2/17/2008

Gerontology

&
Physiology
h i l
including

Medical
Considerations
RoseannMulliganDDS,MS
UniversityofSouthernCalifornia
Roseann Mulligan DDS, MS

Not All Elderly are Alike!

RetirementPrograms

CategorizationoftheElderly:

Beganin1889inGermany
DesignedbyGerman
Chancellor,OttovonBismarck
agesetat70years
g
y
USAprogrambeganin1935withbenefitagesetat
65years
Duetoa1983legislativechangeSSfullbenefitage
willincreasefrom65to67yearsovera22yr
phaseinperiod

Based on age:
65 74
75 84
85 +
Any age

Young
g (or
( New)) Elderly
y
Old Elderly
Oldest Old
Frail elderly

NormalAging=PathologicAging
Theories of Aging

Random events or injuries

j
from the environment
(wear and tear)
Programmed - in our genes and unique to the species
Evolutionary natural selection process

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UnderstandingAgerelatedChangesvs
UnderstandingAge
relatedChangesvs
Pathology
Helpsusappreciate:
thevulnerabilityofolderpersonstodiseaseand
complications;
thealterationsthatmayoccurinassessmentparameters;
thealterationsthatmayoccurindiseasepresentation and
responsetotherapy;
thecapacities ofolderpersonsandthelackofsignificant
changeinmanyfunctions;
whichagingfunctionsmightbepartiallymodifiable.

ActivitiesofDailyLiving
(selfcareactivities)
(self

Theabilityto
bathe
dress(andundress)
(
)
eat
maintaincontinence
usethetoilet
transferfrombedtochairandback

10

11

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InstrumentalActivitiesofDailyLiving
(allowindependenceincommunityliving)
Careofothers(includingselectingandsupervising
caregivers)
Careofpets
Childrearing
Communicationdeviceuse
d
Communitymobility
Financialmanagement
Healthmanagementandmaintenance
Mealpreparationandcleanup
Safetyproceduresandemergencyresponses
Shopping

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ComponentsofSuccessfulAging

SystemicConditionsatHigherRisk
inanOlderPopulation
AlzheimersDiseaseandOther
Dementias
Arthritis
Cancers
CardiovascularDiseases
Diabetes
Hypertension/Stroke
Osteoporosis
SensoryProblems

Successful
Aging

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

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15

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Rate(%)ofEdentulousness
Rate(%)of
Edentulousness intheU.S.
byAgeGroups

CausesofFunctionalDeclines
May be related to

70
60

Physical health
Mental health
Cognition
Medications
Sensory deprivation
Fear and/or anxiety

50
1957
1971
1988
2005

40
30
20
10
0
65 to 74

17

>75

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OralConditionsatHigherRiskinan
OlderPatientPopulation
Caries
Periodontal Diseases
Traumatic Injuries
Cancers of the Head and
Neck
Oral Mucosal Lesions
Oral Manifestations of
Systemic Diseases

ExamplesofSomeSystemicCausesofOralConditions
inCommunityBasedElders
Osteoporosis

Tooth loss, periodontal disease

Diabetes

Periodontal disease, delayed

healing
O l cancer risk
Oral
i k and
d
periodontal disease

H off smoking
Hx
ki
Medication adverse effects

Xerostomia and salivary gland

hypofunction caries and
periodontal disease

Arthritic involvement of
hand/wrist/shoulder

Caries and periodontal disease

20

19

ComponentsofaWorkUp
ForaGeriatricPatient

BasicFindingsinGeriatric
Medicine/Dentistry

AdequateHistory
MedicationProfile
PhysicianConsultation
OtherConsultations
InterpretationofLabValues
ClinicalExam
TreatmentPlan

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PresentationofDiseasein
GeriatricPatients

Roseann Mulligan DDS, MS

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Immune
System

Individualvariabilityisgreat
Individual variability is great
Declineinphysiologicreserve
Multipleproblems
Atypicaldiseasepresentations

Roseann Mulligan DDS, MS

highprevalenceofchronicdisease
g p
frequentuseofmedications
difficultyingettingcompletehistory
consultsmaybedifficulttoobtain

23

Roseann Mulligan DDS, MS

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ImmuneSystem
Findings

ImmuneSystemChanges
MedicalImpact
incidenceofautoimmunedisease
inabilitytofightinfection
responsivenesstovaccinations
Noincreaseincirculatingantibodies

inthymic
i h i lymphaticmass
l
h i
incirculatinglymphocytes
incell mediatedimmunity
insuppressorcellfunction
ofnaturalantibodytochallenge
inautoantibody
Roseann Mulligan DDS, MS

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Roseann Mulligan DDS, MS

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EndocrineSystem

ImmuneSystemChanges
OralImpact
oralmanifestationsofautoimmunediseases
careneededtominimizetissuedamage
care needed to minimize tissue damage
useofantibioticstofightinfection
incidenceofantibioticsideeffects
incidenceofinfectionseededfromtheoral
cavity
steroidusageeffects
Roseann Mulligan DDS, MS

