16: Medical Complexities

Chapter 16
Medical Complexities

Elisa M. Chávez

Department of Dental Practice, Pacific Dental Program at Laguna Honda Hospital, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, CA, USA

Introduction

In this chapter we will review some of the most common systemic diseases and conditions that challenge older patients and discuss their management in dentistry. The method we will use for reviewing these classifications of diseases and conditions will be through a review of the medications prescribed for these conditions, viewing the medications as a proxy for the conditions themselves. Other chapters focus on coordinating care for patients with complex situations and the specifics of oral disease prevention for patients with complex needs. No one source can provide all the answers; multiple resources for patient management and professional development are required. A review of the references in this chapter’s bibliography will provide additional information and resources for consideration in the management of patients with medical complexities. The websites listed may provide valuable updates to the information provided here.

Advanced age is not a contraindication to dental care. Some practitioners believe that seniors present with some inherent risk for dental care, but this is not the case. Many seniors who seek dental care in private practice are “well elders.” Importantly, diseases that occur more commonly as people age are due to disease processes, not due to aging itself. They are age-prevalent, not age-related. This is true for systemic and oral diseases. Not all seniors will suffer from age-prevalent diseases, and many of those who do, have their disease(s) well under control. Some seniors are coping with multiple concomitant chronic diseases but fewer will fall into the frail patient category with conditions that have significantly impaired their physical and/or cognitive function. For some this a result of some acute event and for some a result of long-standing and poorly controlled disease. Identification of patients with multiple systemic diseases or even one known or unknown condition that may not be controlled is important in order to provide appropriate treatment planning and care. Rarely do the normal physiologic changes that occur with aging add to the medical complexity of dental treatment planning and care alone, but they can add to the overall complexity of providing care (see Chapters 6 and 7.) Rather than focusing solely on the age of a patient, the focus should be on the presence of disease(s) or disability that can impact oral health and the provision of oral health care.

Seniors are a more heterogeneous population with regard to health and function than are younger patients and there are several medical diseases and conditions that do occur with more frequency in senior populations. Even without preconceived notions about treating someone of advanced age, there may be uncertainty about how to manage patients with multiple diseases, conditions, and medications, or how to request appropriate consultations from other care providers. There may be concerns over appropriate treatment planning and dental management in the presence of these conditions.

Prescription and natural drug use as the window to systemic health

Patients take medications because they have underlying disease, or may self-medicate with over-the-counter products due to health concerns. Practitioners must be concerned about the drugs themselves as well as the diseases they are used to manage. Some medications are prescribed in the event of acute conditions such as angina. Some of the desired or undesired side effects of a drug may increase the risk for an adverse outcome in the dental clinic and require laboratory testing to assess risk – such with anticoagulants and immunnosuppressants or insulin and bisphosphonates respectively. Some will require consultation with the patient’s physician or pharmacist regarding alteration of an existing drug regimen or use in concert with a needed dental treatment or prescription. Some medications and their side effects, or the disease they are used to treat, will require an alteration of a dental treatment plan or plan for prevention and maintenance. Some medications will have a direct impact on oral health. In all cases is it important to identify these potential risks and implications when we first evaluate a patient, on routine updating of medical histories, or upon review of any new diagnoses and medications with which a patient may present at any given appointment.

Polypharmacy

Polymedicine describes a patient taking many medications for many medical problems but the term polypharmacy often indicates the inappropriate use of multiple medications. A number of studies have demonstrated that seniors take more medications than any other age group – as much as a third of all prescriptions written. Several studies have demonstrated that as the number of prescription drugs a person takes is increased, the risk of adverse drug reactions (ADRs) also increases, to as much as 100% for those taking 8 or more. Some drugs commonly used in dentistry, corticosteroids, nonnarcotic analgesics, and penicillin have some of the highest ADR rates. ADRs due to the use of nonsteroidal anti-inflammatory drugs (NSAIDs), also commonly used, is among one of the most preventable causes of untoward effects of medications. Among those aged over 65, the incorrect use of multiple medications and ADRs can be a significant cause for acute hospitalizations. A 2005 American Association of Retired Persons (AARP) survey reported 67% of people aged 50–64, and 87% of those over 65 say they regularly take a prescription medication; among those the average number of prescriptions they report taking is four. US Centers for Disease Control and Prevention (CDC) data shows that, from 2007 to 2010, almost 40% of people aged 65 and older reportedly had taken five or more medication in the last 30 days. This is a significant increase compared with the 15.6% occurrence reported from 1988 to 1994.

