geriatri

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Gerontology

&

h i lPhysiology including Medical

ConsiderationsRoseann Mulligan DDS, MSUniversity of Southern California

•

Roseann Mulligan DDS, MS 2

Retirement Programs

‐ Began in 1889 in Germany‐ Designed by GermanChancellor, Otto von Bismarck‐ age set at 70 years

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g y

‐ USA program began in 1935 with benefit age set at 65 years

‐ Due to a 1983 legislative change SS full benefit age will increase from 65 to 67 years over a 22 yr phase in period

Categorization of the Elderly:Categorization of the Elderly:

Based on age:• 65 – 74 Young (or New) Elderly

Not All Elderly are Alike!

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g ( ) y• 75 – 84 Old Elderly• 85 + Oldest Old• Any age Frail elderly

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Normal Aging = Pathologic AgingNormal Aging = Pathologic AgingTheories of Aging

Random – events or injuries from the environment

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j(“wear and tear”)

Programmed - in our genes and unique to the speciesEvolutionary – natural selection process

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Understanding AgeUnderstanding Age‐‐related Changes related Changes vsvsPathologyPathology

Helps us appreciate:

• the vulnerability of older persons to disease and complications;

• the alterations that may occur in assessment parameters;

• the alterations that may occur in disease presentation and response to therapy;

• the capacities of older persons and the lack of significant change in many functions;

• which aging functions might be partially modifiable.

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Activities of Daily LivinActivities of Daily Livingg(self(self‐‐care activities)care activities)

The ability to

• bathe

• dress (and undress) ( )

• eat

• maintain continence

• use the toilet

• transfer from bed to chair and back

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Instrumental Activities of Daily LivingInstrumental Activities of Daily Living(allow independence in community living) (allow independence in community living)

• Care of others (including selecting and supervising caregivers)

• Care of pets • Child rearing

d• Communication device use • Community mobility • Financial management • Health management and maintenance • Meal preparation and cleanup • Safety procedures and emergency responses • Shopping

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Components of Successful AgingComponents of Successful Aging

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Successful Aging

Adapted from: Rowe JW and Kahn RL, Successful Aging: The MacArthur Foundation Study, 1998.

Systemic Conditions at Higher Risk in an Older Population

• Alzheimer’s Disease and Other Dementias

• Arthritis

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Arthritis• Cancers• Cardiovascular Diseases• Diabetes• Hypertension/ Stroke• Osteoporosis• Sensory Problems

Causes of Functional Declines

• May be related to– Physical health– Mental health

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– Cognition– Medications– Sensory deprivation– Fear and/or anxiety

Rate (%) of Rate (%) of EdentulousnessEdentulousness in the U.S. in the U.S. by Age Groupsby Age Groups

50

60

70

1957

18

0

10

20

30

40

65 to 74 >75

1957197119882005

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Oral Conditions at Higher Risk in an Oral Conditions at Higher Risk in an Older Patient PopulationOlder Patient Population

• Caries• Periodontal Diseases• Traumatic Injuries

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• Traumatic Injuries• Cancers of the Head and

Neck• Oral Mucosal Lesions• Oral Manifestations of

Systemic Diseases

Examples of Some Systemic Causes of Oral Conditions Examples of Some Systemic Causes of Oral Conditions in Community Based Eldersin Community Based Elders

Osteoporosis Tooth loss, periodontal disease

Diabetes Periodontal disease, delayed healing

H f ki O l i k d

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Hx of smoking Oral cancer risk and periodontal disease

Medication adverse effects Xerostomia and salivary gland hypofunction – caries and periodontal disease

Arthritic involvement of hand/wrist/shoulder

Caries and periodontal disease

Components of a Work‐UpFor a Geriatric Patient

•Adequate History•Medication Profile

•Physician Consultation •Other Consultations

•Interpretation of Lab Values•Clinical Exam

•Treatment Plan


Basic Findings in Geriatric Medicine/Dentistry

• high prevalence of chronic disease


g p• frequent use of medications

• difficulty in getting complete history • consults may be difficult to obtain

Presentation of Disease inPresentation of Disease inGeriatric Patients Geriatric Patients

