In our study, the prevalence of older patients was women, agreeing with the findings of Aragón et al. (2018) [4] and Machado et al. (2012) [19]. Certainly, this fact occurs because of higher life expectancy in older women than in older men [5]. Also, we also identify that the women had earlier AD than men, as well as mental and cardiocirculatory disorders and diabetes mellitus were more found in men. The main comorbidities were oMD, cardiocirculatory disorders, and endocrine disorders, agreeing with studies of Friedlander et al. (2006) [1], Leelakanok; D’Cunha (2019) [20], and Lane et al. (2018) [2]. We infer that the AD severity may aggravate these disorders due to dependence and loss of autonomy to self-medications. Besides, 43.5% of patients had three or more systemic illnesses, being statistically more found in men. Therefore, the men’s general health was much unsatisfactory, strongly affecting their good quality of life.
The use of multiple medicines is common in older patients with multimorbidity. According to Masnoon et al (2017) [21], polypharmacy has been defined as the use of five or more medicines per patient. Continuous multiple drugs have been administered by our patients. The mean was of 4.72 medicines per individual, being 5.86 medicines for men and 4.08 medicines for women. Briefly, 53.85% of patients ingested five or more medications, indicating cases of polypharmacy in older patients. Among them, 52.38% and 47.62% were men and women, respectively, reinforcing the high prevalence of illnesses in older men. Until now, the medicines used in AD have stabilized its signs/symptoms and/or delayed its progression.
As an alternative symptomatic treatment available for AD, 19, 16 and 7 patients used AChEIs (donepezil, galantamine, and rivastigmine), NMDA receptor antagonist (memantine), or both the medicines, respectively. These medicines temporarily helped in the cognitive-performance, delayed loss of functional capacity and dependency in BADL and improved the behavioral symptoms. AChEIs inhibits the acetylcholine breakdown in the synapse, favoring cholinergic transmission and modulating the cognitive functions. [1, 2, 22, 23]. Other drugs largely used were antihypertensive, antipsychotics, and antidepressants agents. Studies describe that long-time use of antipsychotics may trigger repetitive involuntary movements and/or spasms of masticatory muscles, called tardive dyskinesia. This side effect can limit oral functions and injure the use of removable oral prostheses [1, 24, 25].
Regarding to the study's limitations, some nursing homes had unsatisfactory and precarious healthcare services and sectors. This condition difficulted the patient´s handling and the appropriate intrabuccal clinical procedures, mainly in patients with high severity of dementia and total or severe functional dependence. So, we standardize a protocol of screening intrabuccal clinical exam, so that all the patients could be similarly evaluated. Given that, overall oral health status was properly homogenized in this population. As a strength, all the nursing home administrators fully supported the development of this exploratory study in assessing the residents’ health quality and status. They awakened a great interest in making a real self-acknowledgement of the benefits of the provided social-health services.
After the intrabuccal clinical exam, the obtained data were inserted into the medical-dental records of the health sections at the nursing homes. Subsequently, these records were forwarded to the dental specialists to perform more accurate examinations (e.g., Periodontal Screening and Recording, PSR; Decayed, Missing, and Filled Teeth, DMFT; Community Periodontal Index, CPI; and others) and treatment in these individuals. The screening data showed higher prevalence in dentate subjects than edentate subjects, agreeing with studies of Machado et al. (2012) [19] and Campos et al. (2016) [26]. Residual dental roots, PD, and caries were the oral lesions more frequent. Thus, dental treatment and oral rehabilitation were recommended in almost all the subjects. However, use of dental prostheses must be cautious for dependent patients and monitored by caregivers to avoid adverse complications. Additionally, other authors described masticatory muscle weakness in patients with AD. [4, 27]. Probably, these findings occur due to poor oral hygiene caused by apraxia and apathy in AD, altered physicochemical properties of saliva, and oral-motor muscle hypotonia. Considering the influence of PD in cardiopathies and endocrine diseases (diabetes mellitus/hypothyroidism), we verify that this correlation was well-evidenced in our results. Then, we suggest that the PD could affect the AD progression. Thus, a continuing control treatment of PD must be recommended in healthcare services in nursing home.
With concern to the salivary parameters, we evidence that the mean of flow rate was normal in both sexes; however, some subjects showed reduced flow and hyposalivation. Probably, this occurred due to the synaptic dysfunction and/or alteration of neuronal activity in neurotransmitter synthesis of autonomic nervous system, which is responsible for salivary secretion, affecting mainly major salivary glands. We still conjecture that the long-time use of antihypertensives, anxiolytics, antidepressant, diuretics, benzodiazepines/valproic acid agents contributed to decrease of saliva secretion, agreeing with the studies of Leal et al. (2010) [28] and Liu et al. (2012) [9]. Despite their deleterious effects, hyposalivation was found in 5 subjects, especially in older women. Probably, the cholinesterase inhibitor agents in many patients raised the acetylcholine levels, maintaining normal saliva production.
