Sedation Safety: Best Practices for Patients Over 65

Sedation Safety: Best Practices for Patients Over 65

 

Age is more than just a number—it's a story about a patient's health that shapes how we approach personalized care in sedation dentistry.

By Dr. Michael Silverman

 

When evaluating older patients for dental sedation, age is an important factor, but not the only consideration. Patients 65 and older often have chronic conditions like hypertension, diabetes, heart disease, vascular disorders, and hyperlipidemia, which require extra attention.

 

Additionally, reduced upper airway reflexes can increase the risk of respiratory complications during procedures. However, age alone doesn’t rule out sedation as an option. We'll explore essential data and best practices for safely sedating older patients.

 

An Aging Population

 

As the U.S. population ages, dental practices are treating more patients over 65. By 2030, nearly 20% of the population will be 65 or older, double the number from 2000 (Federal Interagency Forum on Aging-Related Statistics, 2023).

 

Interestingly, only around 5% of these adults have no teeth, and more are keeping their natural teeth compared to previous generations. However, this doesn’t mean they’re free of dental issues—around 18% have untreated cavities, and a staggering 68% suffer from gum disease (NHANES, 1999-2004; 2009-2012). This data highlights the need for dentists, particularly sedation dentists, to consider the unique challenges of treating older patients (ADA, 2023).

 

Health History is Essential

 

Patient selection is critical to a successful sedation workup. During the pre-sedation evaluation, two key questions guide the process: Is the patient a suitable candidate for sedation? And if they are, what adjustments need to be made to the standard sedation protocol? Answering these questions ensures safety and comfort, especially for older patients or those with complex medical histories. The patient's health history should alert you to any red flags, which include:

• Identify high-risk populations: Very young >13, very old >65, very sick (ASAIV).
• Identify systemic disease presence: Assess disease control and severity and the patient's appearance. How long since their last medical evaluation?
• Assess high-risk disease relative to conscious sedation: Medical consultation, ASA classification.
• Are any preoperative, intraoperative, or postoperative modifications needed? The night before and loading dose, existing medication routine, NPO status, bringing medications to the appointment, use of recreational drugs.

 

Take baseline vitals, including:

• Heart rate
• Blood pressure
• Blood oxygenation
• End-tidal carbon dioxide
• Electrocardiogram
• Blood glucose

 

 

Because the dentist monitors the EKG, they also interpret it. For patients over 60, it's crucial to ensure they've had a recent physical evaluation by their primary care physician, including blood chemistry results, within six months of their sedation appointment. This method helps minimize risks and ensure patient safety.

 

Sedation Modifications

 

Patients > 65 are more likely to have medical conditions and be on multiple medications. Meaning that as people age, their response to medication changes. Regarding sedation, this means lower doses due to:

• Less ability to metabolize.
• More likely to desaturate.
• Less alveolar gas exchange surface area.
• Less response to hypercarbia and hypoxia.

 

Aging is associated with physiological changes that affect drug metabolism, leading to an increased sensitivity to anesthetics. These changes necessitate adjustments in medication dosing and underscore the importance of meticulous monitoring during sedation.

 

Furthermore, the sedation team should:

• Discover all medications - including OTC.
• Connect all medications to medical conditions.
• Uncover potential interactions with sedation medications.
• Know the potential impact the patient's medications have on the sedation process, especially CNS and respiratory depression.

 

While it's critical to recognize that not all patients over 65 are automatically precluded from undergoing sedation dentistry, the presence of multiple co-morbidities within this age group can introduce complexities in managing dental treatments. For older adults, it's advisable to consider reducing the dosage of sedation medications by approximately half. This conservative approach aligns with the overarching objective of prioritizing patient safety.

 

When it comes to dental sedation for patients > 65, there are several key factors to consider, including:

• EKG Interpretation: Since dentists monitor the EKG, they're responsible for interpreting it, ensuring they are fully equipped to respond to any abnormalities during the procedure.
• Physical Evaluation: Patients over 60 should have a physical exam from their primary care physician, including blood chemistry, within six months of their sedation appointment. This precaution helps minimize risks and ensures the patient's overall health is stable for sedation.
• Bathroom Needs: If a patient mentions frequent bathroom use, take it seriously. They should not be so sedated that they can't communicate or make it to the bathroom safely, even if assistance is needed.
• Dietary Considerations: Watch for hypoglycemia (below 70 mg/dL) and vomiting. Older patients may need sedation appointments scheduled around mealtimes to prevent long periods without eating and help maintain stable blood sugar levels.
• Cognitive Impairments: Physical, sensory, and cognitive impairments common in older adults can make follow-up care, communication, and patient education more challenging, so planning for these issues is essential (ADA, 2023).

 

All these factors make older adults' sedation safer and more comfortable.

 

Personalize Your Approach

 

A cohort study published in the British Dental Journal (1) sheds light on the unique challenges and considerations of sedating older patients, emphasizing the need for tailored approaches to ensure their safety and well-being. Some of the most important insights found in this research include:

• Increased Risk of Complications: Older patients are at a higher risk for complications during sedation due to age-related changes and common chronic conditions such as cardiovascular diseases, diabetes, and respiratory issues.
• Need for Individualized Protocols: There is a strong emphasis on customizing sedation protocols based on each patient's specific health profile. These steps include considering medications, medical history, and overall physical condition.
• Importance of Thorough Evaluation: A comprehensive pre-sedation evaluation is crucial for identifying potential risks and ensuring patient safety. This evaluation involves assessing medical conditions and understanding the patient’s cognitive and sensory abilities.
• Enhanced Monitoring and Support: The study highlights the need for careful monitoring and potentially additional support during and after the procedure to manage the higher risk of adverse effects in older patients.

 

Overall, the study underscores the necessity of a personalized approach to sedation in older adults to enhance safety and effectiveness.

 

In Conclusion

 

Dentists are committed to prioritizing patient safety and ensuring that all patients receive safe and effective dental care regardless of age. Effective dental sedation begins with a comprehensive medical evaluation and a meticulous dental team review of the patient's health history. It also entails a tailored approach to treating an aging population.

 

With the number of people over 65 on the rise, it's more important than ever to customize sedation plans. Dentists must consider chronic conditions, medication interactions, and age-related changes to manage risks effectively. Age alone doesn’t rule out sedation. However, it does require some tweaking to fit each patient's unique needs. Doing thorough evaluations, monitoring carefully, and tailoring treatment can provide even your most seasoned (and suitable) patients with effective and safe dental sedation.

 

References:

1. Chauhan, M., Carter, E. & Rood, P. Intravenous midazolam dose ranges in older patients sedated for oral surgery – a preliminary retrospective cohort study. Br Dent J216, E12 (2014). https://doi.org/10.1038/sj.bdj.2014.197