Sedation considerations in the dental care of the geriatric population

Over the next 20 years, Canada’s senior population is expected to grow by 68%, with the group aged 75 and older doubling to approximately 10.4 million.¹ With advancements in dental care, more seniors are retaining their natural dentition into older age, many with complex work including crowns, bridges, implants, etc.

For dentists, this demographic shift means a growing number of senior patients, many of whom are healthy and can receive care in standard clinical settings. However, some seniors will present with medical or cognitive challenges. Basic strategies, such as building trust, explaining treatment in simple terms, and allowing extra time for appointments, are essential in managing older patients effectively.²

For the elderly with complex health conditions, such as multiple chronic illnesses or cognitive impairments with limited cooperation, sedation can be a valuable tool to facilitate necessary dental treatments. This paper provides an overview of key considerations for sedation in frail geriatric patients. It will review practical approaches to ensure positive outcomes, minimize risks, and optimize recovery.

Frailty is defined as a clinically recognizable state of increased vulnerability resulting from aging-associated declines in physiological reserve and function across multiple systems.^3,4 Frail patients experience reduced muscle mass and strength, diminished physiological resilience, and emotional instability, such as depression. These factors significantly elevate the risk of postoperative complication and mortality.⁵ Importantly, frailty is a stronger predictor of adverse surgical outcome than chronological age alone.^3-5

Normal physiological and pathological changes with age

The aging process involves both physiological and pathological changes to all organ systems. For sedation and anesthesia, the changes in the nervous system (central and peripheral), cardiovascular system, pulmonary system, hepatic and renal system are most relevant. These changes affect an older patient’s ability to tolerate stress and their response to drug administration (Table 1); they also cumulatively lead to frailty.

Table 1: Physiological and pathological changes in geriatric patients with sedation implications

Organ System	Anatomic Changes	Functional Changes	Sedation Implications
Nervous system	• Attrition of neurons • Decreased neurotransmitter activity	• Deafferentation, neurogenic atrophy, and decreased anesthetic requirement • Impaired autonomic homeostasis	• Sedative dose reduction • Decreased neuroplasticity, increased risk of postoperative delirium (POD) and neurocognitive disorder (pNCD) • Blunted response to hypoxia and hypercarbia, increased risk of apnea and hypoxia
Cardiovascular system	• Decreased arterial elasticity • Ventricular hypertrophy • Reduced adrenergic responsiveness	• Increase impedance to ejection, widened pulse pressure. • Decreased maximum cardiac output	• Disproportionally large change in blood pressure from surgical stimulation and sedative medication • Higher risk of myocardial infarction and diastole heart failure.
Pulmonary system	• Loss of lung elastin • Increased thoracic stiffness • Reduced alveolar surface area • Weaker laryngeal muscle and airway reflex and cough response	• Increased residual volume • Loss of vital capacity • Impaired efficiency of gas exchange • Increased work of breathing	• Extreme susceptible to hypoxia, hypercarbia, respiratory fatigue related to sedatives • Higher risk of upper airway obstruction and infectious disease like pneumonia
Renal system	• Reduced vascularity • Tissue atrophy	• Decreased plasma flow, glomerular filtration rate, drug clearance, and ability to handle salt and water loads.	• Affects the pharmacokinetics of drugs. Decreased clearance of many medications; relative increase duration of effects.
Hepatic system	• Reduced tissue mass	• Reduced hepatic blood flow and drug clearance.	• Affects the pharmacokinetics of drugs. Decreased clearance of many medications; relative increase duration of effects.
Body Composition	• Increased lipid fraction • Loss of skeletal muscle and other components of lean body mass	• increased half-life for lipid-soluble drugs • Decreased O2 consumption, heat production and cardiac output.	• Incorporate temperature goal and maintain normothermia during lengthy treatment.

At the same time, geriatric patients have a higher prevalence of medical conditions like diabetes, ischemic heart disease and dysrhythmias, chronic obstructive pulmonary disease (COPD) and dementia. In 2017-2018, approximately 37% of Canadian seniors reported having at least two chronic diseases, with almost half of those aged 85 years and above reporting multimorbidity⁸ (Table 2). Living with multiple diseases not only impacts daily function and quality of life but also increase baseline mortality risk.

Table 2: Prevalence of Chronic Diseases and Risk Factors among Canadians aged 65 years and older – from Canada.ca¹⁰

Prevalence of the most common chronic diseases and conditions:	Prevalence of common behavioural risk factors:
– Hypertension 65.7% – Periodontal disease 52.0% – Osteoarthritis 38.0% – Ischemic heart disease 27.0% – Diabetes 26.8% – Osteoporosis 25.1% – Cancer 21.5% – COPD 20.2% – Asthma 10.7% – Mood & anxiety disorders 10.5%	– 9.5% report daily or occasional tobacco use – 8.3% report exceeding low-risk drinking guidelines – 77.3% consume fruits/vegetables less than 5x a day – 40.1% & 28.1% report a BMI in the overweight & obese categories – 60.6% do not meet physical activity guidelines – 46.8% report trouble falling asleep

Consequently, polypharmacy – taking multiple medications simultaneously – is common among seniors. This increases the risk of adverse drug reaction and interactions, posing further challenges for dental-sedation care. At all times one must prioritize non-pharmacologic intervention, and weigh the risks versus benefits before dental-pharmacological intervention.⁹ Outside of sedation considerations, if there are signs of medical instability (e.g., signs of drug misuse; recent hospitalization or impending medical procedures etc.), prompt communication with patient’s medical team is critical.