There are seven kinds of ADRs: allergy, side-effect, drug toxicity, drug–drug interaction, drug–physiology interaction, drug–laboratory test interaction, and idiosyncratic. An ADR may occur with the administration of even a single drug (Jacobsen, 2001). These reactions may be relatively mild – such as a localized oral change like mucositis or xerostomia – or a life-threatening event such as anaphylaxis secondary to drug allergy or excessive bleeding due to a drug–drug interaction. Some drugs present an increased risk of an ADR in older individuals when administered alone, even when there are no drug interactions reported, such as with valium – a long-acting benzodiazepine. Because drug metabolism may be slower in older individuals, for reasons such as changes in body composition, they may remain sedated for a longer period of time than expected. The extended and unexpected length of sedation may present a risk on its own but it can also result in over-sedation if multiple doses are taken, even over an acceptable length of time. The risk increases for those with other systemic diseases such as diabetes, asthma, renal, or hepatic disease or those who are malnourished. Some of the more specific and preventable outcomes of the adverse drug events that occur in seniors are: falls, hip fractures, delirium, and urticaria. Approximately a fourth of these reactions are preventable and 95% are predictable because they are often exaggerations of expected side effects of these drugs. Those events may stem from some pharmacokinetic changes that occur with aging or that have occurred as a result of some disease. However, misuse and over- or under-use of medications is often the cause.

Improved patient–physician communication, including monitoring for and responding to symptoms, has been identified as an important strategy for the prevention of adverse drug events in outpatients and may reduce the frequency of these events. Seniors are one of the groups at risk for low health literacy, especially those aged over 85 and those who do not speak English or have English as their first language. Health literacy has been described as “The wide range of skills and competencies that people develop to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, reduce inequities in health, and increase quality of life” (Zarcadoolas et al., 2005). There are many points in the healthcare system that may a present an opportunity for misunderstanding, miscommunications, and result in poor compliance and suboptimal outcomes related to health and oral health. And, apart from low health literacy some patients are unwilling to follow or incapable of following treatment recommendations and instructions to safely manage their medications. There are many social, psychologic, physical, and economic reasons for poor compliance and mistakes in drug usage that are not a result of aging but that may be more prevalent among older patients (see Chapter 6).

Tips for maximizing optimal medication compliance

Strategies for reducing medication errors include making certain the patient understands the reason a medication has been prescribed; the reason they should take it as directed; and that they can repeat how and how often to take the medication. Prescription bottles should not always be “child-proof” because arthritic or neuromuscular changes may make it difficult if not impossible for older adults to open child-proof bottle caps. Generics should be prescribed when possible in combination with a simple regimen in order to improve compliance (minimizing cost and complexity as barriers to compliance). Address physical and cognitive barriers to compliance by enlisting caregivers, friends, and relatives when appropriate. Provide clearly written and readable instructions, in large font, for the patients and caregivers to take home. Encourage the patient or caregivers to consult the pharmacist about their medication and to contact you if they have additional questions. Follow up with the patient to see if they are following the medication regimen. If they are not, try to address the reason they are not or cannot. An example of why a patient might not be complying would be some unpleasant side effect the patient is unwilling to tolerate or cannot tolerate but which might be addressed by using a different drug or altering how and when the drug is administered. Document any issues of noncompliance in the patient record. If there is suspicion that lack of compliance is due to neglect or abuse, report to adult protective services or an ombudsman (see Chapter 19).

Systematic review of the medication list

Since patients may not have a firm understanding of the medications they are taking, or the diseases they are used to treat, it is important to be familiar with certain drugs or drug classes commonly used to manage some of the most commonly encountered systemic diseases and conditions in older patients. This will help identify potentials for problems in the dental management of these patients. These problems may arise from the use of the drug alone or because of the disease the drug is used to treat. For these reasons, a systematic method for reviewing a lengthy drug list will not only help highlight medication issues, but will also emphasize important considerations in caring for a medically complex population. See Table 16.1 for important points to review with patients taking multiple medications and points to address prior to writing a prescription.

