Older adults residing in nursing homes (NHs) experience difficulty maintaining good oral health[1
]. Oral health in NHs has been described as "deplorable,"[[5
](p251)] with evidence that "a high proportion of elderly nursing home residents suffer from poor oral hygiene and oral health neglect."[[4
](p100)] The need for good oral health is significant with older adults for a variety of reasons. The majority of NH residents arrive dentate[6
]. Older adults experience faster plaque production than younger adults because of the dual effects of gingival recession and reduced saliva production[7
]. Poor oral hygiene causes periodontal disease which in turn creates tooth loss. The remaining teeth shift, causing loss of occlusal surfaces and subsequent chewing and swallowing problems. These problems place older adults at risk for malnutrition[8
]. Other systemic diseases associated with poor oral hygiene include aspiration pneumonia, [9
] diabetes, [10
] and coronary artery disease [12
The need for good oral hygiene is complicated by the dependence many NH residents have on others to provide basic care. Most require assistance in at least one activity of daily living while more than half are dependent on others for all activities of daily living, including mouth care[15
]. In addition to dependence, some persons with dementia exhibit care-resistant behavior (CRB) during helping interactions. CRBs are actions "invoked by a caregiving encounter...defined as the repertoire of behaviors with which persons with dementia withstand or oppose the efforts of a caregiver."[[16
](p28)]. In previous research CRBs were categorized as "uncooperative behavior,"[17
]" "disruptive behavior," [20
] and "agitation." [23
] The progression of dementia coupled with an increased need for assistance increases the likelihood of CRB on the part of the NH resident [23
Eighty percent of certified nursing assistants (CNAs) have reported experiencing CRBs while providing mouth care [25
]. These behaviors ranged from mild resistance (e.g. clenching mouths closed or turning the head away) to extreme resistance (e.g., hitting or kicking the CNA) [26
]. CRBs were often triggered by the CNA performing mouth care instead of allowing the older adult to do so [27
]. Other precipitants to CRBs during mouth care included caregivers attempting to forcefully insert the toothbrush or swab into residents' mouths without alerting them; lack of praise or encouragement; compound commands versus simple one-step commands; no smiling or positive facial cues from the caregiver; and attempting to provide mouth care without prompts or gestures[27
]. These findings support the theoretical foundation of this study, that is, CRB is a fear-evoked response to caregivers' unintentionally threatening behavior during mouth care.
As discussed in detail in another publication [28
], CRB is conceptualized as behavioral responses to a perceived threat. In other words, the older adult with dementia sees the caregiving actions as a form of assault. This conceptualization of CRB is based on the neurobiology of the limbic system. The limbic system is designed to detect threat and initiate protective fear responses of freeze, flight, or fight [29
]. The primary structure is the amygdala, comprised of varied sets of nuclei: lateral, basal, basolateral, and basomedial[29
]. These nuclei interface with other structures in the limbic system, primarily the hippocampus, as well as the brainstem[32
]. In a healthy brain, the hippocampus and select areas of the cerebral cortex receive and process signals from the amygdala to provide awareness, context, and judgment to the threat perception and subsequent fear response[30
]. When the brain, especially the cerebral cortices and hippocampus, is compromised by the pathology of dementia, the ability to apply context to the perceived threat deteriorates. As reasoning and perception become altered, persons with dementia may interpret non-threatening situations (such as a CNA attempting to help the elder with mouth care) as an actual assault[33
This protocol is innovative in specifically addressing threat perception and fear responses in individuals with dementia who are unlikely to have sufficient contextual or cognitive control over threat perceptions due to altered neurological structures and functions. The specific strategies proposed here are expected to reduce perceptions of mouth care and caregiver as threatening and, in turn, limit or prevent CRBs associated with automatic and reflexive fear responses.
In summary, there is a tremendous gap in knowledge regarding interventions designed to prevent and reduce CRB during mouth care in order to improve the oral health of persons with dementia. Persons with dementia and CRB have been systematically excluded from intervention studies developed to improve oral health among NH residents, even though older adults with moderate to severe dementia have worse oral health those with no or mild dementia. Interventions to address oral health outcomes for NH residents with moderate to severe dementia, and who resist care, have not been systematically examined in either nursing or dental research studies. In order to improve nursing clinical practice and to address oral health disparities, it is imperative to design studies that focus on these interventions.
The purpose of this study is to determine whether CRBs can be reduced, and oral health improved, through the application of an intervention based on the neurobiological principles of threat perception and fear response. The primary specific aims of the study are to:
1. Evaluate the efficacy of the Managing Oral Hygiene Using Threat Reduction (MOUTh) intervention for reducing CRBs in persons with dementia;
2. Validate the overall efficacy of the MOUTh intervention using nurse-sensitive oral health outcomes-- swollen and bleeding gums, cleanliness of the oral cavity, saliva, and integrity of the lips and oral mucosa; and
3. Calculate the cost of the MOUTh intervention.
The hypotheses based on the specific aims are as follows:
H1. Implementation of the MOUTh intervention will significantly reduce CRBs during mouth care compared to usual mouth care;
H2. The MOUTh intervention will improve oral health in older adults with dementia through the resolution of swollen and bleeding gums, improved cleanliness of the oral cavity, and the resolution of dry, cracked, and fissured oral mucosa and lips compared to usual care.