SEDATION IN THE ELDERLY
- DEFINITION OF ANXIETY :
It is a subjective sensation that can induce various somatic symptoms:
- Cardiovascular disorders: tachycardia, high blood pressure
- Ventilatory disorders: dyspnea, feeling of respiratory discomfort
- Neurovegetative disorders: dry mouth, dysuria
- Neuropsychiatric disorders: feeling of asthenia, sleep disorders, behavioral disorders or state of agitation
- Objectives and interests of sedation
Main goal of conscious sedation → reduction of patient fear, anxiety and discomfort.
Benefit → children, uncooperative adults, with or without motor or mental disabilities → allows to control their behavior and movements during procedures which require relative immobility.
- 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 establish care compromises
- Appropriate management of at-risk patients
- Reduction in procedures requiring hospitalization
- Reduction in the prescription of care under general anesthesia.
- Definition of conscious sedation
- Reduction of anxiety and/or fear in an individual by a psychological or pharmacological approach without inducing loss of consciousness.
- 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)
- Defined as a level of mild depression of consciousness that allows the patient to retain airway protective reflexes and respond to physical stimuli as well as verbal commands According to Hass and the American Society of Anesthesiologists
- Characterized by a depression of the CNS of variable depth, can be defined in several levels of increasing intensity.
- This sedation can be light, moderate or deep. The different levels of sedation, presented in the table:
Techniques that induce even a very short loss of consciousness are considered general anesthesia.
Conscious sedation has nothing in common with general anesthesia and has no anesthetic purpose.
In dental care, sedation, which will be light to moderate, and local and/or regional anesthesia are two practices that must be combined because fear and anxiety are increased as soon as the patient feels pain.
SEDATION IN THE ELDERLY
- PRODUCTS USED DURING SEDATIVE PREMEDICATION :
These are anxiolytics (tranquilizers) also called drugs for anxiety, hyper-emotionality and stressful situations.
We distinguish:
Benzodiazepine anxiolytics:
- Muscle relaxants
- Anticonvulsants
- Sedative action at high doses
- Anxiolytics
- Amnesic action
Non-benzodiazepine anxiolytics:
- Hydroxyzine: Atarax
- Morphines
- Alpha 2 antagonists: Clomidine
- RULES FOR USE IN ELDERLY SUBJECTS :
- Take into account changes in the pharmacokinetics of drugs (decrease in renal excretion) which implies prescribing the lowest active dose, in practice the doses are reduced by 02 or even by 04 compared to adults
- Choose a molecule with a short half-life and little metabolism
- Caution in patients who drive and operate machines
- Prescription at least the day before the procedure and one hour before
Short half-life benzodiazepines:
| DCI | NC | Presentation | Half life | Dosage |
| Clotiazepam | Veratran | Cp 5 and 10 mg | 4 hours | 10 to 30 mg/day |
| Lorazepam | Temesta | Cp sec 01et 2.5 mg | 12 hours | 01 to 1.75 mg/day |
| Bromazepam | Lexomil | Cp 60mg | 8 p.m. | 3 to 12 mg/day in 1 to 3 doses |
- Conscious sedation by inhalation of nitrous oxide (MEOPA)
Accessible to all practitioners under certain conditions, it is most often well tolerated and allows care to be provided to uncooperative people. Its use should develop in geriatrics, because it presents a very interesting benefit/risk ratio.
Pharmacological characteristics and indications of MEOPA (Kalinox®, Entonox®, Antasol®, Oxynox®)
It is a gas composed of half nitrous oxide and half oxygen. It has no anesthetic effect, but induces a state of conscious sedation: the patient is relaxed, relaxed with an attitude detached from the environment.
Its absorption and elimination via the pulmonary route are very rapid.
It should be noted that the majority of studies were carried out with Kalinox® 170 bars.
7.1 Indications:
Sedation in dental care for children, anxious or disabled patients.
But it is also indicated in other situations such as analgesia in emergencies (trauma, burns, transport of patients in pain) or analgesia for short-term painful procedures in adults and children (lumbar puncture, myelogram, minor superficial surgery, burn dressings, reduction of simple fractures, reduction of certain peripheral dislocations and venipuncture).
7.2 Contraindications: these are general contraindications regardless of age.
- Patients requiring pure oxygen ventilation.
- Intracranial hypertension.
- Any alteration of the state of consciousness, preventing the patient’s cooperation.
- Head trauma.
- Pneumothorax.
- Emphysema bubbles.
- Air embolism.
- Diving accident.
- Abdominal gas distension.
- Patient who has recently received an ophthalmic gas (SF6, C3F8, C2F6) used in eye surgery as long as a gas bubble persists inside the eye and for at least a period of 3 months.
- Serious postoperative complications may occur related to increased intraocular pressure.
- Known and unsubstituted vitamin B12 deficiency.
- Recent onset and unexplained neurological abnormalities.
SEDATION IN THE ELDERLY
7.3 Adverse reactions:
They 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 could be observed occurring most often in a context of hyperventilation;
- dizzy sensations;
- agitation, anxiety, euphoria, dreams;
- In case of prolonged or repeated exposure, neurological disorders such as myeloneuropathies, megaloblastic anemias with leukopenia have been reported due to the inhibition of methionine synthetase involved in the synthesis of vitamin B12. In this context, it is recommended to supplement the patient with vitamin B12.
Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.