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Roseann Mulligan DDS, MS

EndocrineSystem
Changes

OvarianFailure
cessationofmenses

ovarianfailure

thinningofskinandmucosa
thinning of skin and mucosa

testicularfailure

changesinhairdistribution

diabetes

acceleratedboneloss

thyroiddysfunction
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arteriosclerosis
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Diabetes
OralHealthImplications

Diabetes

dentalpainandinfectionmaypredisposeto
lossofglycemic control
healingabilitiesimpaired
healing abilities impaired
minimizetissuetrauma
maximizeoralhygiene
antibioticcomplication oralandgenital
candida
easyreagentstickcheckforundiagnosedor
uncontrolleddiabetes

50%over60yearshaveabnormalglucose
tolerance test
tolerancetest
TypeII
Rateincreaseswithage
Mortalityandmorbiditysignificant
Lethargyandconfusionfrequentsigns

Roseann Mulligan DDS, MS

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Roseann Mulligan DDS, MS

DiabeticShockoftenpresents
Differently
shallowrespiration
noacetoneonbreath
markeddehydration
hypotension
oftenoccursinthosenot
knowntobediabetic
termedhyperosmolar,
hyperglycemic,nonketotic
coma

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ThyroidFunction
incidencethyroidnodules
myxedema skinandhairchanges
hypo
hypo presentation
presentation dementiaorcardiac
dementia or cardiac
failure
hyper presentation apathyratherthan
agitation
functiongenerallymaintainedintooldage

Roseann Mulligan DDS, MS

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NervousSystem
NormalAgingChanges

Nervous
System
System

Roseann Mulligan DDS, MS

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inbrainvolume
orlossofcellsincertainareas
morphologiccellularchanges
changesinhormonalneurotransmitters
synaptictransmission withage
nerveconductionvelocity
inspeedofreactiontime
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CardiovascularSystem

NervousSystem
ChangeswithDisease
brainatrophyduetoHTNoratrial fib
invisionandhearing
impairmentofsmell,taste,touchandpain
lossofsensationsmayleadtodelaysin
seekingcare
incognitiveabilities
inmotorskillsorfrankparesisorparalysis
Roseann Mulligan DDS, MS

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Roseann Mulligan DDS, MS

CardiovascularSystem

Valvular Disease

incardiacoutput
majorvalvular
j
changes
g
majorconductionproblems
differenceincoronaryarterydiseaseoutcomes
hypertensionriskgreaterinsystolicthandiastolic
heartfailure

Roseann Mulligan DDS, MS

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thickeningofvalvesubstance
calcificationofvalvetissue
mucoid degenerationofvalves
resultsincalcific aorticstenosis andmitral
valveannulus
riskforSBE

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CoronaryArteryDisease

ConductionProblems
susceptibletoalterationsinnormal
rhythm
cardiacconductivityskeletonundergoesnegative
changes
arrhythmiawithstress,caffeine,epinephrine
h th i ith t
ff i
i
hi
injections
in anticoagulantsto strokerisk
clinicalsymptoms=lightheadedness,weakness,
palpitations,syncope
treatment=implantedpacemakers
dontusemedswitharrhythmiapotential
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anginal painmaynotbepresent
only1/3presentwithclassicsubsternal pain
20%presentwith dyspnea
othercommonpresentationsare:
weakness
malaise
suddenlyworseningheartfailure
syncope
arrhythmia
confusion
MIsmaybesilent
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Hypertension

riskismorecloselyrelatedtosystolicelevation
thandiastolic
evenborderlinehypertension risk
asymptomaticcasefindingandreferralis
important
HTNdrugscancauseproblems:
HTN dr gs can ca se problems
orthostatichypotension
infarctsinmajororgans
urinaryfrequency
drymouth
anxiety,pain,certainmedscanprecipitatehigh
levelsofBP
Roseann Mulligan DDS, MS

Congestive
HeartFailure
cannotliesupine
declineinrenalfunction
moresusceptibletotoxiceffectsofdrugs
eliminatedbykidneys

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Roseann Mulligan DDS, MS

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PulmonarySystem

Pulmonary
S t
System

Roseann Mulligan DDS, MS

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lungcapacity
expiratoryvolume
coughmechanismlessefficient
oflocallyprotectiveIgA innasalandrespiratory
mucosa
inlaryngealprotectivereflex
riskofaspirationoforalsecretions
inarterial/ventilatory imbalances
inarterialO2contentwithnormalbreathing
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PulmonaryDiseases
heartdiseasemaybethecauseofrespiratory
symptomsi.e.SOB
muscleweaknessmayalsocausebreathing
problems
p
COPDcausesinclude:
emphysema
chronicbronchitis
asthmaticbronchitis
combinationsoftheabove
chroniccoughrequiresevaluation
Roseann Mulligan DDS, MS

Musculo
Musculo
skeletal
skeletal
System
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Roseann Mulligan DDS, MS

