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News Bulletin : ADA News Bulletin June 2011
43 JUNE 20 11 Working closely with residential aged care facilities (RACF), it has become very clear that the oral health of elderly Australians is emerging as a significant problem for all dental healthcare workers and the community at large. The average age of entry into a RACF in the 1950's was at least 10 years less than it is now. Eighty was very old and those who got to this venerable age often just needed their dentures adjusted or repaired. What a difference we now have within a relatively short period of time. The average age of admission to a RACF is now closer to 83 with many of today's new residents having several natural teeth present. Whether this is as a result of fluoridated water, better nutrition, a greater understanding of the benefits of looking after one's teeth and periodontal health or just better dentistry doesn't seem to matter much when you enter a RACF. By this stage there are numerous health issues, countless medications being taken, cognitive and fine motor functional deficits, all of which contribute to the inability of many residents to implement good oral and dental care. ACCESSING CARE CAN BE AN ISSUE Our public health system offers Australians some of the most advanced medical procedures, drug treatments and preventive strategies in the Western World. Unfortunately, for the new generation of older Australians, having teeth when you are over 80 can leave you in the invidious position of not being able to access dental care either due to financial constraints, lengthy waiting times in the public sector, cognitive impairment, limited mobility or logistical difficulties in getting to appointments. Dentists can find elderly patients challenging to manage as they often have complex medical histories, are poor medical historians and have difficulty communicating. They will often take considerable time getting in and out of the dental chair and are often late as they wait for public transport or are reliant on others to get them to their appointments. Time consuming consultations with the family, carers and the family doctor are often necessary before commencing even minor dental treatment. As the elderly often tolerate short appointments only, optimum treatment may be relegated to patching up or repairing teeth. Health, age and cost tend to dictate treatment decisions. Dental issues are often not a priority to many residents themselves, their family, carers and RACF personnel. Toileting, getting the resident out of bed, caring for the feet, getting to meals on time, preventing falls, adequate hydration -- these are the pressing and time consuming activities that nursing staff feel they need to attend to first. HOW IMPORTANT IS ORAL HEALTH? Family members may ask, "Does it really matter? My mother is 91. She has lived a good life, why burden her with dental treatment?" My answer to this is an unequivocal, "You're right you shouldn't have to.'' The problem we have is that the current older members of our community have placed a much higher value on good health than in previous generations, including oral and dental health. Many elderly still living in their own home or in a RACF will have had good regular dental care and in many instances complex dental procedures carried out. Unfortunately, salivary glands either cease to function properly or are greatly affected by medications, health issues and ageing itself. Without saliva, teeth which have hitherto been looked after may now start to decay rapidly. It's not hard to understand why the teeth and periodontal health can deteriorate rapidly when you add the uncontrolled consumption of sweets, biscuits and sugar which occurs, even in the better RACFs, coupled with the resident's reduced motivation to look after themselves and the progressive cognitive and fine motor deficits many develop in later life. Oral pain and discomfort can be devastating, compounding psychosocial problems, disrupting family dynamics and frustrate nursing home staff. As appearance, function and comfort suffers so may the person's self esteem and confidence. GENERAL ANAESTHESIA AND COGNITIVE IMPAIRMENT Increasingly, dentists will be faced with the need to consider general anaesthesia (GA) for the management of elderly patients who may have mild cognitive impairment (MCI) or even advanced cognitive changes such as Alzheimer's disease (AD). Unfortunately, many family members, carers and RACF staff are going to be reluctant to agree to a request for a GA as there is a widely held belief that general anaesthesia is linked to cognitive decline. Having been refused consent to proceed with a GA on a number of occasions for nursing home residents by family members, I met with Dr Greg O'Sullivan, Head of Anaesthesiology at St Vincent's Hospital, Sydney to discuss the issues. Dr O'Sullivan did not believe that there was any strong evidence linking general anaesthesia with adverse cognitive decline in the elderly. However, since our meeting, a more recent international workshop on anaesthesia and AD issued the following consensus statement: "Given the available evidence, the possibility that anaesthetics and surgery may have long-term cognitive effects should be taken seriously, particularly in patients at risk of neurodegenerative conditions."1 As the prevalence of AD in Australia is 6.8% for those over 65 and 22.2% for those at age 85 years of age2 this is of concern for dentists. Of even greater concern is the better understanding of the pathogenesis of AD which has established the deposition of precursor amyloid plaques in the brain commencing 10--15 years before any symptoms of deterioration in cognitive function as having a direct correlation with the future development of AD.3 Implications of poor oral and dental health IN AGED CARE opinion page
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