with rheumatoid arthritis: evaluation by medical outcomes study and visual analog sleep scales. J Rheumatol. 2006;33(10):1942-1951.
5. Fragiadaki K, Tektonidou MG, Konsta M, et al. Sleep disturbances and interleukin 6 receptor inhibition in rheumatoid arthritis. J Rheumatol. 2012;39(1):60-62.
6. Lee YC, Lu B, Edwards RR, et al. The role of sleep problems in central pain processing in rheumatoid arthritis. Arthritis Rheum. 2013;65(1):59-68.
7. Dickens C, Creed F. The burden of depression in patients with rheumatoid arthritis. Rheumatology (Oxford). 2001; 40(12):1327-1330.
8. Courvoisier DS, Agoritsas T, Glauser J, et al. Pain as an important predictor of psychosocial health in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64(2):190-196.
1. Centers for Disease Control and Prevention. Arthritis-related statistics. http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm. Updated August 1, 2011. Accessed January 4, 2013.
2. Shih M, Hootman JM, Strine TW, et al. Serious psychological distress in U.S. adults with arthritis. J Gen Intern Med. 2006;21(11):1160-1166.
3. Sato E, Nishimura K, Nakajima A, et al. Major depressive disorder in patients with rheumatoid arthritis. Mod Rheumatol. 2013;23(2):237-244.
4. Wolfe F, Michaud K, Li T. Sleep disturbance in patients with rheumatoid arthritis: evaluation by medical outcomes study and visual analog sleep scales. J Rheumatol. 2006;33(10):1942-1951.
5. Fragiadaki K, Tektonidou MG, Konsta M, et al. Sleep disturbances and interleukin 6 receptor inhibition in rheumatoid arthritis. J Rheumatol. 2012;39(1):60-62.
6. Lee YC, Lu B, Edwards RR, et al. The role of sleep problems in central pain processing in rheumatoid arthritis. Arthritis Rheum. 2013;65(1):59-68.
7. Dickens C, Creed F. The burden of depression in patients with rheumatoid arthritis. Rheumatology (Oxford). 2001; 40(12):1327-1330.
8. Courvoisier DS, Agoritsas T, Glauser J, et al. Pain as an important predictor of psychosocial health in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64(2):190-196.