Geddis-Regan A, Walton G. A guide to treatment planning in complex older adults. Br Dent J. 2018; 200:395-399
Wanyonyi KL, White S, Gallagher J. Conscious sedation: is this provision equitable? Analysis of sedation services provided within primary dental care in England, 2012–2014. BDJ Open. 2016; 2
Sury M R, Palmer J H, Cook T M The state of UK dental anaesthesia: results from the NAP5 Activity Survey. A national survey by the 5th national audit project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland. SAAD Dig. 2016; 32:34-36
Coulthard P, Bridgman CN, Gough L Estimating the need for dental sedation. 1. The Indicator of Sedation Need (IOSN) – a novel assessment tool. Br Dent J. 2011; 215
Smith T A, Heaton LJ. Fear of dental care. Are we making any progress?. J Am Dent Assoc. 2003; 134:(8)1101-1108
Folland L, Brown E, Boyle C. A Review of the use of flumazenil for the reversal of midazolam conscious sedation in dentistry. SAAD Dig. 2017; 33:13-17
Humphris GM, Dyer TA, Robinson PG. The modified dental anxiety scale: UK general public population norms in 2008 with further psychometrics and effects of age. BMC Oral Health. 2009; 20 https://doi.org/10.1186/1472-6831-9-20
Stroml C, Rasmussen S. Challenges in anaesthesia for elderly. Singapore Dent J. 2014; 35:23-29
NICE. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. CG64. 2016. http://www.nice.org.uk/guidance/cg64 (accessed January 2021)
Ludeña JA, Bellas JJA, Rementeria RA Assessment of awake i-gel insertion for fiberoptic-guided intubation in patients with predicted difficult airway: a prospective, observational study. J Anaesthesiol Clin Pharmacol. 2018; 34:490-495
Fox PC, Busch KA, Baum BJ. Subjective reports of xerostomia and objective measures of salivary gland performance. J Am Dent Assoc. 1987; 115:581-584
Galeotti A, Bernardin A G, D'Antò V Inhalation conscious sedation with nitrous oxide and oxygen as alternative to general anesthesia in precooperative, fearful, and disabled pediatric dental patients: a large survey on 688 working sessions. Biomed Res Int. 2016; 2016
Harbuzz D K, O'Halloran M. Techniques to administer oral, inhalational, and IV sedation in dentistry. Australas Med J. 2016; 9:25-32
Chauhan M, Carter E, Rood P. Intravenous midazolam doses ranges in older patients sedated for oral surgery – a preliminary retrospective cohort study. Br Dent J. 2014; 216
Byrne M F, Chiba N, Singh H Propofol use for sedation during endoscopy in adults: a Canadian Association of Gastroenterology position statement. Can J Gastroenterol. 2008; 22:457-459
Kramer K J, Ganzberg S, Prior S, Rashid RG. Comparison of propofol-remifentanil versus propofol-ketamine deep sedation for third molar surgery. Anesth Prog. 2012; 59:107-117
Lim MAWT, Borromeo GL. The use of general anesthesia to facilitate dental treatment in adult patients with special needs. J Dent Anesth Pain Med. 2017; 17:91-103
Hong B, Baker A. General anaesthetic service for adult dental extractions: an ‘a la carte menu’? Survey results. Br Dent J. 2017; 222:261-267
Wandel C, Böcker R, Böhrer H Midazolam is metabolized by at least three different cytochrome P450 enzymes. Br J Anaesth. 1994; 73:658-661
Craig D C, Boyle C. Practical Conscious Sedation, 2nd edn. London: Quintessence; 2017
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. The increasing complexity of dental treatment that older people require will create challenges for those who provide care for this population, including dental treatment under sedation or general anaesthesia. This article discusses the medical, dental and social considerations that need to be taken into account when planning dental care for older patients under sedation or general anaesthesia.
CPD/Clinical Relevance: Dentists who provide sedation must be able to appropriately assess and manage their older patients safely if considering this method of pain and anxiety control for dental treatment.
