End of Life Care Flashcards
What are the different end of life trajectories?
Short period of evident decline- incurable cancer
Long term limitations with intermittent serious episodes
-> occurs over 2-5 years- deterioration occurs over this time, after episodes the patient is worse than before
-> heart and lung failure (death can still be sudden)
Prolonged dwindling over 6-8 years (Slow deterioration)
-> older people (frailty and dementia)
What are the oral health changes seen in different end of life trajectories?
Sudden- minimal changes
Terminal cancer- Xerostomia, oral soft tissue pathology
Progressive functional loss- poor OH, caries, Periodontal disease, infection, tooth loss, xerosotmia
What are the features of the end of life oral condition of older people?
- Gingival inflammation and calculus
- Staining
- Caries
- Recession
- Presence of infection- Candidosis
- Trauma
-> If we manage this better it would improve quality of life in later years
What is the medical and social model in oral health of older patients?
- Medical model- curing disease
- Social/patient centred model- health is bigger than absence of disease (QoL may be more important than treating patients)
What are the oral aspects that lead to better QoL?
- Lack of pain
- Lack of bleeding
- Social interaction
- Ability to chew
- Talking as normal
What are the common complications experienced by end of life patients?
Frailty
Polypharmacy- 5+ medicines
Difficulty in maintaining continence- stress, neuromuscular, functional
Falls
Bone Health
Nutrition and Weight Loss
What is frailty?
State of increased vulnerability to stressors due to age related decline in physiological reserve across neuromuscular, metabolic and immune systems
-> Distinct to single organ conditions associated with advancing age and multimorbidity (but can co-exist)
What are the issues with polypharmacy in older people?
- Dry mouth
- Side effects- cumulative
- Remembering to take medicines
-> Consider whether patient needs to take certain medicines
How can difficulties in maintaining continence be managed?
Easy access/modified toilets
Functional continence issue- patient may be catheterised (ensure this is empty before starting treatment)
Plan appointments at suitable time for patient
What are the signs of Frailty?
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
How is frailty graded?
Presence of 3 or more signs – FRAIL
Presence of 1 or 2 signs – PRE-FRAIL
Nil present – 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
What is considered in the comprehensive geriatric assessment carried out by an MDT?
Physical health
Social/environmental
Function
Mobility
Medication review
Psychological/mental health
-> can devise problem list and personalised plan with relevant interventions and reviews
What are the main causes of falls in older people?
Intrinsic- Hypotension (bring patient up slowly in chair)
Extrinsic- trip hazards in home
What are the dental implications of falls in patients?
Dental trauma can occur as a result of this
May cause isolation- patient worried about falling so don’t leave house (domiciliary care)
What are the features of OP?
- Associated with oestrogen withdrawal in female older patients during menopause
- Abnormal bone production occurs resulting in thinning of the bone and increased fracture risks
- Bisphosphonate drugs are provided- Dental risks
Why is it important that older people have good fitting dentures and/or functional teeth in terms of nutrition?
Necessary for chewing various foods leading to a broader food selection
-> patients with out this may turn to a diet that is easier to chew which may be high sugar and less nutritious
What are the effects of nutritional deficiency in tooth formation?
Enamel hypoplasia
Delayed eruption
What are the dental effects of nutritional deficiency in older patients?
- Delayed healing
- Erosion
What are the general health effects of nutritional deficiency in older patients?
Unintentional weight loss
Sarcopenia
What occurs in Parkinson’s disease?
Accumulation of alpha-synuclein protein causes the formation of Lewy-bodies in cerebral neurons
-> Lewy-bodies disrupt the production of the neurotransmitter dopamine
What are the symptoms of Parkinson’s disease?
Motor:
Tremor
Stiffness
Slow movement
NM:
Drooling
Hallucinations
Consitpation
How can drooling in Parkinson’s patients be managed?
Topical anticholinergics
Botox injections into salivary glands
What considerations may need to be made when treating Parkinson’s patient in dental setting?
Medication- aim to get patient in time where medication is having desired effect
-> do treatment soon after they have taken medication
-> if lengthy procedure allow them to take mid-appointment
Suctioning is important
Dyskinesia- indicates IV midazolam for muscle relaxation (risk of dysphagia- balance)
What should you do if you suspect one of your patients has dementia?
If you notice they have forgotten about appointments or look disorientated
-> signpost to GMP for formal assessment
What are the features of mental health in older people?
- Impacted by age
- Lower levels of referral to services
- High levels of depression in care homes (related to medical diseases?)
- CBT is useful in older people
- Higher mortality with more diseases/co-morbidities - cluster medicine
- May be more likely to neglect self care if poor
- Dental diseases can contribute to poor mental health
What is immunosenescence and its implications?
Changes that occur in immune system due to increasing age
-> increased risk of cancer (due to poorer surveillance)
-> Increased bacterial and viral infection risk (changes to mucous membranes and immune system)
-> autoimmune diseases
What happens to different parts of the immune system due to age?