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Musculoskeletal
System

Osteoporosis

highlimitationofactivity
high limitation of activity
duetomusculoskeletal
problems:
osteoporosis
degenerativejointdisease
(osteoarthritis)
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DegenerativeJointDisease
(Osteoarthritis)

acceleratedbonelosswith
symptoms
4X>inwomen
whiteandAsians>risk
spinalcompressionfractures
spinal compression fractures
highmortalitywithhipfracture
fracturehiprepaircommonsurgeryinthe
elderly
wristfracturealsocommon
kyphosis ofspine
resorption oftheatlasandaxis
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GastrointestinalSystem

85%ofthose>65years
haveradiographicsigns
50millionhavesignificant
complaints
treatment:
aspirinorNSAIDs
heat
jointprotection
properexercise
maybeTMjointinvolvement
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Roseann Mulligan DDS, MS

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GISystemChanges
Gastrointestinal
System

MedicalImpact
achalasia
esophagealspasm
dysphagia
invitaminabsorption
absorptionofminerals
detoxification
incidencegallstones
ischemicboweldisease

atrophyofmucosathroughout
secretions
disorderedmotility
impairedabsorption
inneoplasias
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Roseann Mulligan DDS, MS

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GenitourinarySystem

GISystemChanges
OralImpact
dontgivemedicationsbeforebed
mayneedliquidmeds
dontgiveconstipatingmeds

Roseann Mulligan DDS, MS

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Roseann Mulligan DDS, MS

GUSystemChanges

GenitourinarySystem
inrenalbloodflow
intubularmass
GFR
kidneymass
kidney mass
slowingofpHmetabolicadjustment
changesinfunctionfrequentlyproducedasa
resultofdysfunctioninotherbodysystemsi.e.CHF

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GenitourinarySystem

MedicalImpact
asymptomaticpyelonephritis
resistanturinarytractinfections(UTIs)
associated with:
associatedwith:
prostatichypertrophy(male)
prostaticcancer(male)
cystocele (female)
useofacatheter
generalizedsepsis
Roseann Mulligan DDS, MS

impairedexcretionofmeds
tendencytodehydrationbecauseofreduced
intake
stressincontinence
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Dental Management 1
Appointment Considerations

OralImplications

Roseann Mulligan DDS, MS

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*for cardiac patients

-short appointment length
-morning appointments
*for arthritis patients
-late morning or early afternoon
-when medication is most effective
Roseann Mulligan DDS, MS

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Dental Management 2
Appointment Considerations (cont)

Positioning

*for all
-when there is the most daylight
-discourage driving at dusk
- may need
d tto schedule
h d l around
d ffamily
il

*for patients with Dowagers hump, kyphosis, or

cervical arthritis:
-provide
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

*longer appointments
- may be ok if patients health is up to it
anxiety/stress kept to a minimum

Roseann Mulligan DDS, MS

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Roseann Mulligan DDS, MS

Dental Management 3
Adequate Oxygenation

Positioning (cont)

* COPD, and SOB conditions

deliver O2 via nasal cannula 2 l/min minimum
maintain mixture of room air as well
modifyy or eliminate rubber dam

*for CHF, COPD, and SOB conditions

no supine positions
* for all
do not treat in a head down position
allow recovery from a supine position before
letting patient stand-up

Roseann Mulligan DDS, MS

*for all
encourage behavioral changes i.e. smoking cessation,
losing weight
do not cause hypoxia
be mindful of positioning of head, neck, and torso
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Dental Management 4

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Dental Management 5

Suctioning

Bacteremia Prevention

*post-stroke or other conditions resulting in dysphagia

- assess gag reflex
- meticulous suctioning
- all procedures done with high volume suction
- presence of saliva ejector
- protect the airway
- position patient to minimize flow of fluids into throat
*for all
compromised laryngeal reflex
- diminished cough strength
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*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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Dental
Management 6

Dental Management 7
Muscle fatigue
*for all
may require mouth props
may require rest periods

Tissue
Ti
care
*for all
- loss of elasticity thin and fragile
- mucosa as well as skin
tears easily
- easily traumatized
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Roseann Mulligan DDS, MS

Dental Management 8

DentalManagement9

Anxiety reduction

*for all competent

-may be a conditioned reflex
-loss of teeth has psychological implications
-simple
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
Roseann Mulligan DDS, MS

Forincompetentelderly
Familydefinitelyneeds
to be involved
tobeinvolved
Buildrapportthrough
bodylanguage,gentle
voiceandtouch

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Dental Management 11

Dental Management 10

Drug Effects and Interactions

Physician Consultation

- life of drugs is increased

-dose reduction may be needed
- 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

-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

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DentalManagement13
DentalManagement12

TreatmentPrinciplesinorderofpriority:

Compromisesmaybeneededbecauseof:
p
y
Advancedpathology
Medicalconditions
Psychologicalorpsychiatricconcerns

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Eliminatepain
p
Eliminateinfection
Restorefunctionwhenpossible
Restoreestheticsifrequested

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