Article
The population of the United Kingdom is ageing, with over a quarter of people predicted to be over 65 by 2040. This will create challenges for our health system, including dentistry, where people are retaining their teeth for longer. Since 1978, the proportion of edentulousness has reduced from 28% of the population to 6%, with increasing numbers of patients retaining a complex dentition into old age, which could include crowns, bridgework or dental implants.1
Demand for dental sedation and general anaesthesia is currently high, with the NHS commissioning just over 136,000 courses of treatment in primary dental care involving the use of conscious sedation across England.2 In UK hospitals, general anaesthetia for dental treatment has been ranked the eighth most common reason for a general anaesthetic (111,600 caseload in 2013), with 1.5% being provided in patients aged over 65 years and which is sure to increase.3 Quantifying activity in the private sector is more challenging as a recent report from Northern Ireland suggests that just over half of sedation services provided there were in the private sector.3 The demand for sedation and general anaesthesia may increase as patients who may require complex dentistry, such as dental implants, may choose these modalities of treatment.
The reality is that dentists are treating older patients with more complex needs, which can be challenging for the clinical team. Dental services that offer sedation or general anaesthetic need to take into account several considerations in order to provide safe peri-operative care. While some older patients have complex needs where treatment in a secondary care setting is more appropriate, many patients are living well into older age and can be treated in primary care. This article discusses the management of older patients in relation to sedation and general anaesthesia.
Background
With people retaining their teeth for longer, more complex dentistry may be required later on in a person's life in comparison to the removable prosthetics of past generations. This can involve invasive surgical interventions. These procedures could be difficult for anxious patients to cope with and adjunctive behavioural or pharmacological methods of managing their anxiety might therefore be useful, such as the use of sedation. Quantifying this need can be challenging. Different measures have been developed, such as the Indication of Sedation Need (IOSN) and 5.1–6.7% of patients attending general dental practices have a high need for conscious sedation.4
Dental phobia levels have remained stable over the past few decades,5 despite changes in the types of treatment available for patients. Younger patients are currently four times as likely to have a dental anxiety compared to a population of 60-year olds surveyed in 2009. These people are likely to carry their anxiety through to old age and therefore require pharmacological management of their dental anxiety.7
While we can sometimes manage dental anxiety through behavioural management techniques, such as tell-show-do or taking time to build trust with patients, in some cases sedation or general anaesthetic is the only way a patient can manage dental treatment. Table 1 describes the possible indications for sedation or general anaesthetic.
Dental anxiety and phobia
A need for prolonged or traumatic dental procedures
Medical conditions potentially aggravated by stress
Medical or behavioural conditions affecting the patient's ability to cooperate
Special care requirements
Pre-operative assessment
Medical considerations
Ageing is a physiological process where the structure and capacity of bodily organs degenerates over time. This process is complex and can be influenced by a number of factors such as lifestyle, environment and genetics. Patients who are older have a high prevalence of medical conditions, often more than one, such as diabetes, cardiovascular disease, kidney impairment and dementia, which are described as comorbidities. The prevalence of comorbidities is significant in the older population, affecting 64.9% of those aged 65–84 and 81% of those aged 85 and above in the UK.1
Cardiovascular disease
Older patients can suffer from cardiovascular disease, such as ischaemic heart disease, valvular heart disease, postural hypotension, heart failure and arrhythmias. Those conditions with particular significance when planning dental treatment under sedation or general anaesthetic include postponing elective intervention after a myocardial infarction until seeking advice from the patient's cardiology team. Careful planning with the patient's cardiologist may be required as well as consideration of whether it is safe to consider treatment outside a hospital setting.8
Another factor to take into consideration is the risk of infective endocarditis in those who have valve repairs or prosthetic heart valves. Antibiotics may be indicated prophylatically to reduce this risk and again, liaison with the patient's cardiologist is required. Management of these patients therefore, would be more practical and safer in secondary care.9
Despite these issues, sedation can be considered appropriate as stress management, therefore reducing the risk of cardiovascular stress; however, patients should be assessed on a case-by-case basis and, if there are high risks associated with sedation, a consultant in Special Care Dentistry should be sought.8 If a general anaesthetic is required, additional pre-operative tests might be indicated, for example an electrocardiogram (ECG) or echocardiogram.8
Clotting ability
In older patients, haemostasis could be impaired as a result of medications such as antiplatelet or anticoagulant drugs, but also in liver impairment. A patient's clotting ability should be investigated in these patients prior to treatment to ensure adequate haemostasis is achieved.10
Respiratory disease
Careful planning should be taken for those who suffer from chronic and severe respiratory diseases such as asthma or chronic obstructive pulmonary disease (COPD), especially in the case of IV sedation where midazolam is a respiratory depressant. An alternative modality should be considered in those with severe COPD, and if entirely necessary, additional precautions should be taken, described later.