Macrophages work more slowly
T cells do not respond as well
Less complement protein is produced
Which medications can make a patient become immunosupressed?
Oral corticosteroids- inflammatory autoimmune conditions
-> prednisolone for asthma or temporal arteritis
Disease modifying medications- severe autoimmune diseases
-> methotrexate- RA
-> mycophenolate- SLE
Chemotherapy agents- 5-fuorouracil (5-FU) capecitabine for bowel cancer
Immunomodulatory treatment for cancer treatment
-> rituximab to treat NHL/lymphocytic leukaemia
How may dental treatment be adapted for patients on immunosuppressive drugs?
If very immune supressed- consider ABP
Biologics- strict timing schedule
-> do treatment in window when blood cells are most stable (week 5 in 6-week cycle)
What are the oral effects of cancer treatment?
Mucositis
Xerostomia
Candidal infections
Bisphosphonates causing MRONJ- used in metastatic secondary bone cancers/multiple myeloma
ORN
Why may patients be sent for an oral assessment before starting bisphosphonates or chemo?
So that teeth of poor prognosis can be removed to avoid complications in the future
-> Prevent MRONJ if bisphospohonates
-> Prevent infection due to neutropenia in chemo
What drug types are associated with MRONJ, give examples?
Bisphosphonates- alendronic acid
Tyrosine Kinase Inhibitors- sunitinib
Immunosupressants- methotrexate
SERM- raloxifene
Monoclonal antibodies- Bevacizumab
mTOR- Sirolimus
Radium 223
Fusion proteins- Aflibercept
What are the complications of diabetes?
Associated with obesity
Small vessel disease
-> Renal- CKD
-> Retinal- vision loss
-> Peripheral- peripheral neuropathy
What adjustments can be made for patients who have diabetes in dental setting ?
Written information in larger font
Transfer device from wheelchairs if PVD has lead to amputation or mobility issue
GA- consult medical teams if modifications to insulin regime are required (fasting)
Sessions should be scheduled for the morning
-> higher endogenous cortisol levels increase blood glucose and decrease the risk of hypoglycaemia
Avoid scheduling an appointment time that coincides with the maximum insulin activity peak or when it may lead to a meal being missed
Which Hb1AC levels allow dental treatment to proceed?
<7%- any treatment
9%- only emergency treatment
-> if surgical it should be in hospital setting
> 12%- postpone all procedures until glycemic control improves
What are the risks for diabetic patients in the dental setting?
Hyperglycaemia Hypoglycaemia
Fatigue/reduced tolerance for long treatment
Greater risk of infection
Poor wound healing
Increased risk of periodontal disease
Complications related to comorbidities/secondary vascular complications
What are the causes of stroke?
Ischaemia- blood clot occluding an artery (85%)
Haemorrhage- ischaemic area ruptures
What side does a left hemisphere stroke produce deficit in?
Right side- opposite
What are the risk factors for stroke?
AF
Hypertension
Smoking
Diabetes
What are the complications of stroke?
Complete paralysis on one side
Higher cognitive dysfunction
-> issues sequencing tasks
Loss of speech
Difficulty of swallowing
One sided visual loss
What are the different ways that stroke can affect speech?
Expressive dysphasia- forming words becomes difficult
Receptive dysphasia- difficulty understanding
Dysarthria- physical difficulty with formation of words (slurred speech)
What are the dental implications of stroke?
Mobility may be affected- difficulty getting in chair
Understanding may be lost- consent
Issues with swallowing- tube feeding, retention of medicine (alendronic acid/Fe- full thickness burns)
Difficulty with OH- limited dexterity
Higher risk of dental disease- poor oral clearance, dry mouth, pouching
Anticoagulated- delay invasive treatment for 6 months
What adjustments may need to be made for patients who have suffered a stroke in dental setting?
Patient may have dysphagia- good suction required
Keep patient more upright
Take time with treatment- allow rest breaks
Analgesia- paracetamol is preferred
What factors are deemed important by relatives of patients when they are undergoing end of life care?
Cleanliness
Free of pain
Have family present
Dignity maintained
How may we change our care if a patient is coming to end of their life?
If we know that someone is coming to end of life, adopt more conservative approach to avoid overtreatment
-> Allows patient to spend final period of time not receiving treatment
What are the issues caused by dry mouth in the elderly?
Speech issues
Nutritional function and intake
Impairs social interaction
Protective features of saliva lost
What are the risk factors for restoration failure in older people?
Lower number of tooth brushings/day
Absence of prosthesis
Posterior location of the tooth
Higher baseline plaque index
What is ART?
Remove superficial caries with excavator and patch up with GIC
What is the 2 year survival rate of ART restorations against conventional?
ART- 85.4%
Conventional- 90.9%
Why does candiasis tend to effect older people?
Disease of the diseased- tends to effect immunocompromised patients
How is Oral candidiasis managed?
Topical antifungals, improve OH, practice denture hygiene
-> use systemic antifungals if this doesn’t work
