SEDATION IN THE ELDERLY
Introduction
Sedative administration helps limit the appearance of effects related to the general pathologies of these patients, such as hypertensive crises, agitation or confusion, particularly in patients who present with dementia pathology linked to aging.
The prescription must be adapted to the physiological changes linked to age, to the pathologies presented by the elderly subject
Sedation by inhalation of a mixture of nitrous oxide and oxygen is the solution best suited to the geriatric context.
- Definition of sedation
Refers to all medicinal or non-medicinal means intended to ensure the physical and psychological comfort of the patient in order to facilitate care techniques. It consists of reducing or eliminating apprehension, anxiety and pre-, per- and post-operative fears (French Society of Anesthesia and Resuscitation).
- Sedation levels
- Light conscious, Minimal: pharmacological administration (hydroxyzine for example)
- Moderate: equimolar mixture of oxygen and nitrous oxide (MEOPA)
- Deep: state of depression of consciousness induced by the administration of a drug (most often midazolam)
- General anesthesia
- Assessment of the level of sedation
Several scales, including the Ramsay scale, make it possible to simply assess a patient’s level of sedation:
| 1 | Anxious, agitated patient |
| 2 | Patient cooperative, oriented and calm |
| 3 | Sick person responding to orders |
| 4 | Patient asleep but with a clear response to stimulation of the glabella or to loud noise |
| 5 | Sleeping patient responding weakly to the above stimuli |
| 6 | No response to nociceptive stimuli |
Tab1. Ramsay score (according to Ramsay et al. 1974)
SEDATION IN THE ELDERLY
- Conscious sedation
A technique in which the use of one or more pharmacological agents results in a state of CNS depression, while maintaining the patient’s communication skills and ability to respond to commands. (General Dental Council).
The main goal of conscious sedation → reduction of patient fear, anxiety and discomfort.
- Different interests of conscious sedation
- Reduction of the patient’s psychological suffering
- Motivation for consultation → early access to care allowing the implementation of prevention and screening measures
- Early care → less invasive and/or shorter duration → reduction in the number of sessions → less expensive care (patient and community)
- Improvement in the quality of care linked to patient collaboration, making it easier for the practitioner to concentrate more easily on the actions to be performed and limiting the need to make compromises in care.
6. Different sedation techniques
6.1 Non-pharmacological techniques : called iatro sedation techniques
Acupuncture, audioanalgesia, hypnosis…
6.2 Pharmacological or pharmaco-sedation techniques
Most used for dental care:
- Enteral (gastrointestinal) route (oral +++, rectal, sublingual)
- Parenteral route (not gastrointestinal):
-Topical: local anesthetics
-Transdermal: no medication
-Subcutaneous (slow): hypno and narcotics
-IM (15mn)
-IV (20 to 30 s): limited extra-hospital use
-Inhalation: MEOPA
- Mixed techniques or combined sedation (simultaneous use of several techniques).
- Conscious sedation by inhalation
Conscious inhalation sedation uses an equimolar mixture of oxygen and nitrous oxide (MEOPA), i.e. a concentration set at 50% oxygen and 50% nitrous oxide in the cylinder. The flow rate can therefore be varied but by the content of one or the other of the gaseous components.
- . Indications
- Anxious or phobic adult
- Mental deficiency or dementia in the elderly
- Cerebral palsy
- Autism Down Syndrome
- Complex oral surgery procedures (difficult DDS, bone graft, etc.)
- Contraindications
Absolute :
- Intracranial hypertension (due to its vasodilatory effects on cerebral circulation)
- Patients requiring pure oxygen ventilation (risk of hypoxia), altered state of consciousness (impediment to patient cooperation)
- Head trauma
- Facial trauma in the area of mask application
- Recent injection of air or sulfur hexafluoride for treatment of retinal detachments (minimum three months)
- Neurological abnormalities of recent and unexplained onset
- A temperature < 5°C is also a contraindication, because at such a temperature the mixture risks losing its homogeneity due to the liquefaction of nitrous oxide.
Relatives :
- Sinusitis, recent infection of the ENT area
- Nasal occlusion
- Obstructive pulmonary disease, chronic bronchitis
- Severe respiratory failure
- Patients treated or having been treated in the previous year with bleomycin
- Patients deficient in vitamin B12 (risk of damage to the peripheral nervous system and of causing peripheral polyneuropathy )
- Latex allergy (mask)
- Claustrophobia (patient who refuses the mask)
- Uncooperative patients who refuse sedation and therefore the application of the mask
- Psychotic patients because there is a risk of mental dissociation
- Pharmacological characteristics of MEOPA
Gas composed of half nitrous oxide and half oxygen:
- Has no anesthetic effect but induces a state of conscious sedation: Patient relaxed, relaxed with attitude detached from the environment
- Its absorption and elimination via the pulmonary route are very rapid.
- The majority of studies were carried out with the Kalinox® 170 bars
- MEOPA side effects
May occur during treatment, but usually disappear within minutes of stopping inhalation of the mixture:
- Nausea and vomiting are the most common
- Paresthesia, deepening of sedation, modification of sensory perceptions.
- Abnormal movements observed often occurring in the context of hyperventilation
- Dizzying sensations
- Agitation, anxiety, euphoria, dreams.
SEDATION IN THE ELDERLY
Conclusion
- MEOPA has many advantages for carrying out painful treatments , particularly dental treatments, in the elderly.
- Non-invasive technique, allowing effective conscious sedation, most often well tolerated and easily reversible
- Advantage → Low cost compared to general anesthesia (alternative for short-term dental care)
- It should develop in hospitals as well as in the office, because the needs for dental care among the elderly are numerous and constantly increasing.
- Remember that the elderly person is often a “fragile” person, with multiple pathologies.
- Regularly reassess the prescribed treatment and monitor the occurrence of possible adverse effects, by questioning
SEDATION IN THE ELDERLY
Deep cavities may require root canal treatment.
Interdental brushes effectively clean between teeth.
Misaligned teeth can cause chewing problems.
Untreated dental infections can spread to other parts of the body.
Whitening trays are used for gradual results.
Cracked teeth can be repaired with composite resins.
Proper hydration helps maintain a healthy mouth.