It has been suggested that inhalation sedation is also not suitable for patients with severe COPD due to reducing a patient's hypoxaemic drive. However, if the principles of moderate sedation are followed, the patient can always be instructed to breathe more deeply.11
Cognitive disorders and capacity to consent
Dementia affects 850,000 people in the UK and is expected to increase to affect 1 million by 2025.1 Patients who are living with dementia, therefore, may present for dental care, often with advanced stages of dental disease.
The dental team could not only be faced with a substantial amount of dental treatment to carry out, but also with a patient for whom communication and co-operation are difficult and who does not have the capacity to consent for themselves. Capacity may fluctuate, which can make a mental capacity assessment difficult. The Mental Capacity Act (2005), or applicable legislation in the devolved nations of the UK, provides a framework for determining whether a patient has capacity to consent for particular healthcare decisions.
When treating patients with advanced dementia under sedation or general anaesthetic, clinicians must be able to assess whether the invasive treatment provided outweighs the risks of not providing treatment for the patient. In some cases, a best interests decision, with input from family members or an individual with a lasting power of attorney (if appointed), is advised. If there are no family members or there is a disagreement, an independent mental capacity advocate could also be consulted.1
Dementia is variable and progressive, so it should not be assumed that a patient showing signs of cognitive impairment automatically lacks capacity. Instead, practitioners can take steps to help the patient understand treatments, make decisions and communicate them to the dentist.
Dentists can do this is by using easy-to-understand language that avoids jargon. Information should be delivered verbally as well as in writing, because it has been shown that low literacy rates are more common in older people13 who might not be able to read consent forms or instruction leaflets. Patients might respond better to their regular dentist than to strangers and, therefore, be more likely to have capacity.
Capacity should be confirmed at the beginning of every session and information may need to be reiterated because the patient is likely to forget details between appointments. It would be sensible to book longer appointments so fewer sessions are needed, and treatment can be completed while the patient has capacity.
Polypharmacy and drug interactions
As a result of multiple long-term conditions in older patients, an increasing number of patients experience polypharmacy, with 44% of patients over 65 taking five or more medications, and 12% taking 10 or more medications, rising to over 24% in those aged 80 or over.1
Polypharmacy can have an impact on both dental health and on the delivery of care. Medicines, such as bisphosphonates and anticoagulant or antiplatelet drugs, can impact on the safety and suitability of the provision of dental treatment.1
Do not attempt resuscitation
‘Do not attempt resuscitation’ (DNAR) can be in place, for example, when someone is coming to the end of their life as a result of an advanced illness, or in cases where receiving CPR would deprive them of dignity during the very last moments of their life.14
It is recommended for patients where there is a DNAR in place, the dental team is aware of the arrangement, it is discussed with the patient and their carers and it is recorded. Patients should be treated in a secondary care setting with sedation techniques to avoid the mortality risks associated with a general anaesthetic and, if there is a medical emergency, the usual management applied, ie management of sedation complications and basic life support until a crash team is called who can confirm the cardiac arrest and subsequent DNAR.14
Airway assessment
Assessment of a patient's airway prior to sedation or general anaesthesia is important as sedation causes not only respiratory depression, but muscle relaxation that can occlude the airway. There are several methods of assessing an airway of a patient, for example the Mallampati or LEMON scales. A compromised airway can lead to hypoxia and the need for an airway adjunct that, if complex, may be challenging for the sedationist or anaesthetist.15
In older patients, a person's neck extension may be compromised, for example with ankylosing spondylitis, or osteoporotic fractures, which may complicate airway management. If an airway is compromised, this may require the patient to be managed in secondary care where appropriately trained staff and other equipment are available.16
Diabetes
Diabetes incidence has doubled in the past 20 years, with 4.7 million people in the UK diagnosed with diabetes in 2018.17
While patients with stable diabetes usually do not require special adjustments from the dental and anaesthetic team, those with poor glycaemic control could have damage to other organs and further formal assessment for cardiovascular and renal status might be indicated.8 Pre- and peri-operative glucose monitoring may be advised, and timings of appointments could be significant especially if the patient is required to starve prior to their dental treatment. Care should be taken to avoid disruption to a patient's eating and insulin regimen, for example, avoiding appointments close to lunchtime.
