VOLUMEN DE LA ESTRUCTURA DE LA VIVIENDA

Subject A (73 years old) / Female Previous medical history

July 2003: Cerebral infarction

June 2005: Admitted to this facility Oral hygiene condition (at time of entry)

Functioning teeth: 22 (Treated teeth: 14 / Untreated teeth: 6)

Gingival redness (+) / Swelling of the gums (+) / Halitosis (+) / Bleeding gums (+) / Plaque adhesion (+)

Post-admittance progress

No significant change in physical function was detected in Subject A from date of initial admittance to present, although the subject was incapable of concentrating at mealtimes due to decreased cognition, and showed an increasing frequency to wander around the facility holding dishes and chopsticks. Following Subject A changing living quarters from January 2007, the subject began to spend a sig- nificant amount of time in the adjoining toilet. Subject was able to go to the toilet after meals following instructions from staff, but was unable to follow verbal in- structions and often went past the toilet. A case conference on Subject A was held every 3 months, with the following oral care-related problems brought up by nursing staff and the dental hygienist.

- Lack of recognition of verbal instructions and failure to respond was com- mon.

- Unable to remain in one fixed spot, such as waiting before the washbasin. - Strongly resistant to physical contact, especially of the oral cavity.

- Due to difficulty in self-brushing, concern over onset of decay and periodon- tal disease.

- Often unable to fully expel all water within oral cavity in one motion when rinsing mouth.

- Strong halitosis having an effect on interaction with other people. - Level of assistance, such as verbal instruction, increasing at meal times. In response to these problems, staff established three goals.

1. Prevent infection from the oral cavity and enable Subject A to lead a healthy and comfortable lifestyle.

2. By reducing extent of halitosis, aim to provide for smooth communication and interaction with other residents and staff.

3. Maintain and protect functional teeth and prevent any further deterioration in mastication capability, allowing for further sustained enjoyment at meal- times.

The following approaches to oral care outlined below were subsequently imple- mented in an attempt to achieve these goals, with nursing staff sharing problems and ensuring adequate communication between team members.

• Implement these when Subject A feels good, irrespective of the time.

• Carry out care in location Subject A is comfortable in. Avoid any potential con- fusion.

• Turn off television to ensure no external distractions.

• Remove any excess objects and carry out adjustment of the surrounding envi- ronment.

• Include activities with meaning (such as songs etc.) to connect the act of brushing with enjoyable activities.

• Allow one-on-one situations where instructions are given in a clear and easy to understand manner, allow for maximization of subject’s survival capability. • More important than implementing these goals perfectly was to perform them

on a daily basis to establish a stable lifestyle rhythm.

These activities resulted in Subject A becoming less confused and being able to relax at treatment times, allowing oral care to be performed, with team members seeing an improvement in oral hygiene. Halitosis was also seen as decreasing with the number of visible smiles increasing during one-on-one interaction. An increase in the time in which Subject A concentrated on eating and nutritional uptake was also observed when examining changes to the dietary situation and mealtime environment. Due to changes in subject’s dementia condition, how- ever, there were still occasions in which Subject A continued to refuse treatment due to changes in mood or physical condition. This resulted in restrictions on the time available for performing oral care, with it remaining difficult to achieve re- sults from a single, short time period for care provision.

Through the work of the resident dental hygienist since Facility Sendan-no-Oka’s establishment, it has become natural for residents to perform oral hygiene care following every meal. This has also resulted in all staff members taking an inter- est in ensuring residents perform adequate oral care, and making sure that any problems that do arise are reported to the dental hygienist. The dental hygienists provide specialist oral care once a week (sometimes two to three times depend- ing on the individual case), and regularly provide a review of residents’ oral hy- giene and oral function. In addition, by communicating the necessity of oral care, oral hygiene status, care approaches, and selection of care products for each subject to other staff members, efficient and effective oral care can be imple-

mented at different stages within the dental hygienists’ normal working hours at the facility.

This study revealed that for nursing care for elderly dementia sufferers, providing support that took into account each subject’s lifestyle and pattern of daily activi- ties was extremely important, as was examining each subject’s current physical and mental state. This, therefore, meant providing care for subjects when they were most at ease and accessible, which involved being able to respond flexibly in terms of time and location, and meant it was better for nursing care staff to adopt a cooperative approach to care giving. The facility’s resident dental hy- gienists were able to provide oral care through adopting a team framework ap- proach that placed priority on keeping tune with the rhythm of subjects’ daily life- styles. Through this the facility was able to implement an effective oral care pro- gram.

Although clear changes were observed as part of the three goals that were im- plemented for change at Facility Sendan-no-Oka, the efforts initiated in these changes can be thought of as not limited solely to oral care but as part of a team-based approach to improving the living environment and subject’s lifestyle. This type of case study is one of relatively few examples that have looked at life- style-based nursing for dementia sufferers from the viewpoint of oral care. The involvement of a dental hygienist in the nursing care sector can also be viewed as having a significant effect on treatment in this field.

The importance of oral care is widely recognized by healthcare workers. A vari- ety of methods stressing the importance of team care and interdisciplinary ap- proach to care among care workers and nurses have been introduced and are currently being implemented in actual situations. These case studies are ex- pected to expose any problems or failings for each approach to team care, as well as contributing to carrying out any revisions and improvements.

This work was carried out in Kansei Fukushi Research Center of Tohoku Fuku- shi University, Sendai, Japan, supported by “Academic Frontiers” Project for Pri- vate Universities: matching fund subsidy from the Ministry of Education, Culture, Sports, Science and Technology (2004-2008).

References

Akasaka, H. 2006. Promotion of Alzheimer's disease programs. Journal of Japa- nese Society for Dementia Care, 5(1), 68-74.

Kawakubo, M. and Yamada, T. 2000. 80 points of successful team care for the elderly. Japan Medical Planning. Tokyo.

Terui, M. and Toyoko, N. 2006. Team care self-evaluation model in dementia care. Journal of Japanese Society for Dementia Care, 5(3), 416-425.

Watanabe, Y. 2006. Oral Health Care for the Elderly. Annuals of Kansei Fukushi Research Centre, Special Issue, Refurbishing the Elderly Care – Evidences and Theoretical Targets-, Chapter 9, 75-81.

Watanabe, Y., Wakoh, R., and Abe, K. 2006. Role of Full-time Dental Hygienist in the Health Services Facility for the Elderly as to Keep the Relationship with Dental Services: Oral Health Care including Dental Treatment Support to the Residents. Japanese Journal of Gerodontology, 20(4).