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BDS4 Special Care > End of Life Care > Flashcards

End of Life Care Flashcards

1
Q

What are the different end of life trajectories?

A

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)

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2
Q

What are the oral health changes seen in different end of life trajectories?

A

Sudden- minimal changes

Terminal cancer- Xerostomia, oral soft tissue pathology

Progressive functional loss- poor OH, caries, Periodontal disease, infection, tooth loss, xerosotmia

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3
Q

What are the features of the end of life oral condition of older people?

A
  • 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
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4
Q

What is the medical and social model in oral health of older patients?

A
  • Medical model- curing disease
  • Social/patient centred model- health is bigger than absence of disease (QoL may be more important than treating patients)
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5
Q

What are the oral aspects that lead to better QoL?

A
  • Lack of pain
  • Lack of bleeding
  • Social interaction
  • Ability to chew
  • Talking as normal
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6
Q

What are the common complications experienced by end of life patients?

A

Frailty

Polypharmacy- 5+ medicines

Difficulty in maintaining continence- stress, neuromuscular, functional

Falls

Bone Health

Nutrition and Weight Loss

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7
Q

What is frailty?

A

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)

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8
Q

What are the issues with polypharmacy in older people?

A
  • Dry mouth
  • Side effects- cumulative
  • Remembering to take medicines
    -> Consider whether patient needs to take certain medicines
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9
Q

How can difficulties in maintaining continence be managed?

A

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

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10
Q

What are the signs of Frailty?

A

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

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11
Q

How is frailty graded?

A

Presence of 3 or more signs – FRAIL

Presence of 1 or 2 signs – PRE-FRAIL

Nil present – FIT

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12
Q

What is Rockwood frailty?

A

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

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13
Q

What is considered in the comprehensive geriatric assessment carried out by an MDT?

A

Physical health

Social/environmental

Function

Mobility

Medication review

Psychological/mental health

-> can devise problem list and personalised plan with relevant interventions and reviews

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14
Q

What are the main causes of falls in older people?

A

Intrinsic- Hypotension (bring patient up slowly in chair)

Extrinsic- trip hazards in home

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15
Q

What are the dental implications of falls in patients?

A

Dental trauma can occur as a result of this

May cause isolation- patient worried about falling so don’t leave house (domiciliary care)

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16
Q

What are the features of OP?

A
  • 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
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17
Q

Why is it important that older people have good fitting dentures and/or functional teeth in terms of nutrition?

A

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

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18
Q

What are the effects of nutritional deficiency in tooth formation?

A

Enamel hypoplasia

Delayed eruption

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19
Q

What are the dental effects of nutritional deficiency in older patients?

A
  • Delayed healing
  • Erosion
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20
Q

What are the general health effects of nutritional deficiency in older patients?

A

Unintentional weight loss

Sarcopenia

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21
Q

What occurs in Parkinson’s disease?

A

Accumulation of alpha-synuclein protein causes the formation of Lewy-bodies in cerebral neurons
-> Lewy-bodies disrupt the production of the neurotransmitter dopamine

22
Q

What are the symptoms of Parkinson’s disease?

A

Motor:
Tremor
Stiffness
Slow movement

NM:
Drooling
Hallucinations
Consitpation

23
Q

How can drooling in Parkinson’s patients be managed?

A

Topical anticholinergics

Botox injections into salivary glands

24
Q

What considerations may need to be made when treating Parkinson’s patient in dental setting?

A

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)

25
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
26
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
27
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
28
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
29
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
30
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)
31
What are the oral effects of cancer treatment?
Mucositis Xerostomia Candidal infections Bisphosphonates causing MRONJ- used in metastatic secondary bone cancers/multiple myeloma ORN
32
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
33
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
34
What are the complications of diabetes?
Associated with obesity Small vessel disease -> Renal- CKD -> Retinal- vision loss -> Peripheral- peripheral neuropathy
35
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
36
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
37
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
38
What are the causes of stroke?
Ischaemia- blood clot occluding an artery (85%) Haemorrhage- ischaemic area ruptures
39
What side does a left hemisphere stroke produce deficit in?
Right side- opposite
40
What are the risk factors for stroke?
AF Hypertension Smoking Diabetes
41
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
42
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)
43
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
44
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
45
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
46
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
47
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
48
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
49
What is ART?
Remove superficial caries with excavator and patch up with GIC
50
What is the 2 year survival rate of ART restorations against conventional?
ART- 85.4% Conventional- 90.9%
51
Why does candiasis tend to effect older people?
Disease of the diseased- tends to effect immunocompromised patients
52
How is Oral candidiasis managed?
Topical antifungals, improve OH, practice denture hygiene -> use systemic antifungals if this doesn't work

BDS4 Special Care (9 decks)

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