Elderly Medicine

Question 1

What percent of elderly adults (over 65) have some decayed/ unsound teeth?

Answer 1

over 50%.

Question 2

What are two challenges with elderly patients?

Answer 2

more CHRONIC DISEASES (cardiovascular, neurological, respiratory, diabetes, rheumatological) AND more COMPLICATIONS (more potential complications during treatment, more oral effects of diseases, more drugs).

Question 3

What worsens the oral health issues of frail elderly patients (apart from disease and complications)?

Answer 3

access, income, “nothing can be done’

Question 4

What is fraility?

Answer 4

Think of Ds: disability, dementia, delirium, depression, denourishment (aka malnutrition), destitution, dependency, drugs, death.

Question 5

What is a common frailty scale used?

Answer 5

rockwood frailty score

Question 6

How can patients lose their manual dexterity with age??

Answer 6

1. Neurological disease (ex. parkinsons or stroke)
2. rheumatological disease (ex. osteoarthritis or rheumatoid arthritis).

Question 7

How do patients lose their physical capacity with age?

Answer 7

Respiratory disease
- COPD
Heart disease
Heart failure
Kidney failure
Anaemia
Cancer

Question 8

Examle of how older patients lose their physiology with age?

Answer 8

loss of thirst reflex

Question 9

Disability considerations in dentistry?

Answer 9

High risk of adverse events eg chest pain, shortness of breath
Manual dexterity
Access to services
Visual deficits
Communication issues
Allow for extra time & don’t rush them
Respect

Question 10

What sensory disabilities do elederly people get with age?

Answer 10

• Visual (Age related macular degeneration, Cataracts).
• Deafness
• Impaired taste

Question 11

What is multi-infarct dementia?

Answer 11

• made up of lots of blocked small blood vessels.

Question 12

What is lewy body dementia linked with?

Answer 12

parkinson’s

Question 13

What are 4 causes of dementia?

Answer 13

• alzheimers (60%)
• multi-infarct (20%)
• lewy body (15%)
• others (5%)

Question 14

What is the pathological process of dementia?

Answer 14

Can somewhat tell from disease trajectory and symptoms but can’t fully tell until post-mortem.

Question 15

What is dementia?

Answer 15

Global loss of brain function (cognition, function, personality)

Question 16

How is dementia diagnosed?

Answer 16

Mainly CLINICAL (history taking, examination, rests of cognition, investigations).

Question 17

How is dementia treated?

Answer 17

• Mainly non-pharmacological aka SUPPORTIVE.
• drugs can be used to DELAY, NOT cure (CHOLINISTERASE INHIBITORS).
• symptom control using SEDATIVES, yet these increase mortality

Question 18

What would you be wary of prescribing to patients with dementia? Why?

Answer 18

Codeine, risk of delirium

Question 19

What act to consult for a patient with dementia to assess ability to consent?

Answer 19

Adults with Incapacity Act 2000 Sect 47

Question 20

What document may be needed for a dementia patient who lacks capacity?

Answer 20

Adults with incapacity form from GDP

Question 21

What are some considerations with dementia patients?

Answer 21

• Neglect
• Comprehension
• Capacity to consent (Adults with Incapacity Act 2000 Sect 47)
  Assess capacity for each intervention
  Must be able to understand information, retain , balance information and communicate decision back
  Maximise communication & comprehension
  If lacks capacity needs AWI form from GP
• Compliance
• Interaction with carers and relatives
• Be respectful
• Prescribing
  Risk of delirium (acute confusion) with analgesics

Question 22

What is delirium and how is it diagnosed?

Answer 22

ACUTE CONFUSIONAL STATE

• confusion assessment method
• screening tool (4AT)

Question 23

What are predisposing factors to delirium?

Answer 23

• Frail body (age, multimorbidity, advanced illness, malnutrition)
• Frail mind (age, stroke, dementia, depression)

Question 24

What are CAUSATIVE factors if delirum?

Answer 24

Often multiple underlying causes: Infections, New drugs/drug interactions, Pain, Dehydration, Unusual environment/ people

Often pre-existing dementia

Question 25

What is depression/anxiety more common in elderly?

Answer 25

• social circumstances, physical illness, related issues of malnutrition and dehydration

Question 26

what are dental considerations for depressed/ anxious elderly?

Answer 26

compliance, allow time, oral neglect.

Question 27

How does malnutrition manifest in the elderly?

Answer 27

• 10% of elderly have protein malnutrition
• up to 50% in frail elderly (chronically ill/ institutionalised bc they do not eat enough).

Question 28

What is one of the problems with malnutrition?

Answer 28

impaired healing

Question 29

Why would a patient be malnourished?

Answer 29

Lack of accessibility

Unable to eat food

Impaired appetite

Unwilling to eat food (ex. in dementia).

Gastrointestinal problems
(Poor oral health, Further down GI tract)

Respiratory problems (ex. COPD makes patient breathless and hence less likely to eat)

Question 30

What percent of elderly in the UK live in poverty?

Answer 30

20%, this is likely to go up massively.

Question 31

What are the various forms of dependency?

Answer 31

Family carers

External carers

Institutionalisation (Sheltered Housing,
Residential Homes, Nursing Homes)

Question 32

What is sheltered housing?

Answer 32

Warden 9-5 and alarm system, many will have external carers coming into sheltered housing

Question 33

What is residential home

Answer 33

has carers

Question 34

What is a nursing home

Answer 34

nurses and carers

Question 35

considerations with eledrly patients

Answer 35

Get accurate medication history (carer, patient, GP– try to get TWO SOURCES)

Use BNF/ other resources – look up all medications you are unsure of

Reduced Renal Function in elderly

Consideration of antiplatelets/ anticoagulants

Antiplatelets eg aspirin/ clopidogrel
Anticoagulants inc warfarin/ apixiban/ edoxoban/ dabigatrin

Polypharmacy
Appropriate Vs Inappropriate/Problematic – highlight to GP
Consider potential side-effects in relation to your patients symptoms eg tricyclics
Be alert to interactions eg local anaesthetic risk

Avoid harmful drugs with your prescribing
Avoid NSAIDS in over 80s (GI Side effects in 50%)
Avoid overuse of antibiotics (Clostridium difficle risk)
Use smallest doses possible for moderate strength analgesics eg codeine

Question 36

What should you avoud prescribing in over 80s?

Answer 36

• NSAIDS because 50% have GI side effects.
• use the smallest amount of moderate strength analgesia as possible (ex. codeine).