About pH value, high pH was identified in 3 men and 2 women with PD. Researchers have reported that increased pH may strongly influence on salivary calculus formation and, indirectly, on the development of PD. [4, 29]. The correlation between caries and BC was not detected once 75% of subjects had caries and normal values of BC.
For salivary cortisol, we identified 2 subjects with high and low SC-AM levels in saliva. The high levels of SC-AM were found in a woman, indicating a great risk of physical and/or psychological stress. We infer that this biomarker showed altered because of harmful conditions of this patient, such as: age of 100 years old, bedridden person, no use of medicines, presence of caries, residual dental roots and PD, reduced SFR making it difficult in chewing/swallow and facilitating the action of pathogens on the oral cavity, and total dependence in her functional capacity to personal self-care. Given these facts, we deduce that this woman experienced pain and suffering in the absence of medical and dental clinical practices and other transdisciplinary approaches. In contrast, the low SC-AM level was found in an older man who used antipsychotic medicines. According to Walker et al. (2008) [30], antipsychotic agents may inhibit cortisol release. Therefore, we recommend the SC examination for patients with neuropsychomotor and/or neurodegenerative disorders in routine clinical practices, especially in the health services of nursing home where the communication between patients and professionals in health is impaired by their disability and saliva samples are easily collected and noninvasive.
With respect to sleep quality, 69.2% of older patients showed positive rates to ESS and STOP-BANG questionnaires, being 25.6% of subjects with high risk for OSA and excessive daytime sleepiness. The older men (80%) were more affected than the older women (20%). The men with high risk for OSA had 100% of oMD and cardiocirculatory disorders, 50% of gastrointestinal disorders and 40% of endocrine disorders, particularly diabetes mellitus. These findings were in consonance with the studies of Ing et al. (2000) [31] and Dincer; O´Neil (2006) [32]. When the OSA is not appropriately treated in older patients with dementia, cognitive and functional losses can be exacerbated, compromising largely his/her life quality. The negative impact of OSA in AD has been more evident. OSA is strongly associated with fragmentation in sleep architecture, intermittent hypoxia and oxidative stress, cardiovascular comorbidities and hemodynamic alterations. These conditions together could increase the risk to AD and also accelerate the progression of this disease. So, the treatment of OSA in this population may contribute to AD prevention and/or progression control. [33].
Regarding the functional capacity evaluation, the prevalence of total and severe dependencies was more found in older men (78.6%) than in older women (68%), concomitantly corresponding to the elevated quantity of illnesses in older men. Among them, the oMD and cardiocirculatory disorders were the most frequent in all dependence degrees and in both sexes. Teeth losses caused by caries and PD were well evidenced in all patients, especially in patients with total and severe dependences which were compromised the performance of his/her BADL. Residual dental roots were also identified, mainly in women with all functional dependencies. So, the oral hygienist inserted into the transdisciplinary team become necessary to promote a continuous and appropriate oral prophylaxis in older patients with AD. We still demonstrate that the severity of functional dependence occurred, especially in older men, due to the high number and long-time appearance of comorbidities associated with AD. Therefore, we reinforce that a high severity of AD may be related to bad general and oral health.
With AD progression, the older patients become more dependent, resulting in major limitations in their self-care for prevention and maintenance of general and oral health. Therefore, it is extremely important that family members and/or caregivers are continually guided to control the evolution of preexisting illness and to avoid the appearance of new comorbidities by physicians and dentists. Transdisciplinary approach is also applied to active his/her cognitive skills, including games, music therapy, physical exercises, and others. This surely allow a good adaptation to several limitations which are caused by chronic and progressive exacerbation of AD. Dentists have great difficulty to assist this public-target due to the physical, behavioral, and mental impairments. Oral dysfunctions as sucking habits and involuntary oral and perioral movements are frequent, compromising an appropriate oral rehabilitation. Thus, therapeutic approaches depend on the evolution stages of AD. In initial stage, the dentist must remove all focus infections and to restore the functions of oral and maxillofacial complex. In severe stage, oral health must be preserved through clinical procedures using intravenous sedation or general anesthesia in a hospital environment.
Considering that AD is recognized by WHO (2015) [5] as a global public health priority and the exploratory findings detected in this study, we recommend the management of AD progression, the control of its comorbidities, and the application of the best clinical practices with transdisciplinary approaches, in together, in healthcare services for older patients with AD who lives at long-term private or public nursing-home. Certainly, this may trigger the following benefits, such as: combination of knowledge, skills, and attitude from the interaction among the health multiprofessionals; development of novel innovative therapeutic protocols and approaches; suffering mitigation for residents; lower financial expenses for family; and increased life expectancy for this population.