Social considerations
Escorts
An appropriate escort should accompany and look after the patient following their dental treatment under sedation or general anaesthesia. According to guidelines,18 an escorts must be able to do this and not have any other dependants during the period of recovery. For older patients, this could mean bringing an escort who is not appropriate: for example a partner with dementia or who has physical disabilities. If the escort is a carer from a residential or care home, attention must be taken to ensure all carers who look after the patient have had appropriate instructions regarding aftercare and to ensure adequate hydration and nutrition and to monitor for complications.
The dental team should also be aware of those who live at home alone and unsupported and take this into consideration when planning their care, such as planning for an overnight stay in hospital, or a prolonged recovery period so that the patient can be monitored as they may be at higher risks of falls.
Where do we treat these patients?
When deciding where to treat older patients under sedation, the dentist needs to consider the above medical issues in determining their American Society of Anestheologists (ASA) grade. For many, a person's chronological age does not necessarily match with their physiological age. This can be influenced by many factors such as genetics, lifestyle and environment. A patient over 65 may have the physiological age of a person much younger, with an ASA grade of 1 or 2, that is a healthy person or one with mild systemic disease, such as controlled hypertension or diabetes. These patients can be treated in primary care.
For older patients with additional complex needs, it could be more appropriate for them to be seen by Special Care Dentistry clinics either in community-based dentistry or in hospital settings. Medical considerations, as discussed above, influence the setting in which an older patient is seen, but there are other factors, such as social and commissioning arrangements that are also important.
Commissioning and the NHS
Within the NHS, sedation is commissioned in primary and secondary care. Since 2017, primary care services should be commissioned following NHS England's commissioning guidance within primary care.19 These standards commission any sedation technique listed in the guidelines18 and, therefore, many older patients will have access to sedation services in primary care. In 2012–2013, there were 136,618 courses of NHS care involving sedation in England and 136,263 in 2013–2014. This represented care for 120,035 and 120,468 patients, but only 2.19% and 3.2%, respectively, were provided in patients aged over 65 years.2
Locally agreed referral criteria based on commissioning guidance and national service specifications will inform whether older patients can access sedation within primary care; however, with increasing comorbidities and other factors, many older patients may require referral onto secondary services for consultant-led care, or treatment in an acute trust where there are appropriate staff and facilities to manage possible complications. Dentists and commissioners need to engage to form clearly defined patient-centred care pathways facilitated by managed clinical networks.19 There are examples across the country where membership of the Special Care Dentistry managed clinical network includes representatives from primary care sedation practices as well as hospital and community dental services19
While commissioning guidance is in place, equitable access to all treatment settings may not be in place where there are shortfalls in historical commissioning or geographical discrepancies – for example, whether there is access to a dental teaching hospital. Therefore, not all modalities of treatment may be available.