• Individual variability is great


Individual variability is great• Decline in physiologic reserve•Multiple problems • Atypical disease presentations

Immune Immune SystemSystem


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Immune SystemFindings

↓ i h i l h i


↓ in thymic lymphatic mass↓ in circulating lymphocytes↓ in cell‐mediated immunity↓ in suppressor cell function

↓ of natural antibody to challenge↑ in autoantibody

Immune System Changes –Medical Impact

↑ incidence of autoimmune disease


↓ in ability to fight infection↓ responsiveness to vaccinations

No increase in circulating antibodies

Immune System Changes

Oral Impact↑ oral manifestations of autoimmune diseases↑ care needed to minimize tissue damage


↑ care needed to minimize tissue damage↑ use of antibiotics to fight infection↑ incidence of antibiotic side‐effects

↑ incidence of infection seeded from the oral cavity

↑steroid usage effects

Endocrine SystemEndocrine System


Endocrine System Endocrine System ChangesChanges

• ovarian failure


• testicular failure

• diabetes

• thyroid dysfunction

Ovarian FailureOvarian Failure

• cessation of menses

• thinning of skin and mucosa


• thinning of skin and mucosa

• changes in hair distribution

• accelerated bone loss

• arteriosclerosis

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DiabetesDiabetes• 50% over 60 years have abnormal glucose

tolerance test


tolerance test• Type II• Rate increases with age•Mortality and morbidity significant• Lethargy and confusion frequent signs

Diabetes Diabetes Oral Health ImplicationsOral Health Implications

• dental pain and infection may predispose to loss of glycemic control

• healing abilities impaired


• healing abilities impaired•minimize tissue trauma•maximize oral hygiene• antibiotic complication – oral and genital

candida• easy reagent stick check for undiagnosed or

uncontrolled diabetes

Diabetic “Shock” often presents Diabetic “Shock” often presents DifferentlyDifferently

• shallow respiration• no acetone on breath•marked dehydration • hypotension• often occurs in those not

known to be diabetic• termed hyperosmolar,

hyperglycemic, nonketotic coma


Thyroid FunctionThyroid Function

• ↑ incidence thyroid nodules•myxedema skin and hair changes

• hypo presentation→ dementia or cardiac


• hypo – presentation → dementia or cardiac failure

• hyper – presentation – apathy rather than agitation

• function generally maintained into old age

Nervous Nervous SSSystemSystem


Nervous System Nervous System Normal Aging ChangesNormal Aging Changes

• ↓ in brain volume• ↓ or loss of cells in certain areas


•morphologic cellular changes• changes in hormonal neurotransmitters

• synaptic transmission ↓with age• ↓ nerve conduction velocity • ↓ in speed of reaction time

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Nervous SystemNervous SystemChanges with DiseaseChanges with Disease

• brain atrophy due to HTN or atrial fib• ↓ in vision and hearing


• impairment of smell, taste, touch and pain• loss of sensations may lead to delays in

seeking care • ↓ in cognitive abilities

• ↓ in motor skills or frank paresis or paralysis

Cardiovascular SystemCardiovascular System


Cardiovascular SystemCardiovascular System

• ↓ in cardiac output •major valvular changes


j g•major conduction problems

• difference in coronary artery disease outcomes • hypertension risk greater in systolic than diastolic

• heart failure

ValvularValvular DiseaseDisease

• thickening of valve substance • calcification of valve tissue


•mucoid degeneration of valves • results in calcific aortic stenosis and mitral

valve annulus • ↑ risk for SBE

Conduction ProblemsConduction Problems

• susceptible to alterations in normal rhythm

• cardiac conductivity skeleton undergoes negative changes

↑ h th i ith t ff i i h i


• ↑arrhythmia with stress, caffeine, epinephrine injections

• ↑ in anticoagulants to ↓ stroke risk• ↑ clinical symptoms = lightheadedness, weakness,

palpitations, syncope• ↑ treatment = implanted pacemakers• don’t use meds with arrhythmia potential

