Gerodontology 2 Flashcards

1
Q

What are the different types of end of life trajectory

A
  • short period of evident decline
  • long term limitations with intermittent serious episodes
  • prolonged dwindling
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2
Q

impact of oral health and end of life trajectories

A
  • 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
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3
Q

summarise experience of oral disease in care homes

A
  1. data is difficult to obtain
  2. levels of disease are high
  3. we are seeing an increase in dentate people
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4
Q

OHRQoL vs Disease Model

A

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

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5
Q

What do people struggle with as they age?

A

Mobility –>stairs, getting to the shops

Dexterity –>making a cup of tea , brushing teeth

Communication –>sight and hearing –>isolation

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6
Q

Medical diseases in older people?

A
  • Musculoskeletal – Arthritis, Osteoporosis, gout, fractures
  • Diabetes, Hormonal dysfunction
  • Cognitive Impairment and
  • Visual conditions
  • Hearing conditions
  • Cardiovascular conditions
  • GI conditions
  • Malignancy
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7
Q

what things do older people experience

A
  • Frailty
  • Polypharmacy
  • Continence
  • Falls
  • Bone Health
  • Nutrition and Weight Loss
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8
Q

Define frailty

A

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

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9
Q

Describe the features of frailty phenotype

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 (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
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10
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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11
Q

Two different ways of thinking about frailty?

A

Frailty Phenotype
“Rockwood Frailty”

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12
Q

Factors in a comprehensive geriatric assessment

A
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13
Q

What is polypharmacy

A

Five or more medications?

Increasing number of medication increases risk of oral side effects

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14
Q

How does continence affect older people

A

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

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15
Q

How do falls affect older people and their dental treatment

A
  • 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

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16
Q

How does bone health affect older people

A
  • 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
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17
Q

how are older people affected by nutrition and weight loss

A
  • 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.
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18
Q

pathology of parkinsons

A
  • 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
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19
Q

symptoms of parkinsons

A
  • 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
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20
Q

Why is timing important for medications in parkinsons

A

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.

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21
Q

Features of Altzheimers

A
  • 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
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22
Q

impact of mental health on older people

A
  • 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
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23
Q

in what ways does being immunocompromised affect older people

A
  • 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.
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24
Q

the four groups of medicines which affect the immune system?

A

1. Oral corticosteroids for treating a range of inflammatory autoimmune conditions (e.g., prednisolone for asthma or temporal arteritis).
2. Disease modifying medications for more severe autoimmune diseases (e.g., methotrexate for rheumatoid arthritis or mycophenolate for systemic lupus erythematosus).
3. **Chemotherapy agents **for cancer treatment [e.g. 5-fuorouracil (5-FU) capecitabine for bowel cancer].
4. Immunomodulatory treatment for cancer treatment (e.g., rituximab to treat non-Hodgkin lymphoma or chronic lymphocytic leukaemia).

25
Q

Why are medications affecting the immune system relevant to dentists

A

For the dentist, this is relevant as patients taking such medications are more at risk of dental infections and prolonged healing if invasive procedures are required.
TIming of treatment - (immunomodulating drugs)best to do treatment when cell numbers have recovered best e.g. if on 6 weekly treatment regime, carry out dental treatment week 5

26
Q

how might cancer impact older people

A
  • increase in risk of getting cancer as you get older (highest rates in 85-89 year old group)
  • In some instances, the older person and their oncology team may decide not to investigate or treat further.
  • Head and neck cancer is the eighth most common cancer in the UK, and incidence rates are highest in people aged 70–74
  • Cancer treatments may affect the oral cavity ranging from mucositis, xerostomia, and candida infections.
  • Bisphosphonates, often used for metastatic secondary bone cancer, is associated with an increased risk of jaw necrosis
  • Haematological malignancies are common in older patients, such as acute or chronic myeloid leukaemia, chronic lymphocytic leukaemia, or multiple myeloma.
  • As with other malignancies, older patients may not tolerate aggressive chemotherapy treatments, and outcomes are less favourable.
  • There is increasingly a role in the Comprehensive Geriatric Assessment process for these patients.
27
Q

why might someone need bisphosphonates

A
  • osteoporosis
  • haem-oncology
28
Q

management of people on bisphosphonates

A
  • For example, patients diagnosed with multiple myeloma should have a dental examination and extraction of teeth of poor prognosis before commencing the bisphosphonate drug due to the increased risk of medicine-related osteonecrosis of the jaw.
  • Similarly, when chemotherapy is planned, teeth of poor prognosis should ideally be managed before starting to allow teeth with chronic infections or at risk of infection to be managed before a patient becomes neutropenic.
  • When patients with existing haematological malignancies require surgical management; they should be assessed for bleeding
29
Q