Table 16.1 Polymedicine checklist

Important drugs to identify from an existing drug list Issues to identify prior to writing a new prescription
Drugs needed in the event of emergency a Drug classes, or the conditions they are used to treat, that presents an increased risk for an adverse event a Drug classes that may have specific oral lesions or conditions as side effect a Over-the-counter products with potential for adverse events a Potential for drug-drug interaction with the drug to be prescribed? History of drug allergies and ADRs a Indications to reduce standard drug dosage or to use drugs with a different metabolic route a
nitroglycerin

inhalers

Anti-addictive

  • Disulfiram
  • Methadone

Anticoagulants

  • Warfarin
  • Clopidogrel
  • Aspirin

Chemotheraputics

  • Vincristine
  • 5-fluorouracil [5FU]
  • Cisplatin

Corticosteroids

  • Prednisone

Hypoglycemic and insulin

  • Insulin
  • Sulfonylureas

Immunnosuppressants

  • Methotrexate Cyclosporine Prednisone

Antidepressants

  • MAO inhibitors
  • Tricyclic

Nonselective beta blockers

  • Propanolol
  • Timolol

Recreational drugs

  • Cocaine
  • Methamphetamines

Sedative hypnotics, narcotics, barbiturates

  • Diazepam
  • Meperidine
Xerostomia

  • Antihistamines
  • Antidepressants
  • Calcium channel blockers
  • Diuretic

Fungal infection

  • Antibiotics
  • Immunnosuppressant

Mucositis

  • Anti-neoplastic

Gingival enlargement

  • Anti-seizure
  • Calcium channel blockers
  • Immunosuppressant

Lichenoid reactions

  • Diuretics

Delayed bone healing or necrosis

  • Bisphosphonates (alendronate, zolendric acid)
Increased bleeding

  • Aspirin
  • Bilberry
  • Dong quai
  • Garlic
  • Ginger
  • Ginkgo biloba
  • Ibuprofen
  • St. John’s Wort

Inhibit erythromycin
and ketoconazole

  • Echinacea
  • St. John’s Wort

Increase HR/BP

  • Ephedra
  • Bitter orange

Additive to anti-anxiety and sedation

  • Valerian

Hepatotoxicity

  • Kava-kava
Drugs to be prescribed should be cross-checked with the drugs on the existing drug list for risk of interactions to reduce such events Drug allergies

  • Urticaria
  • Anaphylaxis
  • Edema

Signs of ADRs in seniors

  • Delirium
  • Falls

Known side effects that are excessive or intolerable to patient
Drugs with increased risk of toxicity and ADRs in aged

  • Clindamycin
  • Cephalosporin
  • Diazepam
  • Tylenol® #3
Impaired kidney function
Kidney function test: GFR:

  • <10 ml/min 1 dose q 24 h
  • 10–50 ml/min 1 dose q 8–12 h
  • >50 ml/min 1 dose q 8 h

Examples of drugs with renal elimination

  • Amoxicillin
  • Tetracycline
  • Penicillin
  • Fluconazole

Impaired liver function
Liver function tests: ast/alt/liver transminases:

  • Normal = 30–40 u/l
  • If >4 times normal, do not use drugs toxic to or metabolized by the liver
  • Examples include:
  • Acetaminophen
  • Codeine
  • Lidocaine
  • Ibuprofen
  • Lorazepam
  • Erythromycin

85 years or older and/or weight below 100 pounds

  • Reduce dosage by 50% or to the lowest therapeutic level

aThese lists are not exhaustive. The drugs and conditions listed are examples.

ADR, adverse drug reation; GFR, glomerular filtration rate; q, every.

The following sections will address classifications of drugs that may be needed in emergency situations and drugs on the medical history that may suggest potential risk during treatment.

Emergency drugs for emergency situations

Upon first review of a patient’s medication list, determine if there are medications that may be required in the event of a medical emergency – such as nitroglycerin used for angina or bronchodilators inhaled during acute exacerbation of chronic obstructive pulmonary disease. These medications may be needed even before any care is provided to the patient and should draw our attention to the underlying medical conditions, which may have an impact on our overall management of and treatment planning for this patient. These may not be patients who can tolerate lengthy appointments or may have guarded prognoses for their oral health due to other conditions related to their overall systemic health, such as xerostomia from medication use or dependence upon others due to limited functional ability. Patients should be reminded to bring medications that might be required in the event of a medical emergency with them to each appointment and to set them out when they come to the office, so that in the event they are needed, time is not lost in looking through their belongings for them. These drugs should also be available in an emergency kit.

