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CHAPTER 30 Dental Management of Older Adults

 Dental Management
of Older Adults
CHAPTER
30
A
fter reaching the age of 40 years, people experi-
ence a progressive decline in homeostatic control
and in the ability to respond to stress and change.
The World Health Organization defines the population
between 65 and 75 years as "elderly." The term "old" is
used for individuals between 76 and 90 years and "very
old" for those over age 90. Elderly and old individuals
are often very different with respect to their physiologic
function, burden of illness, and any associated disability.1
This chapter uses the term "older adults" for individuals
65 years or older. It is interesting that of all of the people
who have ever lived to age 65 years, more than half are
alive today.2 The organization of this chapter differs from
that of the others because the content does not lend itself
to the usual presentation. An average general dental
practice would be expected to have about 260 or more
patients 65 years of age or older.
EPIDEMIOLOGY
Incidence and Prevalence
More than 35 million individuals age 65 and older live in
the United States. This represents about 13% of the
population.3 In 1900,'just 3 million individuals age 65 and
older accounted for less than 4% of the population.3 By
the year 2030, this group will represent about 20% of the
population.3 These significant increases in the older pop-
ulation in the United States are due to a dramatic increase
in life expectancy over the past century, which is pre-
dicted to continue into the present century.3 In 1900, at
birth, men were expected to live 48 years and women 51
years.3 By 1997, life expectancy had increased to 74 years
for men and 79 years for women.3
Today, a significant number of years are lived after the
age of 65 by a number of older adults.3 In fact, the 85 and
older age group is the most rapidly growing segment of
the U.S. population.4
534
NOT
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)DE)
The leading causes of death in 1900 were pneumonia
and influenza, tuberculosis, diarrhea, and enteritis, which
accounted for 30% of all deaths in individuals 65 years
or older.3 In 1997, heart disease was the leading cause of
death in older adults, followed by cancer and stroke; the
three conditions were responsible for about 60% of all
deaths among older adults.3 In 1997, heart disease alone
accounted for 40% of all deaths among persons age 85
years and older.3
Although heart disease and stroke remain leading
causes of death in individuals 65 years and older, their
death rates from 1980 to 1997 have declined by 30% for
heart disease and by 36% for stroke.3 Improved medical
care, reduction in risk factors, and changes in lifestyle are
responsible for these declines in death rates.3 Death rates
from cancer, pneumonia, and influenza increased slightly
during this period. In contrast, the death rate for chronic
obstructive pulmonary disease increased by 57%, and for
diabetes mellitus by 32%. 3
Cancer (lung, breast, prostate, and colon) is the second
most common cause of death in older adults. Since 1940,
a 20% increase in cancer deaths among persons 55 years
of age or older has been documented. Statistics show that
37% of men and 22% of women aged 60 to 79 years will
develop invasive cancer. The risk for invasive cancer from
birth to death is 50% in men and 30% in women. The
most marked increase has occurred in cancer of the lung
in both men and women.3'5
The proportion of adults who report very good or
excellent health decreases with increasing age. Very good
or excellent health is reported by 82% of individuals aged
18 years, 68% of persons aged 18 to 64 years, and 39%
of individuals aged 65 years and older.3
One primary cause for death in older adults is usually
identified, but often, multiple contributing causes are
revealed.3 These contributing causes include sociodemo-
graphic characteristics, health habits, cardiovascular risk
factors, clinical diseases, subclinical diseases, physical dis-
 C H A P T E R 30
ability, and cognitive impairment.3 When these risk
factors and conditions are taken into account, age becomes
less important as a predictor of mortality.3 However,
overall, the death rate increases with aging until patients
are very old, at which time it slows down.'
Nearly 90% of all older adults have a chronic illness.3'6
At present, 30% of individuals older than 65 years of age
have three or more chronic illnesses and account for more
than 33% of the costs paid for health care in the United
States.4 Illnesses most commonly found in older American
adults are arthritis, hypertension, impaired hearing, heart
disease, diabetes, and impaired vision, in that order.
Older patients differ in several important ways from
young to middle-aged adults with the same disease.3
Many older adults have two or more diseases at the same
time. This comorbidity can result in added risk for
adverse outcomes, such as death.3 In addition, treatment
for one disease, such as aspirin for stroke prevention, may
adversely affect another disease such as peptic ulcer. 3
Some pairs of diseases significantly increase the risk of
disability. For example, when arthritis or heart disease is
found alone in an older adult, the risk for disability is
increased by 3 to 4 times. However, when they occur at
the same time (they coexist in 18% of older adults), the
risk of disability increases by 14 times.3 Another way that
older adults differ from younger adults is that often the
signs and symptoms associated with a disease are nonspe-
cific. For example, the frequency of silent myocardial
infarction increases with age.
Frailty, a condition that is primarily found in older
adults, consists of a wasting syndrome with reduced
muscle mass, weight loss, weakness, poor exercise toler-
ance, and low levels of physical activity, which, in late
stages, can lead to death.3 Cognitive impairment, which
increases in frequency as people age, is a risk factor for
falls, immobilization, dependency, institutionalization,
and mortality.3 Physical disability (i.e., being dependent
on others for basic self-care, shopping, paying bills, etc.)
is a serious and common outcome of chronic disease in
older adults.
On the basis of the information provided here, a dra-
matic increase is expected in the number of older adults
in this country and in the proportion with significant
chronic illness and disability. These older adults will need
increasing levels of dental cafe in the years to come.
Dentists must be aware of the special management needed
to treat this group of patients. For example, drug dosages
and duration of treatment may have to be modified, some
drugs may have to be avoided, antibiotic prophylaxis may
have to be administered, and special precautions may
have to be made before surgery is performed, to avoid
excessive bleeding.
Etiology
Normal aging can be subdivided into successful and usual
aging. Successful aging describes individuals who demon-
strate minimal physiologic decline from aging alone.
Healthful strategies such as exercise, modification of diet,
Dental Management of Older Adults 535
TABLE 30-1
Older Adults' Life Expectancy and Number of
Years Free of Dependency in Activities of
Daily Living
Disability-Free
Life Expectancy, Years
Average Remaining
Age (yr) Men Women Men Women
65-69 13 20 9 11
70-74 12 16 8 8
75-79 10 13 7 7
80-84 7 10 5 5
>85 and older 7 8 3 3
From Resnick NM. Geriatric medicine. In Fauci AS, et al (eds).
Harrison's principles of internal medicine. New York, McGraw-Hill,
1998, p 39.
social and intellectual stimulation, and cessation of
smoking enhance a person's quality of life and promote
successful aging. Usual aging refers to the more common
mode of aging. It is associated, for example, with an
observed decline in renal, immune, visual, musculoskele-
tal, and hearing function.' Table 30-1 shows the estimated
life expectancy and number of years free of dependency
in activities of daily living for different age groups.
It is important to understand that with normal aging,
many things do not change.' Many hormone levels, liver
enzymes, electrolytes, body temperature, and basal glucose
remain constant throughout life.' No age-related anemia
has been reported (a slight decline does occur in hemato-
crit in men owing to decreasing testosterone levels).'
As individuals age, changes occur in their health and
reaction to disease. These changes are due to variations
in physiology that occur with aging, the presence of other
diseases that develop over time, genetic predisposition
for certain diseases, lifestyle factors (diet, exercise, expo-
sure to medicines and toxins, smoking, alcohol taken in
excess), and the variation intrinsic to diseases.7
Theories of Aging. No single hypothesis fully explains
the process of aging. At the present time, two main theo-
ries have been presented to explain aging (Table 30-2).
The first relates to programmed (genetic) causes, domi-
nated by genetic theories, and the second involves random
damage (stochastic or process-of-living theories).2'7
Programmed theories include programmed senes-
cence (genes interfere with the ability of cells to repro-
duce), hormonal (biologic clock alters hormone secretion)
and immunologic factors (T-cell function declines, with
increasing risks for infection and cancer), and telomere
shortening (shortening of telomeres in somatic cells
reduces the ability of cells to divide).2'' Telomeres are
regions of DNA that cap the ends of linear chromo-
somes.8 In somatic cells, telomeres shorten progressively
with every cell division, thereby reducing the number of
tandem repeat sequences that occur.8 Eventually, the
536 Geriatrics PART TEN

TABLE 30-2
Pathobiology of Aging
Genetics (G)/
Theory Definition Cause Environment (E)
PROGRAMMED THEORIES
Programmed Aging results from gene interference with Master clock G
senescence the ability of the cells to reproduce
Hormonal Biologic clock alters hormone secretion, Decrease in levels of insulin-like G
resulting in tissue changes growth factor-1 and the
hormones estrogen, testosterone,
testosterone, DHEA, and
melatonin
Immunologic T-cell function declines, increasing the Alteration in the (cytokines) that are G
chances of developing that infections responsible for communication
and or cancer may develop between immune cells
Telomere shortening Shortening of telomeres in somatic cells Cells cannot divide G/E
lessens the ability of cells to divide