The dental workforce and skill mix
The Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) guidelines came into force in 2015 and set out the national standards for sedation in dental care across the UK.18 Recently, Level 2 accreditation guidance for commissioners and providers has laid out the process for recognizing advanced skills in sedation and is likely to inform the structure of sedation within primary care, particularly for community dental services and has implications for who can provide treatment.20
Inhalation sedation can not only be provided by a dentist, but it is also within the scope of practice of appropriately trained dental therapists (on prescription from a dentist). Over time, this could increase the availability of this modality of treatment, not only within community and hospital dental services, but also within general practice.21
Domiciliary care
With an increasingly older population, domiciliary dentistry remains an important option for some patients. More people are becoming house bound and accessing care at home.1 It has been shown that dementia patients tend to require domiciliary dental care and are generally more at ease in familiar environments,22 so it needs to be considered whether there a place for sedation in a domiciliary setting, otherwise appropriate transport into clinics will need to be available.
Access
As people age, they can develop mobility limitations and physical disabilities. Frailty is an increasing problem among the older population – current prevalence is 14% and is defined as ‘a dynamic state affecting an individual who experiences losses in one or more domains of human functioning (physical, psychological, social), which is caused by the influence of a range of variables and which increases the risk of adverse outcome’.1 This in itself can be a barrier to accessing dentistry through transport issues, or even that the dental surgery is on the first floor with no lift. Patients may be wheelchair users, which can make accessing the mouth for dental treatment difficult. Few surgeries are equipped with wheelchair tippers or hoists, the majority of these being in the community dental services.
To overcome these barriers, patients could be referred to services that have the appropriate equipment and premises to see these patients, or alternatively be sedated in their wheelchairs, especially if these chairs have additional functions that allow the reclination of the headrest. As discussed above, if transport arrangements need to be put in place, appropriate support may be required, for example, a wheelchair-accessible ambulance or stretcher transfer.
Choice of sedation
Sedation choice should be patient-centred, taking the views of the patient into account where they can communicate them, or on relatives/carers who can advocate on their behalf.
Nitrous oxide (inhalation sedation) is a colourless and virtually odourless gas that can act as an effective analgesic and anxiolytic agent with little effect on the respiratory system.23 Inhalation sedation is a very safe method of sedation, but may not be possible in patients with limited co-operation or physical disabilities where a good seal for the inhalation mask is not possible. Inhalation sedation is appropriate for a larger proportion of adults with comorbidities, yet may be insufficient to provide anxiolysis for more complex treatment, such as implant placement.
The majority of intravenous sedation in dental settings is with midazolam. Midazolam is water-soluble, and because older patients have a decreased total body water content, this could result in a relatively higher dose being administered.8 Older patients also have reduced cardiac output, resulting in decreased hepatic and renal perfusion, leading to slower removal of the drug from the body. A lower initial and total dose is likely to be used.24 As a benzodiazepine, older people are also often sensitive to midazolam. Its elimination half-life has also been found to be significantly prolonged and total clearance of the drug significantly reduced in older males compared to young males, though no significant difference was found in females.25
Advanced sedation techniques
For management of the complex older patient under sedation, advanced techniques could be considered. These could be anaesthetist-led or administered by an appropriately trained sedationist. This will allow the dental team to focus on the treatment and have a dedicated team monitoring the patient.
Advanced sedation can also allow for other drugs to be used instead, or as well as midazolam, such as propofol, fentanyl and ketamine. This may then avoid a general anaesthetic in patients who are at a higher risk of complications, but decreases the margin of safety compared to midazolam-only sedation. For these other drugs, the difference between the doses needed to cause a general anaesthetic compared to sedation dose is much smaller than that for midazolam, hence why additional training is required.
Many of these other drugs have advantages over midazolam. Propofol has the advantage of quicker onset of action and a shorter recovery time. These advantages could prove useful in the older population as it would shorten their overall visit and they can be discharged home quicker. Propofol can also be given by targeted continuous infusion (TCI), which can mean a more lengthy sedation period if needed, but also a targeted amount of drug is titrated, which is calculated from the patient's age, weight and gender.26,27
Ketamine has the advantage of not causing significant depression of the respiratory drive and produces significant bronchodilation secondary to sympathetic stimulation. While ketamine does not prevent obstruction and airway compromise in an unconscious patient, airway reflexes tend to be better preserved than with other induction agents and so it may more suitable for patients with respiratory conditions.27
Often, these drugs are not used in isolation, but can be combined to achieve the desired effect. This can reduce the dose of midazolam given overall, reduce recovery time and can be useful in analgesia, for example if fentanyl is used.27 These advantages need to be weighed against the risks associated with advanced techniques, and the increased cost of multiple drug sedation.