Coronary Artery DiseaseCoronary Artery Disease

• anginal pain may not be present• only 1/3 present with classic substernal pain

• 20% present with ↑ dyspnea• other common presentations are:

‐weakness


weakness‐malaise

‐ suddenly worsening heart failure‐ syncope

‐ arrhythmia‐ confusion

•MIs may be silent

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HypertensionHypertension• risk is more closely related to systolic elevation

than diastolic• even borderline hypertension ↑ risk

• asymptomatic case finding and referral is important

HTN dr gs can ca se problems


• HTN drugs can cause problems:‐ orthostatic hypotension‐ infarcts in major organs

‐ urinary frequency‐ dry mouth

• anxiety, pain, certain meds can precipitate high levels of BP

Congestive Congestive Heart FailureHeart Failure

• cannot lie supine


• decline in renal function•more susceptible to toxic effects of drugs

eliminated by kidneys

Pulmonary Pulmonary S tS tSystemSystem


Pulmonary SystemPulmonary System

• ↓ lung capacity• ↓ expiratory volume

• cough mechanism less efficient↓


• ↓ of locally protective IgA in nasal and respiratory mucosa

• ↓ in laryngeal protective reflex• ↑ risk of aspiration of oral secretions • ↑ in arterial/ventilatory imbalances

• ↓ in arterial O2 content with normal breathing

Pulmonary DiseasesPulmonary Diseases

• heart disease may be the cause of respiratory symptoms i.e. SOB

•muscle weakness may also cause breathing problems


p• COPD causes include:

‐ emphysema‐ chronic bronchitis‐ asthmatic bronchitis

‐ combinations of the above• chronic cough requires evaluation

MusculoMusculo‐‐skeletalskeletalskeletal skeletal SystemSystem


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Musculoskeletal Musculoskeletal SystemSystem

• high limitation of activity


• high limitation of activitydue to musculoskeletal problems:

• osteoporosis • degenerative joint disease

(osteoarthritis)

OsteoporosisOsteoporosis• accelerated bone loss with

symptoms• 4 X > in women•white and Asians > risk

• spinal compression fractures


• spinal compression fractures• high mortality with hip fracture• fracture hip repair common surgery in the

elderly•wrist fracture also common• kyphosis of spine• resorption of the atlas and axis

Degenerative Joint DiseaseDegenerative Joint Disease(Osteoarthritis)(Osteoarthritis)• 85% of those > 65 yearshave radiographic signs

• 50 million have significantcomplaints


complaints• treatment:

‐ aspirin or NSAIDs‐ heat‐joint protection‐proper exercise

•may be TM joint involvement

Gastrointestinal SystemGastrointestinal System


Gastrointestinal Gastrointestinal SystemSystem


• atrophy of mucosa throughout• ↓ secretions

• disordered motility• impaired absorption

• ↑ in neoplasias

GI System Changes GI System Changes Medical Impact • achalasia

• esophageal spasm• dysphagia


• dysphagia• ↓ in vitamin absorption• ↓ absorption of minerals

• ↓ detoxification• ↑ incidence gall stones• ↑ischemic bowel disease

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GI System Changes GI System Changes

Oral Impact


• don’t give medications before bed•may need liquid meds

• don’t give constipating meds

Genitourinary SystemGenitourinary System


Genitourinary System Genitourinary System

• ↓ in renal blood flow• ↓ in tubular mass

• ↓ GFR• ↓ kidney mass


• ↓ kidney mass• slowing of pH metabolic adjustment

• changes in function frequently produced as a result of dysfunction in other body systems i.e. CHF