RANDOM DAMAGE (STOCHASTIC) THEORIES

Metabolic rate The higher the basal metabolic rate (the Energy demands needed to G
rate at which the body, at rest, uses maintain basal metabolism
energy), the shorter the life span
Glycation Glycation (browning) causes proteins to Elevated glucose G/E
be joined, resulting in rigidity and
decreased function
Somatic mutation Mutations in genes occur with aging, Errors in the transmission of G
eventually causing cells to stop genetic messages over time
functioning
Wear and tear Parts of cells wear out over time Accumulated debris mechanically E
disrupts cell function
Oxygen free radicals Tissue damage is caused by free radicals, Oxygen free radicals are unstable E
such as superoxide or hydroxl radicals; chemical compounds that can
this is a specific form of the wear-and- oxidize cell components such
tear theory as DNA and proteins

From Minaker KL. Common clinical sequelae of aging. In Goldman L, Ausiello D (eds). Cecil Textbook of Medicine, 22nd edition.
St. Louis, Elsevier, 2004, Table 23-1, p 106.
DHEA, Dehydroepiandrosterone.

chromosomes become unstable, and the cell is no longer
able to replicate. This process acts in the manner of an
inherent biologic clock by limiting the number of divi-
sions that can be accomplished by the cells. In contrast,
germ cells do not undergo telomeric shortening and have
relatively unlimited capacities for cell division.8
Random damage theories include metabolic rate (the
higher the rate, the shorter the life span), glycation
(causes proteins to become joined, resulting in rigidity
and decreased function), somatic mutation (mutations in
genes associated with aging cause cells to stop function-
ing), wear and tear (parts of cells wear out over time), and
oxygen free radicals (free radicals such as superoxide or
hydroxyl cause tissue damage).2'7
Pathophysiology and Complications
Human aging after the age of 40 years is accompanied by
physiologic deterioration. However, this decline is highly
variable among older persons and within organ systems
of any given individual.2'4 Studies suggest that by main-
taining good nutrition, exercise, and social activities,
older adults can maintain better health.2'4'9 For example,
this approach has been reported to delay the onset of type
2 diabetes in older adults who are genetically programmed
for this disease.
Certain homeostatic regulators appear to be affected
by aging (Table 30-3). Muscle mass decreases, body fat
increases, and total body water decreases with aging. The
increase in body fat and the reduction in body water have
an important impact on drug usage in older adults. The
increase in fat volume affects the actions of lipophilic
drugs, such as diazepam, by decreasing their initial effects
and prolonging their action. Reduction in total body
water has the opposite effect on water-soluble drugs, such
as acetaminophen, in that it produces an exaggerated
initial effect. These drugs often must be given in reduced
dosage to older adults.2'4'7'10
Baroreflex sensitivity is impaired with aging. This
leads to increased risk for orthostatic hypotension and
decreased thermoregulation. Increased orthostatic
 C H A P T E R 30 Dental Management of Older Adults 537

TABLE 30-3
Selected Age-Related Changes and Their Consequences*
Age-Related Physiologic Consequences of
Organ/System Changes Consequences of Age-Related Change Disease, Not Age
GENERAL Increased fat Increased volume for fat-soluble drugs Obesity
Decreased total body water Decreased volume for water-soluble drugs Anorexia
EYES/EARS Presbyopia (cannot focus) Decreased accommodation
Lens opacification Increased susceptibility to glare Blindness
Decreased high-frequency acuity Difficulty discriminating words if Deafness
background noise is present
ENDOCRINE Impaired glucose Increased glucose in response to illness Diabetes mellitus
Decreased thyroxine clearance Decreased T4 dose in hypothyroidism Thyroid dysfunction
and production
Increased ADH, decreased renin, Decreased Na+,
and decreased aldosterone increased K+
Decreased testosterone Impotence
Decreased vitamin D absorption Osteopenia Osteomalacia, fracture
and activation
RESPIRATORY Decreased cough reflex, Microaspiration, ventilation/perfusion Aspiration pneumonia,
decreased lung elasticity and mismatch and decreased PO2 dyspnea, hypoxia
increased chest wall stiffness
CARDIOVASCULAR Decreased arterial compliance Hypotensive response to increased heart Syncope
and increased systolic BPleft rate, volume depletion, or loss of atrial
ventricular hypertrophy contraction
Decreased (3-adrenergic response Decreased cardiac output and heart rate Heart failure
response to stress
Decreased baroreceptor Impaired BP response to standing, volume Heart block
sensitivity and decreased SA depletion
node automaticity
GASTROINTESTINAL Decreased hepatic function Delayed metabolism of some drugs Cirrhosis
Decreased gastric acidity Decreased Ca+ absorption on empty Osteoporosis, B[2
stomach deficiency
Decreased colonic motility Constipation Fecal impaction
Decreased anorectal function Fecal incontinence
RENAL Decreased glomerular filtration Impaired excretion of some drugs Increased serum
rate creatinine
Decreased urine concentration/ Delayed response to salt or fluid Increased/decreased
dilution restriction/overload; nocturia Na+
MUSCULOSKELETAL Decreased lean body mass, Functional impairment
muscle
Decreased bone density Osteopenia Hip fracture
NERVOUS SYSTEM Brain atrophy Benign forgetfulness Dementia, delirium
Decreased catechol synthesis Depression
Decreased dopaminergic Stiffer gait Parkinson's disease
synthesis
Decreased righting reflexes Increased body sway Falls
Decreased stage 4 sleep Early wakening, insomnia Sleep apnea
Impaired thermal regulation Lower resting temperature Hypothermia,
hyperthermia

