Registered Nurses' Association of Ontario

Approaches to Care in Older Adults with Cognitive Impairment - Behaviour/Communication/Dementia Problems

Problem

Strategy

Note

Client won’t open

their mouth

  • Assess ways to get oral hygiene completed.
  • Break peri-oral muscle spasms and gain access to the mouth.
  • Keep the mouth open during oral hygiene care.
  • Use a backward-bent toothbrush to break the muscle spasms.
  • Use another toothbrush or mouth-prop (e.g., Open-Wide Plus) to keep the mouth open.
  • Enlist the assistance of another caregiver.
  • Use other techniques such as rescuing, distraction, etc.
  • Try oral hygiene care at another time of day when client is more cooperative or in a different environment that is more suitable.
  • List successful strategies in the client’s oral hygiene care plan

Dentures can’t be

taken out or put in

client’s mouth

  • Assess ways to get oral hygiene care completed.
  • Assess if there is any aggressive behaviour involved.
  • Assess if there is any sign of tardive dyskinesia or other movement disorder.
  • Discuss with other caregivers who look after the client to see if they are more successful at denture care for this client and see what they do.
  • Enlist the assistance of another caregiver.
  • Consult with medical and dental professionals concerning tardive dyskinesia or other movement disorder.
  • Use other techniques such as rescuing, distraction, etc.
  • Try oral hygiene care at another time of day when client is less aggressive or in a different environment that is more suitable.
  • See if the other carers are more successful at denture care for this client and observe what they do.
  • List successful strategies in the client’s oral hygiene care plan.

Patient refuses oral

hygiene care

  • Assess ways to get oral hygiene care completed.
  • Assess the cause for the refusal of oral hygiene care – environmental, pain, fear.
  • Enlist the assistance of another caregiver.
  • Consult with medical and dental professionals concerning tardive dyskinesia or other movement disorder.
  • Use other techniques such as rescuing, distraction, etc.
  • Try oral hygiene care at another time of day when client is less aggressive or in a different environment that is more suitable.
  • See if the other carers are more successful at denture care for this client and observe what they do.
  • List successful strategies in the client’s oral hygiene care plan.

Client bites

toothbrush/caregiver

  • Assess ways to get oral hygiene care completed.
  • Assess if the biting is of an aggressive origin or is a consequence of tardive dyskinesia or other movement disorder
  • Enlist the assistance of another caregiver.
  • Use other techniques such as rescuing, distraction, etc.
  • Have several toothbrushes on hand during oral hygiene care and let the client chew on one brush while the caregiver cleans with another.
  • Use a mouth-prop to kept the mouth open (e.g., Open-Wide Plus)
  • Consult with medical and dental professionals concerning tardive dyskinesia or other movement disorder.
  • List successful strategies in the client’s oral hygiene care plan.

Client kicks or hits out

  • Assess ways to get oral hygiene care completed.
  • Assess the cause of the aggression.
  • Attempt oral hygiene care at a time when the client is more cooperative.
  • Use other techniques such as rescuing, distraction, etc.
  • Enlist the assistance of another caregiver.
  • List successful strategies in the client’s oral hygiene care plan.
  • Enlist the assistance of another caregiver.
  • Use other techniques such as rescuing, distraction, etc.
  • List successful strategies in the client’s oral hygiene care plan.

Client does not

understand caregivers

directions about oral

hygiene care

  • Assess ways to get oral hygiene care completed.
  • Enlist the assistance of another caregiver.
  • Use other techniques such as rescuing, distraction, etc.
  • List successful strategies in the client’s oral hygiene care plan.

Client cannot rinse

and/or spit and

swallows all

liquids/toothpastes

  • Assess ways to get oral hygiene care completed.
  • Assess the client’s abilities for rinsing/spitting/swallowing etc.
  • Assess the need for the use of toothpastes versus mouthrinses.
  • Consider strategies related to dry mouth, hypersalivation and swallowing problems, and list successful strategies in the client’s oral hygiene care plan.
  • Enlist the assistance of another caregiver.
  • Use a suction toothbrush.

Client uses offensive

language

  • Assess the cause of the offensive language.
  • Assess the feasibility of completing oral hygiene care at that time.
  • Assess ways to get oral hygiene care completed.
  • Ignore the offensive language and attempt oral hygiene care if no other signs of aggression.
  • Use other techniques, such as rescuing, distraction, etc.
  • Enlist the assistance of another caregiver.
  • Try oral hygiene care at another time of day when client is less aggressive or in a different environment that is more suitable.
  • List successful strategies in the client’s oral hygiene care plan.

Client is aggressive

  • Assess the cause of the aggression.
  • Assess ways to get oral hygiene care completed.
  • Try oral hygiene care at another time of day when client is less aggressive or in a different environment that is more suitable.
  • Use other techniques such as rescuing, distraction, etc.
  • Enlist the assistance of another caregiver.
  • List successful strategies in the client’s oral hygiene care plan.

Client is tired/sleepy

  • Assess ways to get oral hygiene care completed
  • Try oral hygiene care at another time of day when client is more alert.
  • Use other techniques such as rescuing, distraction, etc.
  • List successful strategies in the client’s oral hygiene care plan.

Client’s head faces

down toward chest

  • Assess ways to get oral hygiene care completed
  • Enlist the assistance of another caregiver.
  • Do oral hygiene care as best as is possible from different positions.
  • Investigate the success of the use of different dental products such as toothbrushing, mouthrinses, spray bottles, suction toothbrushes, etc.
  • Use other techniques such as rescuing, distraction, etc.
  • List successful strategies in the client’s oral hygiene care plan.

Client’s head moves

around constantly

  • Assess ways to get oral hygiene care completed
  • Enlist the assistance of another caregiver.
  • Use other techniques such as rescuing, distraction, etc.
  • Do oral hygiene care as best as is possible from different positions.
  • Investigate the success of the use of different dental products such as toothbrushing, mouthrinses, spray bottles, etc.
  • If required, discuss holding the client’s head gently during oral hygiene care with them and other parties involved.
  • List successful strategies in the client’s oral hygiene care plan.

Client forgets to do oral

hygiene care

  • Assess the best way to remind the client to do oral hygiene care.
  • Use task-breakdown to break all the steps of the oral hygiene care task down into small steps.
  • Use other techniques such as rescuing, distraction, etc.
  • Write reminder notes for the client, if helpful.
  • Ensure that the need for reminding about oral hygiene care is listed in the client’s oral hygiene care plan.

Client can do some oral

hygiene but not all of

the tasks

  • Assess the client’s abilities to do their oral hygiene care and if they need reminding or assistance during the different stages of the task
  • Use task-breakdown to break all the steps of the oral hygiene care task down into small steps.
  • Use other techniques such as rescuing, distraction, etc.
  • Write reminder notes for the client, if helpful.
  • Ensure that the parts of the oral hygiene care task that the client can do themselves are listed in their oral hygiene care plan.

 

Clinical Management
Oral Health: Nursing Assessment and Intervention
Point of Care Resources