Elderly patients require you to make extra considerations when treating them, and they will also surprise you with what they might say. Here are 6 of the most common requests you may hear from these patients and how best to handle them.
Elderly patients require extra care and consideration when crafting a treatment plan for them, so listen to what they have to say.
As life expectancy increases, it is important to know how to manage geriatric patients, especially the very old (80 years old and up) in the office. In my own practice, it is not uncommon to see elderly patients as I have quite a handful of 100-year-old patients walking in my office for treatment with a set of natural dentition and very little health problems!
In order to keep these patients healthy, and keep them coming back to your practice, it is important to listen and respond to what they are saying. Here are 6 of the most common remarks I hear and how to handle them.
Many geriatric patients wear hearing aids. When I examine the patient, I position myself at eye-level with the patient in a sitting position and speak clearly and slowly when delivering my message. Many elderly patients are accustomed to reading lips, so remove the mask you are wearing and sit closer. Use simple words when speaking to make lip-reading easier. Repeat your messages and write down instructions for them regarding their treatment or next visit.
Patients may be accompanied by family members or a nursing aid to help answer questions. When making an appointment over the phone, have the receptionist indicate that you would need a complete list of medications to be brought to the office for the initial visit. Any recent hospitalizations need to be noted as elective procedures may need to be delayed.
Ask additional guiding questions when reviewing history, for example, many patients put down Coumadin on the paper without specifying the reason why they are on it in the first place; whether Coumadin was prescribed for atrial fibrillation or mechanical heart valve placement. Asking additional questions can help establish risk factors in the overall medical picture. For example, INR of patients with atrial fibrillation are maintained between 2 to 3, versus 3 to 4 in patients with mechanical heart valve placement. Often times, someone with mechanical valve placement needs to continue coumadin throughout the peri-surgical period. Risk for bleeding is therefore increased. Request a medical evaluation if the history is not clear or if medical clearance is needed.
Osteoarthritis and the presence of cervical hump can make positioning of X-rays difficult. Postural reflexes are weaker, making falling more likely. Elderly patients often have decreased GI tone which also makes swallowing more difficult. Xerostomia is common. The combination of these factors translates into longer time getting in and out of chair. It is imperative to have a staff member standing by the patient for fall prevention.
I typically like to sit the patient in a slightly reclined position when performing a procedure and prop their neck with a small roll. As swallowing is usually more difficult in elderly patients, aspiration and coughing would be more likely during the procedure. Therefore, a nearly supine position is not recommended. Airway protection is paramount. Use of mouth props and throat pack can prevent aspiration and stabilize the jaw especially for those who have essential tremor or Parkinson’s disease. Watch for orthostatic hypotension when getting them up from the chair.
Patients who are wheelchair-bound should stay in their own wheelchair during examinations and X-rays if mobility is an issue. In our office, we always ask our patients if they can stand, and how long they can stand holding themselves, to determine whether this patient should be moved to dental chair. Use of headlights, tracking lights, and portable x-ray devices such as NOMAD are useful to aid examining these patients. If the patient is to be transported to dental chair have one person standing on either side of the chair when transporting the patient from the wheelchair to the dental chair to prevent them from falling.
I prefer to schedule elderly patients early or midweek. In my office I perform sedation in the morning; therefore, geriatric patients are often scheduled in the early afternoon. When certain comorbidities exist, such as renal failure patients receiving hemodialysis on a Monday-Wednesday-Friday schedule, I find that Tuesday early afternoon is the best day to schedule such patients for surgery in my office. For those who are on anticoagulants for various reasons such as atrial fibrillation or coronary artery disease status post stent placement, I prefer to schedule these patients earlier in the week and earlier in the day.
In rare instances where delayed bleeding occurs after surgery, the patient will have a chance to return to the office before the end of the day. Even just supportive care like offering more gauze packs and reinforcing post-op instructions gives an additional layer of security. After-hours phone numbers should also be available to these patients.
Schedule and perform shorter procedures if possible. Due to increasing time in communication and transportation, a half an hour procedure might turn into 45 minutes or an hour of your office time. Make sure to schedule these appointments at a time where you have enough flexibility to deal with any changes.
Elderly patients have decreased cardiac and pulmonary reserve and increased sensitivity to local anesthesia and other medications. Many are on various different home medications. The presence of comorbid factors can make anesthesia riskier. In my office, very old patients (80 and up) usually receive local anesthesia only for their procedure. From time to time I receive requests for full-mouth extractions under general anesthesia on an elderly patient. I typically break up the treatment plan into multiple visits without deep anesthesia.
As a general rule, the patient’s age should be inversely proportional with the number of anesthetics used per procedure due to physiologic changes. I perform more infiltrations instead of IAN blocks on elderly patients to avoid palpitations from inadvertent intraarterial injections. So, inject slowly and allow breaks in between.
One time, I saw an elderly gentleman with a history of labile hypertension with systolic as high as 200 and as low as 40 at unexpected times. He was sent to be treated in the hospital setting as it would be safer for this particular patient. For management of anxious patients consider enteral sedation and/or nitrous oxide, but reduce the dosage on the anxiolytics to avoid over-sedation.
Often times, geriatric patients in my area have home medications delivered by a local pharmacy. There is a “routine” and the pharmacy know these patients well. It is important to find out the delivery time schedule. For example, I treated a patient who needed anbiotics and pain medications to be delivered. When the pharmacy was called we were told that the delivery of medications wouldn’t happen until the next day. Under those circumstances, I would dispense a limited amount of medications from my office to get them through the night until medications are delivered.
Many geriatric patients are taking multiple home medications, so be sure to check for drug interactions. Choose medications with a wide margin of safety, and the least frequency, to ensure patient’s safety and compliance. For example, Amoxicillin 500mg TID may be favored over Penicillin VK 500mg QID because patients may forget a dose here and there. Z-pack is a great alternative for its once-a-day dosing. Medications with wide safety margin should be written in such a way that they are taken during waking hours.
For example, Amoxicillin 500mg may be divided up to be taken with three meals (TID), rather than every 8 hours (Q8H). It is not necessary to have patients wake up in the middle of the night to take medications with wide safety margins. I had an elderly woman with severe osteoporosis showing me a Q8H antibiotic prescription. She was waking up in the middle of the night to take the medication in fear of developing the infection. If she falls, the consequences are far greater than the possibility of getting a dental infection.
Taking care of geriatric patients require us to take extra steps. Many seniors live alone. Some have part-time or full-time aids. Others might live in a nursing home or assisted living facility. Knowing their social disposition ahead of time helps treating them safely and efficiently without major delay, confusions, frustrations and interruptions to your daily flow. Asking patients to fill out office forms ahead of time and to bring in a list of medications will save you time. Ask guiding questions during health history review and allow more chair time to position the patients. Most importantly, all of your office team needs to be trained on how to adapt to these specific needs.
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