From Resnick NM. Geriatric medicine. In Fauci AS, et al (eds). Harrison's Principles of Internal Medicine. New York, McGraw-Hill, 1998,
p 38.
ADH, Antidiuretic hormone; BP, blood pressure; HR, heart rate; SA, sinoatrial; T4, Thyroxine.
*Changes generally observed in healthy elderly subjects free of symptoms and detectable disease in the organ system studies. The
changes are usually important only when the system is stressed, or when other factors are added such as drugs, disease, or environmental
challenge are added.
538 Geriatrics P A R T TEN
hypotension increases the risks of falls and serious injury.
Also, the hypotensive effects of antidepressants, nitrates,
and antihypertensives may be compounded by decreased
baroreflex sensitivity. Impaired thermoregulation results
in the absence of shivering, failure of the metabolic rate
to rise, poor vasoconstriction, and insensitivity to low
body heat. These effects increase the risk for hypother-
mia and heat stroke in older adults. Some drugs such
as chlorpromazine and alcohol should be used with
caution in these individuals because they may cause
hypothermia.2'4'7
The level of activity of aortic and carotid chemorecep-
tors has been reported to decrease in older adults. The
use of normal adult dosages of morphine can lead to
severe respiratory depression in these individuals. Neu-
rologic control of bowel and bladder function may be
altered in older adults. Anticholinergic drugs such as
antidepressants, antihistamines, antipsychotics, and many
cold preparations must be used with care.4
Organ Systems and Functions Affected by Aging
Cardiovascular. A number of physiologic changes
occur in the aging heart that may help to explain some
of the more common age-associated cardiac disorders.2'7
One of the most important is delayed left ventricular
filling. Between the ages of 20 and 80, a 50% decline
occurs in left ventricular filling,7 which becomes more
dependent on active filling late in diastole during
atrial contraction.7 This decline is due to thickening
and stiffening of the left ventricular wall. The clinical
result of these ventricular changes is diastolic heart
failure.2'7
Resting heart rate tends to slow with advancing age,
as does maximum exercise-induced heart rate.7 Much of
this change is due to loss of sinus node pacemaker cells
(90% up to age 80 years).' The aorta dilates and its walls
thicken with the calcification of medial walls; this reduces
elasticity,7 and the process tends to lead to a secondary
increase in systolic blood pressure.7
Heart valves (particularly the mitral and aortic valves)
thicken and stiffen with advancing age, and 25% of older
individuals have flow murmurs.2'7 The heart of a 65-year-
old person beating at an average of 70 times per minute
has opened and closed the heart valves 2,391,500,000
times. It is not surprising, therefore, that the valves show
evidence of degenerative change, which is the most
common cause of valve disease in these patients. Aortic
and mitral valves are most often affected. Aortic stenosis
in persons 50 to 59 years of age is most often caused by
degeneration of a congenitally abnormal aortic valve.
When it occurs for the first time in a 60-year-old or older
individual, aortic stenosis usually is caused by degenera-
tion of a normal aortic valve. Older adults with valvular
heart disease are more prone to atrial fibrillation than are
younger adults with similar lesions."
The arrhythmia that is most commonly found in older
individuals is atrial fibrillation. It may occur in about
33% of older persons who are undergoing surgery and is
detected in about 4% of community-dwelling older
adults.2'7 Postural hypotension is common in older adults;
about 20% are affected.7 Sensitivity to filling volumes and
impaired heart rate response to stress appear to contrib-
ute to this problem.7 Postural hypotension is also com-
mon in older adults after large meals, severe infection
(depressed salt and water intake), and volume-depleting
stresses (diarrhea, diuretic therapy, bowel preparation for
colonoscopy).7 When older patients who may be prone
to postural hypotension are evaluated, standing blood
pressure becomes more important than sitting blood
pressure.7
The incidence of all ventricular arrhythmias in older
adults ranges from 69% to 96%. Ventricular tachycardia
occurs in 2% to 13% of older adults.2'7 The higher fre-
quency13%is reported in patients with known heart
disease.12 Arrhythmias in older adults often require the
use of pacemakers. In addition, many older adults are
treated with warfarin (Coumadin) for prevention of
thrombosis and embolism (see Chapter 25).
Endocarditis is a rare disease that has become more
common among older adults. More than 50% of patients
who have the first episode of endocarditis are 60 years of
age or older. The clinical presentation of endocarditis in
older adults is often atypical. The patient may be asymp-
tomatic or may describe vague nonspecific symptoms
such as anorexia, nausea, and vomiting. Only 50% to
70% of affected older adults will have fever. Neurologic
symptoms, such as confusion, occur in about 33% of
affected older adults. The diagnosis of endocarditis must
be considered in any older adult with heart murmur,
malaise, and fever (see Chapter 2)."
The annual incidence of new cases of heart failure
increases from less than 1 per 1000 patient-years for
individuals younger than 45 years, to 10 per 1000 patient-
years for patients older than 65 years, to 30 per 1000
patient-years for those older than 85 years." Prevalence
figures for heart failure show a similar increase: 0.1% in
those younger than 50 years of age to nearly 10% in
persons older than age 80.l3 Today, about 4.8 million
Americans have been given a diagnosis of heart failure,
and about 75% of these individuals are 65 years of age or
older.13 Mortality rates are higher in older adults, and
they are higher in older men than in older women (see
Chapter 6).13
Arteriosclerotic heart disease (ASHD) is the most
common category of heart disease in older adults, with a
prevalence of 168.9 per 1000.3'14 ASHD is the leading
cause of death in all ethnic groups of older adults in the
United States. The incidence of ASHD increases in
men and women until age 75. By age 80, the incid-
ence of ASHD is 20% in both men and women (see
Chapter 4).12
Respiratory. With advancing age, the chest wall
becomes stiffer as the result of thickening and calcifica-
tion of cartilage; in addition, spinal ligaments become
stiff, and joints become stiffer.7 Loss of elastic recoil in
 C H A P T E R 30
the lungs occurs with aging.7 These changes have little
effect on resting lung function but decrease maximum
breathing capacity by about 40%.7 In addition, at the
alveolar level, a significant reduction is seen in the capac-
ity to exchange oxygen and carbon dioxide (decreases by
about 50% between ages 30 and 65 years).7 The major
clinical impact of normal physiologic aging in the lungs
is an earlier appearance of shortness of breath as a warning
signal of underlying disease.7 In addition, risk for infec-
tion of the lungs is increased. Oral organisms may con-
tribute to pulmonary infection in older adults.7
Gastrointestinal. The esophagus continues to func-
tion relatively normally in older adults. However, the
strength of muscular contraction declines and peristaltic
waves slow. Also, the lower esophageal sphincter tends to
become lax with advancing age.7
The gastric mucosa secretes less acid with advancing
age. ' This does not affect digestion in most individuals
unless associated conditions such as atrophic gastritis are
present; when this occurs, the absorption of nutrients and
drugs is reduced.7 Delayed gastric emptying appears to
be a feature of aging that can lead to a false sense of
satiety.7
The surface area of the small intestines is reduced with
aging. This leads to a reduction in the absorption of some
dietary components such as calcium. Colonic function
appears to decline with advancing age, and stool fre-
quency tends to decline, while stools become harder.
Diverticula become more common; they are detected in
about 50% of individuals older than 80 years.7
The most important age-related symptom in later life
is constipation (may affect 60%).' Following is a list of
the more common medical problems involving the gas-
trointestinal tract reported in older adults: gastroesopha-
geal reflux, esophagitis, gastritis, peptic ulcer, enteritis,
intestinal obstruction, diverticulitis, hemorrhoids, and
colorectal carcinoma (see Chapter 12).
Renal. Kidney size declines by about 33% from 30 to
65 years of age, and blood flow through it declines by
about 1% per year.2'7 Starting in the late 30s, cortical
nephrons drop put and sclerose at a higher rate than
medullary nephrons. This can lead to a hyperfiltration
syndrome that limits concentrating capacity. Resultant
functional changes include a decreased ability to excrete
a salt load, reduced glomerular filtration rate, delayed
ability to regain sodium and potassium balance during
deprivation states, and difficulty in conserving water
under conditions of dehydration.7 The kidney is suscep-
tible to the effects of medications such as nonsteroidal
anti-inflammatory drugs (NSAIDs) that can lead to
hypertension due to sodium and fluid retention (see
Chapter 13).7
Dehydration is common among frail older adults
because of decreased fluid intake and increased fluid loss.
A recent study showed that total water intake, output, and
balance are maintained in healthy older adults, and an
Dental Management of Older Adults 539
increase is noted in hydration of the fat-free mass.15 Vom-
iting and diarrhea are the most common causes of iso-
tonic dehydration and fever, and delirium is the leading
cause of hypertonic dehydration.7 Urinary concentrating
defects and reduced thirst in these individuals increase
the risk of dehydration during illness.
With advancing age, the bladder tends to become
more irritable and to generate less power during contrac-
tion. Atrophy of vaginal and urethral tissues in postmeno-
pausal women makes them more prone to urinary tract
infection. Benign prostatic hyperplasia is common in
older men and causes urinary retention; this and other
factors (increased residual bladder volume and loss of
protective factors) lead to an increased frequency of
urinary tract infection.
Hepatic. Liver weight declines by one third between
ages 30 and 90 years because of the loss of hepatocytes.
In addition, blood flow to the liver decreases by 40% to
45% with advanced age.2'7 This results in reduced ability
to process medications such as benzodiazepines, alcohol,
and vitamin K-blocking agents.' Significant decreases in
plasma albumin (seen in hospitalized or poorly nourished
older adults) may result in greater amounts of free or
unbound drug, which can cause greater drug effects.
Doses of these drugs often must be adjusted and blood
levels monitored when possible (see Chapter 11).'
Endocrine. Growth hormone levels fall with advanc-
ing age.2'7 This decline appears to contribute to decreased
muscle strength, thinning of bones and skin, and increased
fat associated with aging.7 Production and clearance rates
of the thyroid hormones appear to remain constant with
advancing age.7 Parathyroid hormone levels increase with
advancing age, and this increase is more marked in
women.7 Cortisone secretion by the adrenal glands is
maintained with advancing age,7 and renin and aldoste-
rone secretion rates do decline.7 The insulin content of
the pancreas is increased in older adults, but its release
may be blunted. Insulin resistance may increase in older
adults, and glucose tolerance decreases, independent of
obesity and physical inactivity. The primary cause of this
decrease is insulin resistance in peripheral tissues, pri-
marily skeletal muscle, at the postreceptor level. Gluca-
gon secretion appears to be unchanged in older adults,7
although a dramatic decline in estrogen and progesterone
secretion by the ovaries is due to fibrosis and scarring.
Menopause occurs at an average age of 51 years. Hot
flashes, accelerated bone loss, and atrophy of estrogen-
sensitive tissues may occur.' In men, levels of testosterone
may begin to fall at about the age of 50 years; however,
the potency of semen does not appear to be affected.7
Immune. Amarked decrease in the size of the thymus
gland occurs between puberty and the age of 60 years.2'7
A corresponding drop in thymosin levels directly affects
the number of functional T cells found in older adults.
Also, T cells in older adults are less active in responding
540 Geriatrics P A R T TEN
to foreign proteins.' Although antibody responses occur
in older adults, these are less robust and less long lasting
than those seen in younger individuals.7 The decline in
immune function in older adults results in increased mor-
bidity and mortality with influenza and pneumonia.' The
risk of reactivation of tuberculosis, herpes zoster, and
other infections is increased in older adults because
immune function is reduced.' In contrast, the decline in
immune function reduces the risk that older adults will
develop autoimmune disease.7
Hematopoietic. No age-related change has been
noted in basal hematopoiesis. However, the hematopoi-
etic system in older adults is less able to respond to
increased demand. This is demonstrated by a slower
recovery from anemia and a reduced rise in hemoglobin
during hypoxia.' In addition, the marrow in older adults
is not as well stimulated by erythropoietin, as it is in
younger adults.' Neutrophils from older adults may show
less activity.7
Nervous. After the age of 60 years, the size of the
brain is reduced by 5% to 10%, mainly as the result of
decreased cerebral cortex tissue.7 A progressive decline in
the synthesis of neurotransmitters and in the number of
their receptors has been observed.2'' Slower reaction
times occur as a major functional change.' The lens of
the eye becomes thickened and stiffens, causing the far-
sightedness of aging. The ability to distinguish colors
(particularly blue) is reduced.7
Also, transmission of light through the lens may be
reduced by as much as 65% between the ages of 25 and
60 years.' The thickened lens in older adults causes worse
glare because of the scattering of light.' Tear production
is reduced and visual acuity tends to decrease in older
adults.'
About 25% of older adults experience hearing loss;
however, this event is more common among men.2'' It is
more difficult for these individuals to identify a voice or
to understand a spoken message when background noise
is present.' Often, the ability to hear high-frequency
sounds and to distinguish high-pitched consonants is
diminished.7
Sleep patterns change with advancing age. Older
adults spend more time in bed and are more wakeful
during the night.' Sleep-disordered breathing associated
with sleep apnea (see Chapter 10) appears to increase in
prevalence with advancing age.7
Musculoskeletal. Bone mass and density begin to
decrease with age after the 20s.7 In women, this loss may
occur at a rate of about 1 % per year until the time of
menopause. After the onset of menopause, bone loss
increases to 2% to 3% per year for 5 to 10 years, after
which it returns to a rate of 1 % per year7 and may accel-
erate again in the late 80s. Men have greater bone mass
than women and experience an annual loss of about 1 %
after the 20s. The clinical effects of this loss in men are
not seen until they reach an advanced age.' The most
important age-related clinical syndrome associated with
advancing age is osteoporosis.2'' Women have increased
susceptibility to osteoporosis with aging, and the major
impact has been noted to occur after menopause. Micro-
fractures of bone take longer to repair because of
decreased osteoblastic cell activity. One study indicated
that older adults are aware of the risk for osteoporosis
but have an incomplete understanding of the causes of
and ways to prevent the condition.16
Bisphosphonates are used to treat osteoporosis in
postmenopausal women and to a lesser degree in men.1''18
Alendronate and risedronate are bisphosphonates
(Fosamax, Actonel, Boniva, Didronel, and Skelid) that
have been approved by the U.S. Federal Drug Adminis-
tration (FDA) for prevention of bone loss or for treat-
ment of established osteoporosis in postmenopausal
women.17'18 The FDA has also approved alendronate for
the treatment of osteoporosis in men. The bisphospho-
nates are given orally to treat osteoporosis and are used
to prevent bone loss in patients with cancer. Several
bisphosphonates (Zometa, Aredia, Didronel, and Bonefos)
are given by intravenous injection. Osteonecrosis of the
jaws is a significant complication that is associated with
bisphosphonate therapy, particularly when treatment is
given intravenously to patients with cancer. For a more
detailed discussion of these agents and their uses, see
Chapter 26.
With advancing age, tendons and ligaments become
less elastic. This can lead to rupture of these structures,
especially the Achilles tendon, in older individuals.' Car-
tilage and ligaments of the ribs and spine tend to become
calcified and less elastic in older adults.' Flattening of the
arches of the feet also occurs. Osteoarthritis is a very
common problem in older adults, and many of the major
joints are affected.
The ultimate size and strength of muscles is reached
during the 20s and 30s. By the age of 70 years, both men
and women have lost about 25% of their muscle mass,
unless this was offset by exercise.' Loss of muscle mass
continues, and by the age of 80 years, it may occur at a
30% to 40% lesser rate than in the peak years. Muscle
mass in late life depends on exercise in earlier life (results
in a higher early mass) and exercise late in life to stimulate
muscle preservation.' An important complication of loss
of muscle mass in older adults is a predisposition for
falling. Falling is the leading cause of death at home for
older individuals.
Skin. In the mid-40s, subcutaneous tissue starts to
thin, independent of injury from sun exposure. The epi-
dermis and the dermis lose adherence, increasing the
tendency for blistering, friction burning, and pressure
ulceration.' These changes also lead to development of
senile purpura (Figure 30-1) caused by tears in the small
venules and trauma to the skin.7 Ultraviolet sunlight,
wind, and smoking can damage the subcutaneous tissues
(elastin fibers) and epidermis, leading to the development
 C H A P T E R 30
Figure 30-1. Senile purpura. (From Hoffbrand AV, Pettit
JE. Color Adas of Clinical Hematology, 3rd ed. London,
Mosby, 2000.)
of wrinkles. Sun exposure can lead to slower repair of skin
injuries and predisposes to the development of skin cancer
(basal cell carcinoma, squamous cell carcinoma, and mel-
anoma).' About 66% of older adults have at least one skin
problem.'
Environmental exposure and age-related skin changes
greatly prolong healing time for skin injuries. Skin healing
takes about 50% longer in older adults than in individuals
in their 30s.' The hair in older adults grows more slowly,
and graying occurs as the result of loss of melanocytes
within hair bulbs. The ability to sweat is reduced in older
adults, which lessens heat loss by conduction and evapo-
ration.' Older adults must protect themselves from tem-
perature extremes.7 Skin changes in older adults predispose
to pressure sores (necrotic areas of muscle, fat, and skin)
with prolonged bed rest.' The incidence of pressure sores
among older adults in acute care hospitals is 8%, and
the prevalence rate is 16%.' These rates are even
higher for patients in intensive care and in those with
hip fracture.'
% ping, and cracking, and they become more susceptible to
Oral. Age-related changes in the mouth include
slower production of dentine, shrinkage of the root pulp,
and decreasing bone density of the jaws. Taste and smell
decline progressively with advancing age, and thresholds
for salt, sweets, and certain proteins are increased.' Food
may taste more bitter, and more sugar is required. Sali-
vary gland function usually does not change with age, and
the loss of bone and tongue musculature makes the
tongue appear to be enlarged.'
Age does not appear to play a major role in the
decline of oral health. Oral cancer can lead to death by
local extension or metastasis. Radiation therapy for head
and neck cancer can lead to oral disorders such as muco-
sitis, dental caries, xerostomia, or osteoradionecrosis.
Dental Management of Older Adults 541
Cancer elsewhere in the body can metastasize to the
oral cavity (represents about 1 % of cancers found in the
oral cavity), and in some cases (about 20%), this may be
the first sign of the presence of a distant primary
cancer.19
Older adults underutilize dental services. Less than
one third of older adults have annual dental visits, and
