Reducing Care-Resistant Behaviors During Oral Hygiene in Persons With Dementia

Nursing home (NH) residents with dementia are often dependent on others for mouth care, yet
will react with care-resistant behavior (CRB) when receiving assistance. The oral health of
these elders deteriorates in the absence of daily oral hygiene, predisposing them to harmful
systemic problems such as pneumonia, hyperglycemia, cardiac disease, and cerebral vascular
accidents. 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. When faced with a threat, all organisms
react with "flight-fight" responses. These responses are both autonomic (e.g. elevated heart
rate, sweating) and behavioral (e.g. moving away, attacking). Persons with dementia have
heightened threat perception as a result of neurobiological changes that affect the cerebral
cortex, hippocampus, and amygdala. These individuals may interpret mouth care as a
threatening action by threatening people. The intervention, called Managing Oral Hygiene
Using Threat Reduction (MOUTh), combines best mouth care practices with a constellation of
behavioral techniques that reduce threat perception and thereby prevent or de-escalate CRB.
The primary specific aims of the study are to: 1)Evaluate the efficacy of the 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. Using a randomized repeated measures design,
80 elders with dementia from 5 different NHs will be randomized at the individual level to
the experimental group, which will receive the intervention, or to the control group, which
will receive standard mouth care from research team members who receive training in the
proper methods for providing mouth care but no training in resistance recognition or
prevention/mediation. Oral health assessments and CRB measurements will be obtained during a
7-day observation period and a 21-day intervention period. Individual growth models using
multilevel analysis will be used to estimate the efficacy of the intervention for reducing
CRBs in persons with dementia, and to estimate the overall efficacy of the intervention using
oral health outcomes. Activity-based costing methods will be used to determine the cost of
the MOUTh intervention. At the end of this study, the research team anticipates having a
proven intervention that prevents and reduces CRB within the context of mouth care. Long-term
objectives include testing the effect of the intervention on systemic illnesses among persons
with dementia; examining the transferability of this intervention to other activities of
daily living; and disseminating threat reduction interventions to NH staff, which may
radically change the way care is provided to persons with dementia.

Inclusion Criteria:

- English-speaking

- age 55 or older

- documented diagnosis of dementia, Alzheimer's disease, vascular dementia, or Lewy body
dementia

- identified by NH staff as resistant to mouth care

- at least 2 adjacent teeth AND/OR daily wearing of at least one denture plate

- the ability to hold a toothbrush

- the ability to move his or her hand to his or her mouth.

Exclusion Criteria:

- age less than 55

- no documented diagnosis of dementia

- inability to hold a toothbrush

- inability to raise his or her hand to his or her mouth

- receiving treatment for an active dental or denture problem

- a diagnosis of dysphagia requiring thickened liquids