Sedation in Older People: Dental Update Article

If anyone is subscribed to Dental Update you might have seen my latest publication about sedation and general anaesthesia in older patients...



The UK population is ageing, with over a quarter of people predicted to be over 65 by 2040. People are retaining their teeth into old age, often having experienced complex restorative dental work over the years. This increasing complexity of dental treatment that older people require will create challenges when planning dental treatment under sedation or general anaesthesia (GA). So what considerations need to be taken when safely planning care for older patients under sedation or GA?

Pre-operative assessment

  1. Medical Considerations - older people are more likely to have multi-morbidities that can affect care e.g. diabetes, or be on 
  2. Cardiovascular Disease - Ischaemic heart disease which can be exacerbated with dental anxiety, endocarditis risk
  3. Respiratory Disease - such as COPD or asthma and airway considerations
  4. Cognitive Impairment - such as dementia, capacity assessment
  5. DNAR status
  6. Polypharmacy and drug interactions such as anticoagulants/platelet drugs, bisphosphates

Setting

Depending on pre-assessment and ASA status this will inform the safest environment for the patient to have sedation. This might also be influenced by local commissioning pathways and availability of services, whilst GA can only be provided in a secondary care setting. 


Choice of Sedation/GA

The choices for sedation/GA are:
  1. Inhalation sedation with nitrous oxide
  2. Single drug sedation with midazolam (IV, Oral, Intranasal)
  3. Advanced sedation techniques using propofol or multidrug sedation
  4. General Anaesthesia
A summary of considerations for each option can be seen below. 

Click to enlarge


Peri-operative Care

  1. Titration and doses of drugs - consider reducing overall dose or slowing down titration of the drug
  2. Supplemental oxygen might be required, or use of capnography could be considered
  3. Clinical holding could be required for patients with involuntary movement 

Post-operative Care

  1. Pro-longed recovery might be required 
  2. Although for the medically complex it might be sensible to treat patients under GA as inpatients, this needs to be weighed up again the risk of Post operative Delirium (POD) in those with cognitive impairment

To access the full article online please see here


Do you have any questions about sedation and GA for older people? Please leave them in the comments below

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