almost one half have not seen a dentist in 5 years.20 The
primary reason for older adults to visit the dentist is to
undergo a diagnostic or preventive procedure.21 Those
who are not seeking dental care do not see a need to do
so, or they report that cost is a barrier.21 A study of rural
Iowa residents (65 years of age or older) found that more
individuals were retaining more teeth and consequently
may need and seek dental services more often than previ-
ous cohorts who were more edentulous.22
Dentistry should provide an aggressive educational
program to get older adults to be seen and evaluated by
a dentist. Other health care professionals need to provide
older adult patients with an oral screening assessment and
must refer to dentistry those with oral disease.20
Many adults 40 years ago thought that tooth loss was
part of "aging." In 1957, only 40% of older adults had all
or some of their natural teeth. This increased to more
than 66% in 1994.20 Tooth loss in young patients is
usually due to caries or trauma. Tooth loss in adults (30
to 64 years of age) most often is caused by periodontal
disease. Tooth loss in older adults is caused by periodon-
tal disease and dental caries. Recurrent caries (involving
margins of restoration) and root surface caries account
for the vast majority of lesions found in older adults.23
Older adults are predisposed to caries and tooth loss
associated with aging changes. These include diminished
tooth sensation, root exposure, gingival recession, com-
promised oral hygiene, changes in the composition of
saliva, and decreased salivary flow.20'24
The most common age-related changes in teeth are
occlusal attrition, pulpal recession, fibrosis, and decreased
cellularity. Severe attrition can lead to loss of vertical
dimension of occlusion. Secondary and reparative dentin
leads to acellular and dehydrated dentin, and a decrease
in the number of nerve fibers in the pulp of teeth occurs
with aging. With aging, the teeth undergo staining, chip-
fracture.24
Older adults often feel no pain with advancing carious
lesions. Acute, throbbing pain is not a common symptom
of caries in the older adult, as it is in younger individuals.
Older adults most often seek treatment because of food
impacting within the carious lesion, or fracture of the
tooth that is unsightly or lacerates oral soft tissues.20
Older adults show evidence of gingival recession and
loss of periodontal attachment and bony support. Changes
in the periodontium due to aging alone are not sufficient
to cause tooth loss.20 However, the additional effects of
poor oral hygiene, systemic disease, and medication lead
to increased periodontal disease and dental caries, result-
ing in tooth loss.
542 Geriatrics P A R T TEN
Gingival recession makes the teeth more susceptible
to caries by increasing the total tooth surface that the
patient must maintain and by exposing tooth surfaces
not covered by enamel (e.g., cementum).20 Results of
the Health, Aging, and Body Composition cohort study,
which was undertaken to determine the association
between periodontal disease (6 mm or greater pocket
depths) and weight loss, found that periodontal disease
may be causally related to weight loss in older adults and
may increase risks of morbidity and mortality.25 Glycemic
control in older patients with type 2 diabetes and peri-
odontitis may be better controlled by effective periodon-
tal therapy.26
Physical and cognitive impairment in older adults can
interfere with the patient's ability to perform oral hygiene
procedures. In many cases, caregivers have to take over
these procedures. In cases in which no caregivers are
available to assist with oral hygiene procedures, dental
problems such as dental caries, tooth abscess, tooth frac-
ture, and gingival and periodontal disease may be
expected.20
In healthy older adults, no general diminution occurs
in the volume of saliva produced.20 Many older adults
report dry mouth, and some have diminished salivary
output. Systemic diseases such as diabetes mellitus can
cause dry mouth. Radiation therapy for head and neck
cancer can decrease salivary flow. Medications taken
by older adults also can cause this problem. More than
400 drugs have been reported to cause dry mouth.20 The
following groups of drugs have been noted to cause
xerostomia: tricyclic antidepressants, sedatives and tran-
quilizers, antihistamines, antihypertensives, cytotoxic
agents, and antiparkinsonian drugs.24
Prolonged salivary dysfunction leads to numerous oral
and pharyngeal problems in older adults. These problems
include dry and friable oral mucosa, fissured tongue,
decreased antimicrobial activity, diminished lubrication,
caries, periodontal disease, fungal infection, burning,
pain, and difficulty with mastication and swallowing.24
Early diagnosis and treatment can prevent the problems
associated with prolonged dry mouth. Diagnostic proce-
dures may include review of the patient's history and
physical findings, sialometry, sialograms, labial gland
biopsy, and T99 pertechnetate scintiscans.24 (The man-
agement of xerostomia is covered in Chapter 26.)
Changes in mastication, swallowing, and oral muscu-
lar posture occur with aging. These changes may not
have adverse effects on healthy older adults. However,
when compounded by systemic diseases (e.g., stroke,
Parkinson's disease) and drug regimens (e.g., tardive dys-
kinesia associated with antipsychotic drugs), serious com-
plications associated with chewing and swallowing, such
as choking or aspiration, may occur.24
Older adults may report reduced food recognition and
enjoyment and altered smell and taste function. Taste
function undergoes few age-related changes. However,
smell is dramatically diminished across the human life
span.24 Decreased smell capacity combined with changes
in oral motor, salivary, and other sensory functions
appears to account for the loss of flavor perception and
interest in food in older adults.24 These patients re-
quire nutritional counseling to prevent malnutrition and
dehydration.24
The prevalence of oral mucosal lesions in U.S. adults
was investigated in the Third National Health and Nutri-
tion Examination Survey.27 Oral examinations were per-
formed on 17,235 individuals aged 17 years and older.
Oral lesions (6003) were noted in 4801 (27.9%) persons.
Denture-related lesions (8.4%) were most common.
Tobacco-related lesions accounted for 4.7% of all lesions,
and amalgam tattoos (3.3%) were the most prevalent
lesion. Lesion prevalence increased with advancing age,
wearing of dentures, and use of tobacco.27
An interesting association between periodontitis and
oral cancer was suggested by findings from the Third
National Health and Nutrition Examination Survey.28
The severity of periodontal disease was represented by
loss of clinical attachment. The independent effect of loss
of clinical attachment on three separate dependent vari-
ables (tumor, precancerous lesions, and any soft tissue
lesion) was assessed. Results suggested that loss of clinical
attachment was related to tumors and to precancerous
lesions but not to soft tissue lesions. Prospective or well-
designed case control studies with histologically con-
firmed oral cancers are needed to confirm this possible
relationship.28
Most oral cancerssquamous cell carcinomasare
reported in persons older than 50 years of age. Hodgkin's
disease occurs in two peaks: early adulthood, and around
the fifth decade of life. Non-Hodgkin's lymphoma is
reported in all age groups. Benign and malignant salivary
gland neoplasms are more common in older adults.
Other Considerations
Cognitive. Dementia is the loss of established intel-
lectual ability in a way that interferes with occupational
and social function. It includes impairment of memory,
language, perception, calculation, abstract thinking, judg-
ment, and executive function. Alzheimer's disease causes
more than 50% of cases of dementia that is irreversible.
The next most common cause of dementia is small mul-
tiple infarcts of the brain; this condition also is irrevers-
ible. Dementias are more fully discussed in Chapter 27.
Alzheimer's disease is discussed here briefly because it
is the most common type of dementia. Global cognitive
impairment occurs with Alzheimer's disease. Approxi-
mately 10% of older adults over 65 years of age and
45% over age 85 have Alzheimer's disease. Tacrine
(Cognex) has attained short-term gain in the treatment
of Alzheimer's disease, but no evidence suggests long-
term benefit. Tacrine is associated with a high rate of
drug toxicity.4'29'30 Another drug, donepezil (Aricept), has
shown about the same level of benefit as tacrine but
without the high rate of toxicity. Tacrine and donepezil
are cholinesterase inhibitors.31 Galantamine (Reminyl)
and rivastigmine (Exelon) are two other cholinesterase
 C H A P T E R 30
inhibitors that are currently used to treat mild to moder-
ate symptoms of Alzheimer's disease.2 The newest avail-
able drug for the treatment of Alzheimer's disease is
memantine (Namenda), an NMDA (N-methyl-D-aspar-
tate) receptor inhibitor. The FDA has approved donepe-
zil, galantamine, rivastigmine, and memantine for the
treatment of patients with mild to moderate Alzheimer's
disease. Two new drugs are under investigation for the
treatment of Alzheimer's diseaseAJzhemed (dissolves
beta-amyloid) and LY450139 (interferes with secretases
and the formation of beta-amyloid). AJzhemed is under
development by Neurochem Inc. of Canada, and
LY450139 by Eli Lilly and Company.'"5
Depression. Although depression is common in older
adults, age itself is not a significant risk factor. Illness and
loss of a spouse or loved one are the most striking risk
factors for depression. In treatment settings, the preva-
lence of depression in older adults is as follows: 9% to
15% in primary care practices, 15% to 25% in geriatric
clinics, and 33% to 45% in hospitals and nursing homes.
Medical treatment and psychotherapy both offer about
the same treatment benefit, which is significant.
Treatment should be offered to all older adults with
depression.4'30 Depression is more fully discussed in
Chapter 29.
Suicide. Suicide rates for older men and women are
higher than the average rate in the general population.30
A decline in suicide rates has been seen in older adults of
both sexes in recent years.30 Male suicide rates increase
with age, and rates in females increase until about age 60
years; they then decline from that point. Fifty to ninety
percent of older adults who commit suicide have depres-
sive illness.30 Substance abuse or dependence is reported
in about 44% of older adults who commit suicide.30 Other
important findings in older adults who commit suicide
include schizophrenia, dementia, delirium, physical
illness, chronic pain, and cancer.30 With increasing age,
the tendency to use more violent methods to commit
suicide increases. Suicide is more fully discussed in
Chapter 29.
Infectious disease. From 1981 through 2004, about
12% (114,951) of all cases of acquired immunodeficiency
syndrome (AIDS) (944,306) in the United States occurred
in individuals 50 years of age or older.36 About 1.53%
(14,410) of cases were reported in persons 65 years
or older.36 Severe immunosuppression was the AIDS-
defining condition in more than 50% of individuals 50
years or older. The vast majority of these cases occurred
in homosexual men, blood transfusion recipients, injec-
tion drug users, those who had heterosexual contact, and
men who were having sex with men who were injection
drug users.
The prognosis for HIV infection in individuals over
age 50 years is much worse than for younger adults. HIV
infection in older adults leads more quickly to subclinical
Dental Management of Older Adults
immunodeficiency. Survival time after AIDS is diagnosed
is inversely related to age. Leading causes of death
in older adults are the same as for younger adults
opportunistic infection and bacterial infection (see
Chapter 19).
Older adults are prone to develop complications when
infected with the influenza virus. The aging process
decreases one's ability to clear secretions and to protect
the airway. Older adults with chronic illness are especially
at risk for the complications of influenza, and older adults
account for 80% to 90% of all influenza-related deaths.
All older adults should receive an influenza vaccine each
year just before the start of the flu season.37'38
Pneumonia is a very serious disease in older adults that
often results in death. The increased risk is due to age-
related deterioration of the immune system, underlying
chronic illness, weakened cough reflex, decreased mobil-
ity, and the presence of oral bacteria. Older adults often
do not display the classic symptoms of pneumonia (i.e.,
fever, chills, anorexia, and general malaise) seen in
younger adults. The older adult with pneumonia often
has symptoms of dehydration, confusion, and increased
respiratory rate. Streptococcus pneumoniae is the leading
cause of community-acquired pneumonia in older adults,
accounting for up to 66% of cases. Nosocomial pneumo-
nia in older adults is most often caused by Staphylococc^ls
aureus. All older adults should receive the pneumococcal
vaccine, starting at the age of 65 years.38"
Diabetes. The prevalence of type 2 diabetes in the
United States is estimated at 6% but may exceed 10% to
15% in individuals older than 50 years of age.41 It is esti-
mated that about 33% of cases are undiagnosed.41 The
prevalence rate for type 1 diabetes in the United States
is between 0.3% and 0.4%. Incidence rises from infancy
to puberty and then declines. However, in about 30% of
patients, the condition is diagnosed after the age of 20
years.41 Type 2 diabetes is much more common than type
1 diabetes in older adults. Over all ages, type 1 diabetes
accounts for less than 10% of cases, and type 2 diabetes
accounts for more than 90% of all cases of diabetes.41
Patients with type 2 diabetes who are older than 65 years
of age have the highest rates of comorbiditycoronary
artery disease, hypertension, and osteoarthritis.4 Diabetes
mellitus is more fully discussed in Chapter 15.
Hypertension. From the age of 20 years, systolic
blood pressure tends to increase with age in both men
and women. In contrast, diastolic blood pressure from
the age of 20 years increases until about the age of 60
years, when it begins to decrease each year.42
After the age of 50 years, the most common form of
hypertension is isolated systolic hypertension, that is, a
systolic blood pressure of 140 mm Hg or greater with a
diastolic pressure less than 90 mm Hg. It is now the most
common form of uncontrolled hypertension in the United
States.42 This problem was perpetuated by a past persis-
tent focus on lowering of diastolic blood pressure, a fear
544 Geriatrics P A R T T E N
of lowering blood pressure excessively in older adults,
and the greater difficulty associated with lowering sys-
tolic blood pressure with available medications.42 In older
adults with isolated systolic hypertension, cardiovascular
risk increases curvilinearly with increasing systolic pres-
sure, but with an inverse relationship to diastolic pres-
sure. For example, a blood pressure of 170/70 mm Hg
carries twice the risk of coronary heart disease as a blood
pressure of 170/110 mm Hg.42 The treatment goal now
with most older adults with isolated systolic hypertension
is to reduce systolic blood pressure to below 140 mm Hg.42
Hypertension is more fully discussed in Chapter 3.
Urinary incontinence. Urinary incontinence consists
of the involuntary loss of urine of sufficient quantity to
be a health and/or social problem.2'7 It occurs commonly
in young and middle-aged women, often in association
with childbirth. It is common in middle-aged and older
men with benign and malignant prostate enlargement7
and is reported in about 33% of women and 20% of men
60 years and older who are healthy community dwellers.7
The prevalence of urinary incontinence is about 40% in
hospitalized older adults and 70% to 80% in adults living
in long-term care centers.7 Urinary incontinence causes
significant physical and psychosocial problems and results
in significant health care costs.7 It contributes to skin
problems and falls in older patients who rush to the
bathroom.7 It carries a social stigma and can lead to
embarrassment, isolation, and depression.7
Medications. About 30% of all prescription medica-
tions are taken by older adults, even though they repre-
sent only about 14% of the population.7 Nonprescription
medications (herbal and over-the-counter drugs) are also
used more frequently by older adults. Although gastro-
intestinal changes are reported in older adults, absorption
of most medications does not appear to be affected7;
however, drug distribution does change with advancing
age. With declining muscle mass, fat increases as a pro-
portion of body weight.7 Thus, older adults are more
sensitive to the effects of water-soluble drugs (i.e., a
decrease in total body water concentrates water-soluble
drugs) and experience prolonged but reduced initial
effects with lipophilic drugs (fat-soluble drugs have
longer half-lives).7 Serum albumin levels decline with
advancing age, particularly in sick older patients, result-
ing in a decrease in protein binding of drugs such as
warfarin and phenytoin and an increase in their avail-
ability, thus enhancing drug actions. Declining renal
function associated with normal aging reduces the clear-
ance of drugs such as digoxin, aminoglycosides, and
cimetidine.7
Hepatic metabolism of some drugs may also decline
with age.7 Oxidative reactions (phase 1) may become
impaired during normal aging, although conjugation and
glucuronization reactions (phase 2) do not appear to be
affected. Diazepam requires phase 1 and phase 2 metab-
olism and has a prolonged half-life in older adults,
whereas oxazepam requires only phase 2 reactions and its
half-life is not affected.7
The brain in older adults may be more sensitive to
drugs such as opiates, benzodiazepines, and neuroleptics.
Doses of these medications often must be reduced when
they are used in older adults. Warfarin (acts on the liver)
must be used at lower doses in older adults because the
liver is sensitive to blockage of vitamin K-dependent
systems.7
Reduced compliance in taking their medications is a
problem often noted in older adults. Adherence is influ-
enced by the cost of medications, inadequate education
about medications, unacceptable adverse effects, and
complex medical regimens. Lower compliance is common
in patients who are taking more than three prescription
drugs.7 A significant problem in older adults who are
taking multiple drugs is the progressive accumulation of
anticholinergic effects such as dry mouth, constipation,
poor vision, urinary retention, balance disorders, and
cognitive difficulties.7 Drug classes involved include neu-
roleptics, antispasmodics, antianxiety agents, antihista-
mines, and medications used for urinary incontinence.7
Falls. Falls are a major age-related syndrome that
results from changes in the neural, musculoskeletal, and
cardiovascular systems.2'7 Reported accidental falls usually
exclude those resulting from syncope, stroke, or seizure.
Approximately 3 3 % of community-dwelling older adults
fall each year.4 In nursing homes, more than 50% fall at
least once per year. Across all settings, 1 of every 6 falls
produces injury, usually to soft tissue; 1 in 20 results in
fracture of the hip, rib, or wrist; and 1 of every 100 leads
to hospitalization.4 Injury is the sixth leading cause of
death in older adults (Table 30-4).
Intrinsic risk factors for falls in older adults consist of
reductions in physical function (strength, balance, gait),
neurologic disorders (stroke, dementia, parkinsonism,
arthritis), sensory deficits (vision, hearing), and postural
hypotension. Extrinsic risk factors for falls include poorly
fitting shoes, long and loose garments, slick floors, loose
rugs, obstacles, poor lighting, lack of handrails, and the
number and type of medications being taken. Multiple
drugs, regardless of type, increase the risk for falls in
older adults.4'7 Some drugs, however, pose a greater risk
(i.e., those that affect central nervous system function and
balance, such as benzodiazepines).
Laboratory Findings
Laboratory tests used to assess the older adult patient are
discussed in the chapter that covers the specific illness
under consideration. Little variation is noted in complete
blood count, calcium, blood urea nitrogen, and cortisol
or growth hormone with increasing age. Age-related
decreases in levels of aldosterone, androgens, and angio-
tensin II are observed in older adults. In addition, age-
related increases in levels of thyroid-stimulating hormone,
triiodothyronine, and vasopressin may occur in these
individuals.1
 C H A P T E R 30 Dental Management of Older Adults 545