Medications associated with MRONJ + types of drug

A
30
Q

Describe diabetes and difference between type 1 and 2

A
  • Diabetes is a condition where the regulation of blood sugar is affected.
  • Insulin usually is produced by the body to move sugar from the blood into the cells.
  • When the blood sugar level is raised, sugar is excreted into the urine, which pulls water with it, leading to polyuria and polydipsia—the hallmark symptoms of diabetes.

Two main types:
* Type 1 diabetes, the pancreas does not produce insulin and is often a condition that older people have lived with for many years and would be treated with insulin injections.
* Type 2 diabetes is the most common form (around 90% of cases) and is where the body becomes less responsive to insulin.

31
Q

What is type 1 diabetes

A

The pancreas does not produce insulin and is often a condition that older people have lived with for many years and would be treated with insulin injections.

32
Q

What is type 2 diabetes

A

The most common form (around 90% of cases) and is where the body becomes less responsive to insulin.

33
Q

Treatment of diabetes

A

This develops over time and is associated with obesity. Treatment can be via insulin injections but is often initially managed with tablets to modulate the response to endogenous insulin. The longer patients live, the longer people live with diabetes and its potential complications.

34
Q

complications with diabetes

A
  • People with diabetes may have a range of complications—mostly related to its effect on small blood vessels:
  • Renal, retinal, and peripheral small blood vessels can become damaged
  • Leading to, chronic kidney disease, visual loss, and peripheral neuropathies.
35
Q

elements of patient care for people with diabetes

A
  • Written information in larger font size
  • Transfer from wheelchairs when the peripheral vascular disease has significant impacts on mobility or has led to amputation.
  • Wound healing can be compromised with diabetes, and infections can progress rapidly in uncontrolled diabetes, requiring aggressive management.
  • Dental wounds and infection risk are no exception.
  • Type 1 diabetic patients or those needing insulin for type 2 diabetes undergoing general anaesthesia for dental procedures may need modifications to their insulin regime in the pre-operative and peri-operative period, especially as fasting is required before anaesthesia.
  • Medical teams should support the planning of care in such situations.
36
Q

important test for managing diabetic patients

A
  • HbA1c levels are <7%, any type of dental treatment can generally be performed within the dental clinic
  • If HbA1c levels are 9%, only emergency treatments should be conducted and surgical procedures should preferably be undertaken in a hospital setting
  • With HbA1c readings >12%, all procedures should be postponed until the glycaemic control has improved
37
Q

risks with treating diabetic patients

A
  • The sessions should preferably 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
  • Hyperglycaemia
  • Hypoglycaemia
  • Fatigue/reduced tolerance for long treatment
  • Increased risk of infection
  • Poor wound healing
  • Increased risk of periodontal disease
  • Complications related to comorbidities/secondary vascular complications
38
Q

What is a stroke

A

In a stroke, there is a sudden onset of focal ischaemic changes in the brain.
Ischaemia is most commonly caused by a blood clot occluding an artery (85% of all strokes).
Whatever function the affected area of the brain is responsible for will be affected (for example, a stroke affecting the left hemisphere would give rise to a right-sided weakness).

39
Q

risk factors for a stroke

A

Risk factors include atrial fibrillation, hypertension, diabetes, and smoking.

An ischaemic area can also result from a rupture in the blood vessel wall leading to haemorrhage (around 15% of all strokes).

40
Q

impact of a stroke on peoples health

A

Following a stroke, a patient can have a wide range of neurological problems, from complete one-sided paralysis with higher cognitive dysfunction, loss of speech, poor swallowing function, and one-sided visual loss (a total anterior circulation stroke) to a relatively minor weakness.
For some people, the sequencing of tasks may be affected.