General anaesthesia
For some patients, general anaesthesia is the only option for their dental treatment, but there are associated risks. Dental treatment provided via this modality should be limited to options that are definitive and predictable, namely scaling, extractions or simple restorations, in order to avoid repeat general anaesthetics. Decision-making requires a careful balance of risks and benefits, with a comprehensive consent process or suitable best interests decision for those unable to consent, as already mentioned.28
Patients who are very frail or have multiple comorbidities can have long-lasting symptoms following a general anaesthetic, which can include cognitive dysfunction, even months after surgery.29 Careful planning is required by the anaesthetic team, which could include pre-operative tests such as ECG, bloods, input from an anaesthetist skilled in the management of geriatrics, or planning for an overnight stay as an inpatient.
A summary of the advantages and disadvantages of each treatment modality can be found in Table 2.
Treatment modality
Advantages in the older patient
Disadvantages in the older patient
Inhalation sedation
Reversible in the surgery
No escort required
Anxiolytic
Can be performed by appropriately trained dental therapists
May not provide sufficient anxiolysis for more complex treatments
Requires sufficient cooperation throughout procedure, which may not be possible with adults with dementia or cognitive impairment
Patient positioning or patient physical disability may not allow adequate placement of nasal hood
May be inequity of access to appropriately trained clinicians
Intravenous sedation
Can provide adequate anxiolysis for complex treatment
Provides muscle relaxation, which can facilitate access to the mouth
Can reduce stress and therefore reduce the risk of cardiovascular stress
Older patients likely to be more sensitive to drugs, so reduce dose and titrate slowly
Causes respiratory depression, especially in those with respiratory disease
Requires an appropriate escort
Theoretical risk of POD
May be inequity of access to appropriately trained clinicians
Advanced sedation techniques
Allows for continuous monitoring by another medical professional (sedationist or anaesthetist)
Allows for clinical team to focus on treatment provided
Prolonged recovery arrangements often in place
Allows for multi-drug sedation, if required, or other special measures, eg IV fluids
Can plan for longer treatments if infusions are given, eg implants, root canal treatment
Recovery with other drugs, eg propofol, can be quicker
Theoretical risk of POD
May be inequity of access due to commissioning arrangements
May incur higher costs for patients if visiting sedation services are employed or multiple drugs administered
Staff require additional training
Additional equipment and storage cost of drugs
General anaesthesia
Allows for complete co-operation and ability for clinician to render patient dentally fit in one visit
Can plan for additional non-dental procedures alongside dental treatment
Highest risk of POD
Higher risk of anaesthetic-related complications
Patient may require admittance overnight for monitoring and recovery
Dental treatment provided is often more extraction-based to reduce need for a repeat general anaesthesia
Post-operative care
Drug doses and titration
Many drugs used in sedation and general anaesthesia, such as midazolam, are metabolized in the kidney or liver.30 In patients with reduced liver or kidney function, care must be taken when administering these drugs. It is recommended that overall doses are reduced and the amounts of drug are titrated slowly. Similarly, for those with respiratory disease, slow titration can allow for careful monitoring of respiratory effort. There is evidence that in older patients lower doses are required – a significant relationship between the dose of midazolam required using titration and the age of the patient has been found. In 800 patients, only 7.2% of those aged over 70 years required more than 5 mg of midazolam, compared to 83% of patients below the age of 70 years.25Table 3 gives a protocol for when sedating patients over 65 years old with midazolam.
Maximum of 2 mg to be drawn up at any one time
Maximum dose of 2 mg (although occasionally exceeding this may be appropriate)
Single bolus dose should not be administered
Initial dose to be administered is 1 mg over 30 seconds, then pause for 4 minutes before continuing with 0.5 mg increments every 2 minutes if required
Oxygen
It is standard practice to monitor a patient's oxygen saturation when providing IV sedation in order to prevent hypoxia.