TABLE 30-4
Intrinsic Risk Factors for Falling and Possible Intervention
Risk Factor
Reduced visual acuity, dark
adaptation and perception
Reduced hearing
Vestibular dysfunction
Proprioceptive dysfunction,
cervical degenerative
disorders, and peripheral
neuropathy
Dementia
Musculoskeletal
Foot disorders (calluses,
bunions, deformities,
edema)
Postural hypotension
Use of medications/
sedatives: benzodiazepines,
phenothiazines,
antidepressants,
antihypertensives, others:
(anti-arrhythmics,
anticonvulsants, diuretics),
alcohol
Medical
Refraction: Cataract extraction
Removal of cerumen: audiologic evaluation
Avoidance of drugs affecting the vestibular
system: neurologic or ear evaluation, if
indicated
Screen for vitamin B12 deficiency and cervical
spondylosis
Detection of reversible causes, avoidance of
sedative or centrally acting drugs
Appropriate diagnostic evaluation
Shaving of calluses, bunionectomy, treatment of
edema
Assessment of medications, rehydration, possible
alteration in situational factors such as meals,
change of position
Steps to be taken:
Attempts to reduce number of medications
being taken
Assessment of risks and benefits of each drug
Selection of the shortest acting medication
with the least effect
Prescription of lowest effective dose
Frequent reassessment of risks and benefits
Rehabilitative or Environmental
Home safety assessment
Hearing aid if appropriate: reduction in
background noise
Habituation exercises
Balance exercises, walking aid,
correctly sized footwear, home safety
assessment
Supervised exercise and ambulation,
home safety assessment
Balance and gait training, muscle
strengthening exercises, walking aid,
home safety assessment
Trimming of nails, appropriate footwear
Dorsiflexion exercises, pressure-graded
stockings, elevation of head of bed,
use of a tilt table if condition is severe

