Gerodontology 2 Flashcards
What are the different types of end of life trajectory
- short period of evident decline
- long term limitations with intermittent serious episodes
- prolonged dwindling
impact of oral health and end of life trajectories
- Progressive Functional Loss Trajectory
- Slow and Progressive
- Less Reliable
- Decreased
- Poor oral hygiene
- Caries
- Oral pain/infection Tooth loss
- Denture-related
- Problems
- Xerostomia
- Soft tissue pathology
summarise experience of oral disease in care homes
- data is difficult to obtain
- levels of disease are high
- we are seeing an increase in dentate people
OHRQoL vs Disease Model
HIstorically determined to treat disease (medical based model)
Now, health is more than absence of disease. What is it the patient wants?
Things to consider:
* Social/ emotional
* Oral health (free of pain, bleeding gum, spaces between teeth)
* Function (chewing talking)
* Treatment expectations
* environment
What do people struggle with as they age?
Mobility –>stairs, getting to the shops
Dexterity –>making a cup of tea , brushing teeth
Communication –>sight and hearing –>isolation
Medical diseases in older people?
- Musculoskeletal – Arthritis, Osteoporosis, gout, fractures
- Diabetes, Hormonal dysfunction
- Cognitive Impairment and
- Visual conditions
- Hearing conditions
- Cardiovascular conditions
- GI conditions
- Malignancy
what things do older people experience
- Frailty
- Polypharmacy
- Continence
- Falls
- Bone Health
- Nutrition and Weight Loss
Define frailty
Frailty is defined as ‘a state of increased vulnerability to stressors due to age related declines in physiological reserve across neuromuscular, metabolic, and immune systems’
Distinct to single organ conditions (such as a stroke) associated with advancing age and multimorbidity, but these can co-exist
Describe the features of frailty phenotype
- Unintentional weight loss (4.5 kg in last year)
- Self-reported exhaustion
- Weakness (measured by grip strength in lowest 20% per age)
- Slow walking speed (slowest 20% by gender/height)
- Low physical activity (based on Kcal expended per week in lowest 20%)
- Presence of 3 or more of above – Defined as ‘frail’:
- Presence of 1 or 2 of above – Defined as ‘pre frail’
- Nil present – Defined as ‘fit
What is “Rockwood frailty”
Consequence of and defined by an accumulation of deficits that are associated with ageing.
Measured by adding the number of deficits a person has to create a Frailty Index
Two different ways of thinking about frailty?
Frailty Phenotype
“Rockwood Frailty”
Factors in a comprehensive geriatric assessment
What is polypharmacy
Five or more medications?
Increasing number of medication increases risk of oral side effects
How does continence affect older people
Stress
The sphincter around the urethra is no longer strong enough to overcome additional pressure from the abdomen (such as that which comes about when coughing or sneezing). When this happens, the patient may leak a small amount of urine. Individuals are often very aware of this and may well be very embarrassed
**Urge **
Neuromuscular system is abnormal. As the bladder flls, signals are sent to the micturition centre too early in the flling process, creating an urgent need to pass urine. The bladder is still relatively empty on passing urine, meaning a person only passes small volumes. This urgency can be highly signifcant and can lead to urinary incontinence. One treatment is anti-muscarinic medication, but this has the side effect of xerostomia. overfow,
Functional forms.
More common in men with enlarged prostate glands, and there may be a continual small volume of leaking urine. This is often treated with a urinary catheter inserted into the bladder, which drains the urine into a bag attached to the patient’s leg. There is no problem with the urogenital system in functional incontinence, but the person cannot get to the bathroom to pass urine on time. The risk is greater for people with mobility diffculties, such as arthritis or following a stroke. For all older patients, it is essential to understand their needs and work with them to maintain their dignity wherever possible.
Signage, modified toilet facilities
How do falls affect older people and their dental treatment
- 1 in 3 people over 65 falling per year
- Rises to 1 in 2 people over the age of 80
- Intrinsic factors are related to the individual, e.g., postural hypotension,
- Extrinsic factors are related to their environment, e.g., trip hazards in the home
Dental Trauma:
* Care should be taken when older patients have been supine for an extended period during dental treatment, and they should be sat up slowly due to the risk of orthostatic hypotension.
* Some patients may not leave their homes due to an increased risk, or fear of falling, meaning consideration should be given to domiciliary dental care
How does bone health affect older people
- Prevalence of osteoporosis increases sharply with age from approximately 2% at 50 years to more than 25% at 80 years.
- There is a greater incidence among females than males due to oestrogen withdrawal during menopause which will impact on bone density. There is abnormal bone production in osteoporosis, and the bone becomes “thinned”; thus, there is an increased risk of fractures.
- Falls from a standing height leading to a fracture are commonly called “fragility fractures” and are pathognomonic for osteoporosis in people over 75 (there are around 500,000 of these per year in the UK)
- Bisphosphonates
how are older people affected by nutrition and weight loss
- Functional teeth or good fitting dentures are necessary for chewing various foods leading to a broader food selection.