GU System Changes GU System Changes

Medical Impact• asymptomatic pyelonephritis

• resistant urinary tract infections (UTIs) associated with:


associated with:‐ prostatic hypertrophy (male)

‐prostatic cancer (male)‐cystocele (female)‐use of a catheter‐generalized sepsis

Genitourinary System Genitourinary System

Oral Implications


• impaired excretion of meds• tendency to dehydration because of reduced

intake• stress incontinence

Dental Management 1Dental Management 1•Appointment Considerations

*for cardiac patients


-short appointment length-morning appointments

*for arthritis patients-late morning or early afternoon

-when medication is most effective

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Appointment Considerations (con’t)

*for all-when there is the most daylight

-discourage driving at duskd t h d l d f il


- may need to schedule around family

*longer appointments- may be ok if patient’s health is up to it

anxiety/stress kept to a minimum

Dental Management 2Dental Management 2• Positioning

*for patient’s with Dowager’s hump, kyphosis, or cervical arthritis:

provide stability of neck/and/or back


-provide stability of neck/and/or back-pad the dental chair with special pillows to support or

comfort-use articulated head rests on dental chairs and

wheelchairs

Positioning (con’t)

*for CHF, COPD, and SOB conditionsno supine positions


* for alldo not treat in a head down position

allow recovery from a supine position before letting patient stand-up

Dental Management 3Adequate Oxygenation

* COPD, and SOB conditionsdeliver O2 via nasal cannula 2 l/min minimum

maintain mixture of room air as wellmodify or eliminate rubber dam


y

*for allencourage behavioral changes i.e. smoking cessation,

losing weightdo not cause hypoxia

be mindful of positioning of head, neck, and torso

Dental Management 4Dental Management 4• Suctioning

*post-stroke or other conditions resulting in dysphagia- assess gag reflex

- meticulous suctioning- all procedures done with high volume suction


- all procedures done with high volume suction- presence of saliva ejector

- protect the airway- position patient to minimize flow of fluids into throat

*for allcompromised laryngeal reflex- diminished cough strength

Dental Management 5Dental Management 5• Bacteremia Prevention

*for all-risk may be greater because of decreased immune

function


-particularly a problem if periodontal disease present

-susceptible to infective endocarditis and septic emboli

- need optimum oral hygiene-prophylactic antibiotic usage will be needed in

more patients

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DentalDentalManagement 6Management 6

Ti


• Tissue care*for all

- loss of elasticity – thin and fragile- mucosa as well as skin

tears easily- easily traumatized

Dental Management 7Dental Management 7

• Muscle fatigue*for all

may require mouth props


may require mouth propsmay require rest periods

Dental Management 8Dental Management 8•Anxiety reduction

*for all competent -may be a conditioned reflex

-loss of teeth has psychological implications simple explanations needed


-simple explanations needed-friendly rapport

-include competent elderly in decisions -give choices

-inform re: time, cost, outcome, discomfort level-family members may need to be involved


• For incompetent elderly‐ Family definitely needs to be involvedto be involved

‐ Build rapport through body language, gentle voice and touch



Physician Consultation

-often needed-to confirm and clarify medical and medication

hi t


history-polypharmacy is a risk-collaborate as a team

-be explicit concerning amount of treatment stress and level of bacteremia expected


Drug Effects and Interactions

-½ life of drugs is increased-dose reduction may be needed

- ask patient/family what has worked before


ask patient/family what has worked before and what dose

-drugs produce exaggerated effect on CNS-interactions with multiple drugs-side-effects are major problem

-escorts for patients

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• Compromises may be needed because of:


p yAdvanced pathologyMedical conditions

Psychological or psychiatric concerns


• Treatment Principles in order of priority:

• Eliminate painp

• Eliminate infection

• Restore function when possible• Restore esthetics if requested


geriatri

Documents

old elderly

age frail elderly5normalaging

delayed healingh f ki

successful aging

rowe jw

macarthur foundation

kahn rl

new elderlynot