From Tinetti ME, Speechley M: Prevention of falls among the elderly. NEJM Apr 20;320(16):1055-1059, 1989.

DENTAL MANAGEMENT Clinical Examination. The clinical examination may

Patient Management
History. An older adult with vision loss may be unable
to fill out a health questionnaire. The history of the
patient should be obtained in whatever way possible; this
can be done by oral interview. In cases of severe dysfunc-
tion that does not allow the patient to participate effec-
tively, relatives or care providers will have to be involved
with the medical history of the patient. The history
should establish what medical problems the patient has
and should uncover signs and symptoms that may indi-
cate the presence of an undiagnosed condition.
Of particular importance are the medications older
adults may be taking. Each medication that the patient is
taking must be identified, including prescription, herbal,
and over-the-counter drugs. Many older adults are taking
multiple drugs; thus, the medication history is even more
important in this group of patients. The dentist must
know what drugs the patient is taking to prevent drug
interactions with agents that the dentist may need to
prescribe.
be more difficult in some older adults. For example,
patients with arthritis of the temporomandibular joint,
head and neck cancer treated by surgery or radiation,
neurologic disease, disorders of the musculoskeletal
system, or adverse effects of antipsychotic drugs such as
Parkinson-like symptoms or tardive dyskinesia may
present a problem. These patients may have difficulty in
opening their mouths, being able to hold still, and fol-
lowing the dentist's instructions regarding mouth or head
positioning. The dentist may need to spend additional
time and use sedative agents to complete the clinical
examination. The dentist will need to speak louder, face
the patient, and use shorter statements when giving
directions or asking questions of patients with hearing
loss or dementia. With gentle hand or finger pressure,
the patient can be directed to move the head or jaws to
facilitate the examination. In some patients, complex
examination procedures cannot be performed. Clinical
examination should include inspection of the exposed
skin of the arms, legs, neck, and face and intraoral soft
tissues for signs of benign and malignant lesions.
546 Geriatrics P A R T T E N