- There are two main considerations for older adults and poor nutrition: sarcopenia and unintentional weight loss.
- Unintentional weight loss is recognised as part of the frailty phenotype but would usually only be attributed to frailty as a diagnosis of exclusion by someone able to assess the root causes thoroughly.
- Chronic conditions will lead to a catabolic state or insufficient nutritional requirements to meet the body’s metabolic demands
- Poor nutrition may have affected teeth formation, including enamel hypoplasia and delayed eruption of teeth that can have lifelong consequences.
- Inadequate nutrition in later life can also cause delayed healing, or tooth erosion, depending on the nature of the consumed diet.
- Restriction in food choices due to an impaired dentition may lead to a high sugar diet lacking many essential nutrients and increasing the risk of developing caries.
pathology of parkinsons
- Parkinson’s disease (PD) is the second most common neurodegenerative condition after Alzheimer’s dementia.
- In PD, the accumulation of alpha-synuclein protein causes the formation of Lewy-bodies in cerebral neurons.
- The Lewy-bodies disrupt the production of the neurotransmitter dopamine
symptoms of parkinsons
- Patients have a wide range of potential symptoms, divided into those associated with movement (motor) and those that do not affect movement (non-motor)
- early stages: of PD, patients present with a tremor, stiffness or slowness of movement
- The non-motor symptoms (drooling, cognitive changes, hallucinations, and constipation) become more prominent with disease progression.
- Drooling is a particularly common complaint and can be managed non-pharmacologically with boiled sweets (but with an increased risk of dental disease) that can stimulate swallowing or with topical medications such as anticholinergics or botulinum toxin injections to the salivary glands.
- The change in salivary fow substantially impacts the oral microbiome
Why is timing important for medications in parkinsons
Closer that treatment is to when they take their medications the more under control their symptoms are.Therefore, when planning dental procedures, it is essential to be aware of the timing of a patient’s medication and try to schedule treatment around this.
Some patients
with dyskinesias may find it impossible to sit or lie still at peak times around their medication regime.
Features of Altzheimers
- Alzheimer’s disease is the commonest neurodegenerative condition in the UK.
- The World Health Organisation suggest it accounts for 60–70% of all dementias [26].
- It is associated with a decline in cognitive function across various cognitive domains that progresses over time, and many patients will have problems with memory loss.
- Vascular dementia is less common (around 15% of patients with dementia) and classically follows a stepwise pattern of deterioration.
- Some patients, though, will not already have a diagnosis of dementia.
- Patients wdisorientated) should be signposted to their GP for a formal assessment.
- A sudden change in a level of confusion is rare in dementia and is much more likely to be due to delirium.
- Delirium can be caused by several conditions (from constipation to infection) and should always lead to a more detailed patient assessment by an appropriate healthcare team.
- Dementia and frailty states show significant overlap and often co-exist, especially in the later stages of dementia.
- In the moderate to severe stages of dementia, weight loss is common.
- Can be multifactorial, from either the practicalities of obtaining or preparing food to reduced appetite or catabolic nutritional states.
- Maintaining a good dentition can significantly optimise a person’s intrinsic eating abilities, essential in those who may lack such awareness, such as those with dementia.
- ho may appear to have an undiagnosed cognitive impairment (for example, forgetting about appointments or appearing
impact of mental health on older people
- When patients have multimorbidity and mental health conditions are part of the conditions, they have higher mortality and morbidity rates.
- Healthcare professionals, including the dental team, should be alert to the possibility of mental health problems and ask patients about this as part of their consultation and discuss referral to their general medical practitioner.
- The consideration for the dental team is that patients living with mental health conditions may neglect their physical health, including their oral health, and so may present later to dental services or only when there is an acute problem.
- Poor oral health such as lost dentures, poor appearance of teeth or chronic pain and infection can contribute to mental health issues, including depression.
- The number of older people substance-abusing will increase with demographic changes, including heavy drinking, misuse of prescription medication and recreational drugs.
- Older people may have started substance abuse in their younger age and continued to do so as they got older, or it can be a new pattern in older age.
- The distinction is important because each requires different assessment, intervention, and treatment regimens
in what ways does being immunocompromised affect older people
- The immune system acts as a defence system against infections and detects and destroys malignant or autoreactive cells.
- **Immunosenescence refers to the changes in the immune system with increasing age. **As the immune system ages, it functions less well and the risk of cancer, autoimmune disease, and risk of infections increases.
- Some infection risk is due to changes in mucous membranes (for example, urinary tract infections in older females partly due to the changes in vulval mucosa) and the way the immune system functions.
- Macrophages work slower, T-cells respond less well, and less complement protein is produced.
- As a result, bacterial infections are more common in older people (particularly respiratory, urinary and skin infections). Viral infections, such as fu and COVID-19, also have a more significant effect due to this immunosenescence.
- Vaccination helps to mitigate against these effects for some viral illnesses.
Medications associated with MRONJ + types of drug