Supplemental oxygen should be considered in patients who have respiratory disease or those with low baseline saturation readings. For those trained in the use of capnography, this can be employed to ensure the patient does not become hypoxic, and it is recommended by the Association of Anaesthetists of Great Britain that capnography, i.e. the monitoring of carbon dioxide levels in the blood, is employed in all cases of moderate to deep sedation.28
Positioning of patients with respiratory disease should also be taken into account as they can become obstructed easily, which may be exacerbated by placing them in supine positions. Head positioning should also allow for an open airway, such as a head-tilt chin-lift.
Clinical holding
Clinical holding is defined as ‘the use of physical holds to assist or support a patient to receive clinical dental care or treatment in situations where their behaviour may limit the ability of the dental team to effectively deliver treatment, or where patients' behaviour may present a safety risk to themselves, members of the dental team or other accompanying person’.31 For some older patients, its use may need to be discussed with patients and their carers to help facilitate treatment, for example, for those who may have involuntary movement such as a tremor. If clinical holding is required, staff must have appropriate training and its use be fully documented.
Peri-operative care
Sedation recovery
In older patients, recovery following conscious sedation can be prolonged because they find achieving stability more difficult. This needs to be assessed carefully before discharge since a fall in this group of patients can be significant.8 In some cases, the use of flumazenil may be appropriate to reverse the effects of sedation in order to transport the patient safely home.7
Post-operative complications
Older patients can have an increased sensitivity to drugs that dentists either prescribe or recommend post-operatively, such as analgesics. Reduction in doses for some drugs is recommended, especially if the older patient is of a low weight.7 Dentists should be vigilant when prescribing non-steroidal anti-inflammatory drugs (NSAIDs) because they can cause gastric bleeding.31
Some post-operative complications can be more common in the older patient. Bleeding following dental extractions, for example, can be at high risk of occurrence due to anticoagulants or antiplatelet medication, and therefore local haemostatic measures may be necessary. Post-operative infection can also be a problem owing to a weaker immune system and impaired healing as the patient ages or because of comorbidities or immunosuppressing medication, such as methotrexate. Patients should be consented for these risks prior to treatment, advice given on how to manage them and, if appropriate, be followed-up after treatment.
Post-operative delirium
It has been recognized that there is a significant risk in the older population of post-operative delirium (POD) developing following an operation, and it has been proposed that anaesthetics could induce cognitive alterations.32,33
POD is common, with 15% of older patients experiencing the condition after elective procedures, although this rate is higher among emergency interventions at 30–70%. POD can be responsible for the significant increase in both morbidity and mortality.34 Symptoms of POD include an initial disturbance in consciousness, such as reduced clarity of awareness, reduced ability to focus or sustain attention, or reduced awareness of their surrounding environment. It can also be accompanied by cognitive changes such as memory deficit, disorientation, language disturbances and visual hallucinations. Hypoactive forms of POD may be underdiagnosed as they could be attributed to a patient's dementia, but clinicians should be vigilant in cases of psychomotoric inhibition in older patients, because those who develop a hypoactive form of POD seem to have a relatively increased mortality.34
The aetiology of POD is not fully understood, but there are several predisposing risk factors, which include advanced age, pre-operative cognitive impairment (eg dementia), pre-existing medical disease and genetic factors.34
Incidence of POD within dentistry has been poorly reported, but there have been instances where POD has developed following lengthy dental procedures.33 There have been no reported incidences of POD following dental sedation, but theoretically there is a still a risk POD may develop following sedation. This risk needs to be taken into consideration when planning dental interventions in older patients.
Conclusion
Sedation and general anaesthesia are commonly used methods to control pain and anxiety. Medical, social and dental considerations need to be taken into account when choosing sedation or general anaesthesia technique and setting in which to be treated. Some older patients who are fit and well (ASA 1 or 2) can be seen in general practice with some adjustments, such as reduction in drug doses, or additional monitoring throughout the procedure. In some cases, due to risks such as complex medical or social needs, advanced sedation or general anaesthesia in a secondary care environment may be the safest option.