TABLE 30-5
Selected Dental Care Problems That May Affect Older Patients
Condition
Patient easily stressed because
of advanced age, systemic
disease, and/or behavioral
problems (anxiety)
Prone to orthostatic
hypotension
Dementia, physical disability,
advanced illness
Poor eyesight
Patient taking multiple
medications
Noncompliant patient,
hypertensive patient not
taking medication
Patient with signs and symptoms
of systemic disease, such as
leukemia, diabetes,
hypertension, renal disease,
and liver disease
Patients under medical
treatment for
cardiovascular disease
Patient taking an anticoagulant
Patient with prosthetic heart
valve, history of endocarditis,
congenital heart disease, recent
open heart surgery to correct
cardiovascular problem or
acquired valvular heart disease
Patient taking antihypertensive,
antidepressant, antipsychotic,
or other medications that
cause xerostomia
Problem
Stress may precipitate a
cardiovascular event
Syncope
Difficult to follow directions,
sitting still during appointment,
rendering effective home care
Difficult to fill out health and
dental questionnaires
Possible drug overdose, drug
interactions, and potential
problems with medications
that the dentist may need to
use
Elevated blood pressure, possible
risk of stroke, angina,
myocardial infarction
Patient may be at great risk of
for infection, bleeding, or a
cardiovascular complication
Sudden increase or decrease in
blood pressure may indicate
onset of complication
Surgical procedures may
cause excessive bleeding
Dental bacteremias may
cause bacterial endocarditis
Increases the risk for dental
caries, periodontal disease,
fungal infection, and mucositis
Possible Solutions
Short appointments, late morning or early
afternoon appointments, use of sedative oral
medication or nitrous oxide/oxygen
Change chair position slowly, assist and support
patient when getting out of chair
May need to apply sedation; make short
appointments; request that spouse or relatives
render home care
Have spouse or relative fill out questionnaire, or the
dentist can take an oral history from the patient
Refer patient with obvious toxic drug effects or
interactions; confirm with physician that
medications are current; use the lowest possible
effective dose of drugs needed for dental care,
and avoid drug interactions
Refer patient for reevaluation by the physician;
select a drug without the adverse effects that the
patient may be concerned about
Refer to physician for diagnosis and treatment, as
indicated
Monitor patient's blood pressure and pulse during
dental treatment; leave blood pressure cuff on
during treatment, and take the blood pressure
every 10 to 15 minutes (pulse oximeter can be
used to monitor the heart rate)
Consult with patient's physician; surgery may
be performed if INR is 3.5 or less; higher values
of INR usually require reduction in the
anticoagulant dosage before surgery; requires 3 to
5 days after dosage reduction for the INR to fall
See Chapter 2 regarding the need for antibiotic
prophylaxis to prevent bacterial endocarditis
Ask whether physician can change medication; use
topical fluoride, and good home care, including
brushing and flossing, saliva substitutes, and saliva
stimulants (see Appendix C)

INR, International normalized ratio.