41
Q

how is speech affected in a stroke

A

* Expressive dysphasia—where the forming of language is difficult—the patient may know what they want to say but cannot “get the words out”.
* Receptive dysphasia—where understanding of language is affected. Patients may vocalise, but understanding what others are saying may be lost.
* Dysarthria
—where there is difficulty with the physical formation of words, and speech may appear slurred or harder to understand.

42
Q

dental considerations related to strokes

A
  • Understanding may be affected if they have higher cortical involvement.
  • Movement and mobility around the surgery onto and off the dental chair may be affected
  • Speech and swallowing may be impaired.
  • If a person’s swallowing is affected, they may have a feeding tube inserted into their stomach; they may not take food or drink orally.
  • Adaptions may need to be made to toothbrush handles for people with limited dexterity
  • After a stroke, people may be at a higher risk of dental diseases due to poor oral clearance and limited dexterity for oral hygiene, so prevention is critical.
  • Pouching, dry mouth and retention of medications
43
Q

what is alendronic acid used for

A
44
Q

impact of alendronic acid in the mouth

A
  • Direct trauma to oral mucosa
  • Oral ulceration
  • Pouching
45
Q

dental management of someone who has had a stroke

A
  • The risk of recurrence of a stroke is highest during the first 30days after the initial event
  • Elective and invasive dental treatment is ideally deferred to 6 months after a stroke
  • Consider stability of disease, anticoagulation regime, transfer potential
  • When carrying out dental care for a patient with dysphagia, excellent chair side oral suction is essential
  • Keeping them more upright, taking time with treatment, and allowing the person to rest when needed is important.
  • Paracetamol analgesia is preferrable
46
Q

what do older people value (OHRQoL)

A
  • Company and relationships
  • Time
  • A desire to contribute to society
  • Someone listening
  • Having good social relationships
  • Maintaining social activities and retaining a role in society
  • Having a positive psychological outlook
  • Having good health and mobility
  • To enjoy life and to retain one’s independence and control
47
Q

Health from an older persons perspective

A
  • Health declines in the last year of life
  • Older people are more likely to rate their oral and general health as bad
  • They are twice as likely to report disliking the appearance of their mouth
  • More likely to report difficulty with chewing
  • More than seven times more likely to report an impaired sense of taste
  • Increased reporting of oral pain and discomfort (not significant)
  • Less likely to utilise oral health services (not significant)
  • Oral health behaviours declined towards death due to reduced function (not significant)
48
Q

Older peoples health from medical an caring staff perspective

A
  • Lack of knowledge of oral health
  • 1 / 4 of health and caring facilities had no oral health protocols
  • 48% of those surveyed did not recognise the importance of protocols
  • Range of products were used to provide oral healthcare
  • The oral products used were often wrong
49
Q

Factors deemed important by the relatives of people receiving end of life care

A
  • Cleanliness
  • Free of pain
  • Have family present
  • Dignity maintained
50
Q

Putting it all together - for older people

A

Pain and Infection
* Immune status
* OHRQoL

Function
* Nutrition
* Communication

Social Well Being
* Communication
* Comfort
* Halitosis

51
Q

Treat or not to treat?

A

Older people’s end of life trajectory tends to be longer

Predicting how long this person is going to live is hugely challenging

If dentists know the person is in the end stages of life they conform to a more conservative approach

There is however a risk of overtreatment

67% of older people received “usual care” of which 62% died within 3 months

52
Q

major complaints of older people relating to their older health

A
  • Dry mouth
  • Ulceration
  • Infection and Pain
53
Q

impact of dry mouth

A

Speech

Nutritional function and intake

Impairs social interaction

Protective features of saliva lost

54
Q

risk factors in restoration failure rate?

A
  • Lower number of tooth brushings/day
  • Absence of prosthesis
  • Posterior location of the tooth
  • Higher baseline plaque index
55
Q

what fungal disease is prevalant in older people

A

Oral Candidosis
- immune factors
- denture hygiene

56
Q

treatments for dry mouth

A
  • electrolyte spray
  • OGT spray
57
Q

what saliva substitute should i avoid and why

A

Glandosane
- it’s acidic and can damage mucosa

58
Q

Caries treatment - Atraumatic restorative technique vs conventional restorations?

A

R.C.T. providing a 2 year survival:

ART = 85.4%
Conventional = 90.9%.

75% of participants were judged to have poor oral hygiene