Drugs that suggest potential risk

Hypoglycemic drugs and insulin

The second group of drugs to identify is drugs that may indicate to us that there is a higher chance for some adverse event in the dental office, either because of the drug itself, or because of the condition it is used to manage. Some drugs in this category have a narrow margin of safety and are highly titrated. One of the most common and recognizable in this group is insulin. Approximately 26% of all adults with diabetes take insulin to manage their disease. Diabetes was the seventh leading cause of death in 2010 for adults aged over 65 and is a major cause of heart disease and stroke, kidney failure, and blindness. The risk of death for patients with diabetes is twice that of age-matched individuals without the disease. Approximately 27% of US people over age 65 had diabetes in 2010 and 50% had pre-diabetes. Type 1 diabetes (DM1) accounts for about 5% of all adults with diagnosed diabetes. Risk factors include autoimmune, genetic and environmental and there is no known way to prevent its occurrence. Type 2 diabetes (DM2) is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity. DM2 accounts for approximately 90–95% of all diagnosed cases of diabetes in adults and usually begins as insulin resistance. In DM2 individuals, insulin is not used properly and as the need for insulin rises, the pancreas gradually loses its ability to produce insulin. The remaining small percent of diagnosed cases of diabetes results from specific genetic conditions, surgery, ADRs, infections, pancreatic disease, or other illnesses.

Patients who have uncontrolled diabetes and/or require insulin to manage their disease are at risk of developing hyper- or hypoglycemia. A random blood sugar test done in the dental office can be useful to assess patient status just prior to treatment. A blood sugar level less than 140 mg/dl (7.8 mmol/l) is normal. The target for people with diabetes before meals is 70–130 mg/dl and the target 1–2 hours after meals is less than 180 mg/dl. Patients with values over 180 ml/dl may have symptoms of blurry vision, tiredness, thirst, or a sick to the stomach feeling. These patients should be referred to their physicians for a consultation and evaluation. A blood glucose level below 70 mg/dl indicates hypoglycemia and the patient should be given a sugar source. Hypoglycemia can strike rapidly and the patient may appear confused, shaky, sweating, anxious, and/or weak. Most cases of hypoglycemia can be managed by quickly giving the patient a source of glucose such as juice, full sugar soda, sugar, honey, candy, or glucose tablets. Check blood glucose again in 15 minutes. If it is still below 70 mg/dl another serving should be eaten and repeated until the blood glucose level is 70 mg/dl or above. If the patient will not eat for another hour or more they should have a snack after the blood glucose level is raised to 70 mg/dl or above. Note that patients taking acarbose (Precose®) or miglitol (Glyset®) must have the pure glucose tablets or gel because these drugs slow the rate of digestion of carbohydrates and, therefore, other sugar sources do not work quickly enough. If the patient loses consciousness they may require a glucagon injection and emergency services should be contacted. Severe hypoglycemia can lead to seizures, coma and even death.

Patients should be advised to follow their usual medication and diet regimen prior to dental treatments. If they may not be able to eat for some time after treatment – for instance following extensive oral or periodontal surgery or due to a long trip to and from home – a physician consultation should be completed to determine if this regimen can be altered on the side of mild hyperglycemia for a brief time to prevent hypoglycemia during the post-operative period. The use of insulin by a patient with DM1 or DM2 should also signal that this patient may be at risk of delayed healing or infection following surgery. As opposed to a random blood sugar test, which tells you only about that patient at the date and time of the test, a glycosylated hemoglobin test or HbA1c is used to assess long-term control for the patient with diabetes. The American Diabetes Association generally recommends an A1C level below 7%, or an average 150 ml/dL blood glucose range over a period of 3 months, if the patient is to have their disease controlled. If significant surgery is planned, a physician consultation should be requested in order to determine their long-term control and whether or not this patient would benefit from a peri-operative course of antibiotics. For patients who do not have well-controlled diabetes, inquire whether or not their kidney function is impaired as a result of their disease, especially if they have been diagnosed with diabetes for many years. In these cases it is important to consider whether prescription dosages need to be changed as a result of impaired renal function. Renal function is an important factor in drug metabolism and the drug’s effect on the patient. Serum creatinine levels are generally regarded as an indicator of renal function. However, serum creatinine level is not a reliable measure in older adults because serum creatinine levels are a function of muscle mass. Muscle mass is reduced with advancing age and there may not be the mass that is assumed by this test. Another test for renal function is the glomerular filtration rate (GFR). GFR is a test used to check how well the kidneys are working. A glomerular filtration rate (GFR) of less than 50 ml/min per 1.73 mm2 is a predictor for drug-related problems. See Table 16.2 for prescribing guidelines for medications metabolized in the kidney.