Blood pressure should be assessed on all new dental
patients, including those already identified as hyperten-
sive, and at all recall appointments. The current upper
limit for normal blood pressure is 140 mm Hg for systolic
and 90 mm Hg for diastolic.4' Blood pressure should be
assessed early during the first dental appointment, then
again later in the appointment. The average of the two
recordings should be used to record the patient's blood
pressure (see Chapter 3).
Medically compromised patients may be best managed
by blood pressure measurement at the start of every
dental appointment and at key times during prolonged,
complex dental procedures. Table 30-5 lists some of the
problems the dentist may face in treating older adults.
General Guidelines. Older adults are often easily
stressed by dental treatment. In general, late morning or
early afternoon appointments are best for this group of
 C H A P T E R 30
patients. Medical complications are more common in
these patients in the early morning as their blood pressure
is rising. By late afternoon, patients may be stressed by
the day's activities. The dentist should see medically com-
promised older adults early in the week, so that if post-
operative complications develop, patients can be seen
promptly. Medically compromised older adults should
have their blood pressure and pulse monitored at the start
of the dental appointment and several times during it
(every 15 to 30 minutes; pulse oximeters are useful for
this assessment). Long appointments should not be sched-
uled for these patients. Stress reduction44 can be attained
with the use of oral, inhalation (nitrous oxide), intramus-
cular, or intravenous sedation (see Chapter 28). Care must
be taken to avoid overdosing with these agents.
Patients with congestive heart failure or chronic
obstructive pulmonary disease may have difficulty breath-
ing in a supine position during dental work. These patients
fare much better if they are placed in an upright or semis-
upine position. Care should be taken when changing the
chair position for older adults. The incidence of ortho-
static hypotension increases with age and as an adverse
effect of many drugs that these patients may be taking. A
sudden change from the semisupine to the upright posi-
tion may cause this type of hypotension. A matter of
particular concern occurs when the older adult first gets
out of the dental chair. Orthostatic hypotension at this
time may lead to syncope (fainting) and a fall that could
cause serious injury. Patients should be placed in an
upright position slowly and should be allowed to sit for a
minute; then, they should be supported by the dentist or
a dental assistant when getting out of the dental chair.
Medications. A dentist who prescribes drugs for older
adults should use the following guidelines: (1) The
patient's medical problems should be known, (2) all drugs,
including herbal and over-the-counter preparations being
taken by the patient, must be identified, (3) the dentist
must know the pharmacology of the drugs, (4) a new drug
should be started at a small dose, and additional doses
titrated on the basis of response ("start low, go slow"), (5)
dosage regimens should be kept as simple as possible, and
(6) visual, motor, or cognitive impairment can lead to
errors or noncompliance; relatives or caregivers may have
to assist with drug administration.
Sedatives and hypnotics must be used with extra care
in the older adult because they may precipitate cognitive
impairment. These medications should be started at the
lowest dose possible, which can then be increased gradu-
ally to the minimum effective dose ("start low, go
slow").32'45 The use of short-acting agents such as tri-
azolam (Halcion) is suggested. Nitrous oxide analgesia
can be used, but care must be taken to ensure that ade-
quate amounts of oxygen are supplied. These patients
will require an escort to get home.
General anesthetics should not be used for older adults
in the general dentist's office and must not be used at all
for medically compromised older adults. Amide local
Dental Management of Older Adults
anesthetics must be used with care or not at all in patients
with advanced liver disease.
Selection of a postoperative oral analgesic requires
knowledge of systemic health and medicines taken by the
older adult patient. The most common adverse reaction
associated with aspirin and NSAIDs is gastrointestinal
upset. These agents should not be used in older adults
with gastrointestinal disorders such as ulcers, gastritis, or
hiatal hernia. In other older adults, these agents can be
used, but care should be taken to avoid gastrointestinal
irritation. This can be done by administering them with
food, milk, or water (a full glass), or by having patients
take a liquid antacid with aspirin or NSAIDs.
Medical Considerations
Hypertension. Any patient with a mean initial diastolic
pressure of 110 mm Hg or greater should be referred at
once for medical evaluation and diagnosis. Patients with
initial diastolic pressures between 90 and 109mmHg
should have their blood pressure taken again at the next
dental visit. If the mean repeat diastolic pressure is greater
than 90 mm Hg, the patient should be referred for
medical evaluation.
Any patient with an initial mean normal diastolic pres-
sure and a mean systolic pressure of 180 mm Hg or
higher should be referred at once for medical evaluation
and diagnosis. Patients with an initial normal diastolic
pressure and an initial systolic pressure between 140 and
179 mm Hg should have their blood pressure taken again
at the next dental visit. If the mean repeat systolic pres-
sure is greater than 140 mm Hg, the patient should be
referred for medical evaluation. Adverse effects associ-
ated with antihypertensive drugs are discussed in Chapter
3; the most common are dry mouth, orthostatic hypoten-
sion, depression, sexual dysfunction, weakness, flushing,
and altered taste. Drug interactions between antihyper-
tensive drugs and agents used by the dentist also are
presented in Chapter 3. In general, only small amounts
of epinephrinemaximum, 0.036 mgshould be used
with these agents. NSAIDs may reduce the effectiveness
of some antihypertensive drugs.
Cardiovascular. As a general guideline, no more than
two cartridges of 2% lidocaine with 1:100,000 epineph-
rine should be used during any dental appointment for
older adults with cardiovascular disease. Older adults
with refractory arrhythmias, recent myocardial infarc-
tion, unstable angina, uncontrolled hyperthyroidism,
recent coronary artery bypass graft, uncontrolled conges-
tive heart failure, and uncontrolled hypertension should
not receive routine dental treatment. If emergency dental
treatment must be provided, a local anesthetic without a
vasoconstrictor should be used (see Chapters 3, 4, 5, and
6). A pulse oximeter (Oxycount Mini Pulse Oximeter;
Weinmann, Hamburg, Germany) may be used to monitor
pulse for patients with atrial fibrillation or a pacemaker.
Panoramic radiographs may reveal images of calcified
atheroma in the internal carotid artery in asymptomatic
548 Geriatrics PART TEN
patients. Lesions that cause more than 50% occlusion
may be associated with increased risk for stroke.46 In a
study of panoramic radiographs of 1548 asymptomatic
patients, 65 patients (4.2 %) were found to have at least
one internal carotid artery atheroma.46
Patients in whom lesions were detected underwent
Doppler ultrasonography to confirm the diagnosis and to
determine the degree of stenosis. Fifteen patients were
found to have an occult atheroma with greater than 50%
occlusion.46 Older dental patients with possible athero-
mas noted on panoramic radiographs should be referred
for medical evaluation.46
Bleeding Problems. Anticoagulation drugs (heparin,
Coumarin), antiplatelet agents (aspirin, NSAIDs), liver
disease, renal disease, and cancer and the agents used to
treat it are common causes of bleeding in older adults.
These causes of bleeding are not related to aging itself.
For example, the platelet count does not change with
increasing age. Although liver mass decreases with age,
this event has little or no effect on production of adequate
amounts of coagulation factors for control of bleeding.
Age-related renal changes, if severe, may lead to bleeding
problems caused by their effects on platelet function.47
Usually, only persons with mild forms of inherited bleed-
ing disorders survive to old age. Dental management
of the patient who may be a bleeder is discussed in
Chapter 25.
Patients for whom the dosage of Coumadin was
reduced before surgery (international normalized ratio
[INR] greater than 3.5, or other patients whose physician
has recommended a dose reduction before surgery)
should be contacted within 24 to 72 hours for determina-
tion of whether postoperative bleeding is occurring.48
The patient should then be seen at least 72 hours after
surgery. If healing is progressing normally, the physician
should be called and the patient returned to the normal
Coumadin dosage. NSAIDs, aspirin, and acetaminophen
in high doses should not be used with patients who are
taking Coumadin or other anticoagulants.48 Aspirin and
NSAIDs must not be used in patients with bleeding
disorders such as thrombocytopenia, hemophilia, and
advanced liver disease.10 Tylenol (acetaminophen) should
not be used or should be used with care in patients who
have liver or kidney disease. The combination of acet-
aminophen and aspirin or an NSAID must be avoided for
long-term use because it increases the risk for nephropa-
thy. (See Chapters 11, 13, and 25 for a more detailed
discussion of the use of analgesics in patients with renal
disease, liver failure, and bleeding disorders.)
Antibiotic Prophylaxis. Older adults with specific
cardiac lesions who are at risk for bacterial endocarditis
as defined by the American Heart Association should
receive prophylactic antibiotics for most dental proce-
dures (see Chapter 2). Older adults who have been given
antibiotic prophylaxis to prevent endocarditis should be
told to return to the dentist or to contact their physician
if symptoms of anorexia, nausea and vomiting, fever, con-
fusion, or anemia occur. These symptoms may be associ-
ated with endocarditis in older adults.
The American Dental Association and the American
Academy of Orthopaedic Surgeons suggest that antibi-
otic prophylaxis should be considered for some older
patients with joint replacements when they are about to
undergo specific dental procedures (see Chapter 21).
In the past, antibiotic prophylaxis was recommended
for surgical procedures performed in patients with brittle
diabetes mellitus or hemophilia, in patients taking anti-
coagulants, and in those with other conditions. Adverse
reactions associated with antibiotics (e.g., superinfection,
bacterial resistance, severe allergic reaction, pseudomem-
branous colitis) and lack of proven benefit no longer
support this type of use. If postoperative infection occurs
in these older adults, treatment in the form of local and
systemic agents may be provided. Older adults who are
about to receive dental implants are given antibiotics at
the time of surgical placement of the implant, to prevent
postoperative infection and failure of the implant. This
treatment is also provided for patients who are about to
receive orthopaedic implants, heart valves, and other sur-
gically placed devices.
Skin and Oral Lesions. Basal cell carcinoma (Figure
30-2) and melanoma (Figure 30-3) of the skin are lesions
that are commonly found in older adults. In addition,
squamous cell carcinoma of the oral cavity (lower lip),
Figure 30-4, is more common in older adults (see Chapter
26). Psoriasis is a dermatologic disorder that is common
in older adults (and in adolescents) (Figure 30-5). Another
common skin lesion that may develop in older adults is
seborrheic keratosis (Figure 30-6). Lesions of senile
purpura (see Figure 30-1) on the face, legs, and arms of
many older adults do not indicate an underlying bleeding
problem. These lesions result from decreased fat content
in the subcutaneous tissue and age changes in the
connective tissue that allow for increased mobility.
Figure 30-2. Nodular basal cell carcinoma located behind
the ear. (Fromjames WD, BergerTG, Elston DM. Andrew's
Diseases of the Skin: Clinical Dermatology, 10th ed. London,
WB Saunders, 2000.)
 C H A P T E R 30
Figure 30-3. Lentigo maligna melanoma. (From James
WD, Berger TG, Elston DM. Andrew's Diseases of the
Skin: Clinical Dermatology, 10th ed. London, WB
Saunders, 2000.)
Figure 30-4, The lower lip is ;i common location for squa-
inous cell carcinoma of the oral cavity.
Figure 30-5. Psoriasis plaque, red plaque with silver scale
on the knee. (From James WD, Berger TG, Elston DM.
Andrew's Diseases of the Skin: Clinical Dermatology, 10th
ed. London, WB Saunders, 2000.)
Increased mobility of the skin produces shearing forces
that rupture small blood vessels. Blood lost through this
bleeding takes about 1 to 3 weeks to be cleared from the
skin. Senile purpura is common in older women. Platelet
count and platelet function are normal in these patients;
Dental Management of Older Adults 549
Figure 30-6. Large and disfiguring seborrheic keratosis
reveals evidence of horn pearls. (From James WD, Berger
TG, Elston DM. Andrew's Diseases of the Skin: Clinical
Dermatology, 10th ed. London, WB Saunders, 2000.)
however, bruising may be a sign of thrombocytopenia or
a bleeding tendency.
Oral lesions may be found in patients with pemphigus
vulgaris, cicatricial pemphigoid, lichen planus, lupus ery-
thematosus, erythema multiforme, leukemia, neutrope-
nia, anemia, salivary gland tumors, cancer, and a host of
other conditions. History, clinical findings, laboratory
tests, cytology, and biopsy are used to establish the diag-
noses of oral lesions (see Appendix C). If the dentist is
unable to establish the diagnosis for a particular lesion,
he or she should refer the patient to an oral medicine
specialist, an oral maxillofacial surgeon, or an oral maxil-
lofacial pathologist.
Referral and Consultation. Older adults with advanced
organ disease such as liver, kidney, lung, or heart disease
may be at increased risk for invasive or prolonged dental
treatment. Before dental treatment is provided, the
dentist should consult with the patient's physician to
establish the patient's current status and to confirm all
drugs that the patient is taking. Special management pro-
cedures that are being planned for the patient should be
reviewed with the patient's physician for input and modi-
fication when needed.
Older adults who are found to be hypertensive should
be referred to a physician for diagnosis and treatment.
Patients with signs or features of oral cancer should be
referred for further diagnosis and treatment. Those with
signs and symptoms that suggest untreated systemic
disease such as diabetes or AIDS should be referred for
diagnosis and treatment.
When surgery is planned for older adults who are
taking anticoagulants (Coumadin), the dentist should
consult with the patient's physician to determine the
550 Geriatrics PART TEN
INR. Most often, dental surgery can be performed
without adjustment in dosage for patients who are being
maintained in therapeutic ranges of anticoagulation
(INR, 1.5 to 3.5). Patients with an INR greater than 3.5
should have their dosage of Coumadin reduced by their
physician 3 to 5 days before undergoing dental surgery
(see Chapter 25).
When problems with the patient's medications such as
signs and symptoms of overdose or drug interaction are
identified, the dentist should communicate those findings
to the patient's physician. Also, the older adult who is
taking multiple medications and who has not seen a phy-
sician over the previous year should be directed to make
an appointment, so the doctor can review the appropri-
ateness of the patient's current medications.
The patient's physician should review the drugs being
taken on a regular basis. If it has been longer than 1 year
since the older adult dental patient has seen the physician,
the patient should be referred for this review. The dentist
and the physician must consider that new symptoms or
problems could be drug induced.29 Use of multiple drugs
must be avoided whenever possible.
Individuals who report dry mouth and who are taking
medications that have been reported to cause xerostomia
(the dentist can measure salivary flow to determine
whether it has been reduced) can best be served by the
dentist's consultation with the physician to determine
whether another drug without this adverse effect could
be used to control the patient's systemic condition.
Patients with signs and symptoms suggestive of sys-
temic disease should be referred for medical evaluation,
diagnosis, and treatment. Patients with oral lesions that
the dentist is unable to diagnose must be referred for
diagnosis and treatment.
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