Table 16.2 Diabetes and associated diseases: impact on oral health care

Potential complications of diabetes with dental implications and considerations Quick facts as they relate to aging and diabetes
  • Heart disease
  • Angina
    • Unstable: urgent care only, possibly in hospital setting, palliative care where possible
    • Stable: caution with use of vasoconstrictors, stress reduction management and sedation may be appropriate, if patient is on anticoagulants, excessive bleeding may be a risk, nitroglycerin should be readily available. If the patient still has chest pain after the third dose of nitroglycerin – call 911
    • If patient is taking nonselective beta blockers: limit epinephrine use to two cartridges of 1/100 000 epinephrine, avoid retraction cord with epinephrine and avoid anticholinergic medications
  • Congestive heart failure
    • If condition is uncontrolled or symptomatic, urgent care only but with careful cardiac monitoring and possibly in a hospital setting
    • If condition is controlled and asymptomatic, proceed with routine dental care
    • Stress reduction management and sedation may be appropriate
    • If patient is taking nonselective beta blockers: limit epinephrine use to two cartridges of 1/100 000 epinephrine, avoid retraction cord with epinephrine, and avoid anticholinergic medications
    • Administration of epinephrine can result in arrhythmia for patients taking digoxin
    • Patient may not be able to lay back in the dental chair
  • History of myocardial infarction
    • If MI less than 1 month ago, urgent care only in consultation with a physician
    • If MI more than 1 month ago, keep stress low, limit epinephrine use
    • If patient is taking nonselective beta blockers: limit epinephrine use to two cartridges of 1/100 000 epinephrine, avoid retraction cord with epinephrine, and avoid anticholinergic medications
  • Orthostatic hypotension
    • Symptoms and signs: dizziness, confusion, blurred vision, feeling faint and falls or syncope
    • Raise patients slowly to the upright position after reclining in the dental chair
    • Support patients as they stand
    • If patient reports feeling faint, elevate their feet above their heart (Trendelenburg position)
  • The rate of heart disease is 2–4 times higher in patients with diabetes than in those without
  • Heart disease was documented as the cause of 68% of diabetes related deaths in 2004
  • Heart disease was the leading cause of death in all adults over 65 years of age from 1997 to 2007 and 2010
  • Individuals with diabetes have 2 times the risk of heart failure as those without diabetes
  • Orthostatic hypotension risk increases with age and can occur even in the absence of cardiovascular disease
  • Hypertension
    • Defer elective dental treatment if BP is uncontrolled (>180 systolic, >110 diastolic) and refer immediately to a physician for evaluation
    • Symptoms and signs
      • BP >140/90
      • Patients may be asymptomatic, others may have dizziness, facial flushing, fatigue, headaches, nervousness, or nose bleeds
      • Oral side effects:
        1. altered taste due to drug metabolism
        2. gingival enlargement (calcium channel blockers)
        3. lichenoid reactions (ACE inhibitors)
        4. salivary dysfunction and xerostomia (potentially from a wide list of medications)
    • There are no contraindications to care or use of local anesthetic if BP is well controlled
    • Monitor BP before and after administration of local anesthetic
    • Excessive use of epinephrine can increase BP
    • Stress reduction management and sedation may be appropriate
  • An estimated 67% of patients with diabetes are on medication for hypertension or have BP >140/90
  • Almost half of all people over 65 have chronic hypertension
  • Almost one third of people with hypertension are unaware they are hypertensive
  • Stroke (CVA)
    • If patients have been prescribed anticoagulants to prevent future CVAs, use laboratory tests appropriate to the medication given to evaluate risk of bleeding
    • Provide emergency treatment as needed but minimize stress of appointment
    • Keep appointments short and monitor blood pressure, limit use of epinephrine and avoid epinephrine-impregnated retraction cords
    • If there is a known or suspected cognitive impairment, consult the physician with regard to patient ability to make treatment decisions
    • Delay elective dental care and definitive treatment planning to 6 months post stroke to allow time for maximum rehabilitation to be reached and considered in the overall treatment plan; consider physician consultation to determine if patient has reached peak of rehabilitation potential in all areas, p/>
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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 16: Medical Complexities
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