ASA Classification and Frailty Score

The American Society of Anesthesiologist Physical Status (ASA PS) Classification (Table 3) is taught in dental schools as part of patient assessment for anesthesia-sedation consideration. It is a grading system, characterizing patient operative risk on a scale of 1-5, where 1 represents a healthy individual and 5 indicates a moribund state. Validated across various surgical procedures, the ASA PS classification is a strong predictor of postoperative complication and mortality.¹¹

Table 3: American Society of Anesthesiology Physical Status Classification System (Appendix II – RCDSO Standard of Practice)^{12, 13}

ASA I: A normal healthy patient ASAIl: A patient with mild systemic disease ASA III: A patient with severe systemic disease that limits activity but is not incapacitating ASA IV: A patient with incapacitating systemic disease that is a constant threat to life

SA V: A moribund patient not expected to survive 24 hours with or without operation ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes ASA E: Emergency operation of any variety; E precedes the number, indicating the patient’s physical status

Numerous frailty assessment tools are available, a meta-analysis by Tjeertes et al.⁴ identified that the modified frailty index (mFI) was most frequently used. This index, initially developed with 11 factors (mFi-11), was simplified in 2015 to 5 factors (mFI-5) with similar predictive accuracy for mortality and complications in non-cardiac surgeries as shown in Table 4. ^4,14,15 Preoperative frailty assessment is a valuable tool for helping both patients and care providers determine who may benefit from invasive dental treatments and who may be better served by alternate approaches.

Table 4: Modified Frailty Index-5 (mFI-5) Score^4,14,15

+1	Functional Status: Non-independent
+1	History of Diabetes Mellitus
+1	History of Hypertension requiring medication
+1	History of Congestive Heart Failure (CHF)
+1	History of Chronic Obstructive Pulmonary Disease (COPD)

Studies on frailty’s impact in dental care decision are scarce,¹⁶ but some findings provide insight. Agathis et al.¹⁴ examined the mFI-5 as a prognostic tool in a study involving of 41,000 patients aged 65 years and over who underwent inguinal hernia repair between 2018-2020. Patients were stratified into three categories: non-frail (mFI=0); intermediate frailty (mFI =1); and high frailty (mFI ≥2). Result demonstrated patients with higher frailty scores (mFI ≥2) were more likely to be discharged to destination not home (OR=2.66 for emergency cases; OR =2.18 for elective cases, p <0.01) and experienced higher rates of postoperative complications, including pneumonia, prolonged hospital stays. Among the five factors, “Non-Independent Functional Status” was a significant predictor of complications across all studied patients.

With the greying of the population, frailty is gaining attention as a public health priority among health care providers and policy makers. Research has showed frailty is a dynamic and progressive syndrome that can be deferred and remedied.^14,17 Early identification and prehabilitation of potentially reversible health deficits provide an opportunity to optimize patient’s clinical condition prior to surgery and anesthetic challenges. Dentistry plays an important role in maintaining functional dentition and oral health of aging patients, which is necessary for quality nutritional intake (especially protein) and preserving muscle mass and delaying progression of frailty.^16,17

Postoperative delirium (POD) and perioperative neurocognitive disorder (PND)

Another concept related to sedation and anesthesia is postoperative delirium (POD). Advanced age is the most significant risk factor for cognitive shifts following surgery and anesthesia. ^18–22 The umbrella term “perioperative neurocognitive disorder” (PND) was adopted in 2018 to replace older term postoperative cognitive dysfunction (POCD).^23,24 PND encompasses various clinical conditions, including postoperative delirium (POD), delayed neurocognitive recovery (dNCR), postoperative neurocognitive disorder (postoperative NCD) and both mild and major cognitive impairments. Postoperative delirium (POD) is relevant for dentistry when treatment involve sedation and especially general anesthesia.

Delirium is defined as an acute, fluctuating disturbance in neuropsychological function characterized by alterations in awareness, attention and cognition that develops over a short period. It is distinct from preexisting cognitive disorder. ³ POD can occur during early stages of anesthesia recovery, or until discharge. It is linked to an up to 12-fold increased risk of dementia, increased necessity for staff resources and surveillance, leading to substantial postoperative and follow up expenses.²⁴ Its diagnosis can be made with validated delirium screening tools like the Confusion Assessment Method (CAM).^3,6,25 One of the strongest predictors for POD is preexisting cognitive impairment, with other risk factors including advanced age, number of medical comorbidities, frailty, higher ASA PS score, and uncontrolled pain.²⁴

A prospective observational study by Alhammadi et al. ²⁶ recruited 90 elderly (mean age = 79 years) between August 2022 to August 2023 undergoing elective or emergency maxillofacial surgical procedures under general anesthesia. Multiple screening tools were employed during the postoperative period to assess variables such as functional ability, cognition, nutritional status, mobility, emotions, healing, and sleep disruptions. POD was screened daily using three delirium screening tools.

The study reported eight patients (8.9%) developed POD; among the 23 geriatric assessment instruments used to evaluate preoperative and postoperative status, the Clock-Drawing Test (CDT) – a tool measuring cognitive status – was significantly associated with POD occurrence (p =0.05). Other significant factors include the type of operation; surgery duration and length of hospital stay (p =0.018, 0.026 and 0.002 respectively).

In a dental office setting, the estimated risk of POD in geriatric patients with ASA PS scores of 1 of 2 – and select ASA PS 3 patients deemed suitable for sedation – is quite low.⁶ However, its potential occurrence has profound implications for patients and their families, including the need for extended, costly care or a loss of independence.^22,24,26 These possible sequelae are important for care teams to consider, especially if the surgical duration is longer than 1-3 hours and involves significant blood loss.^22,24,26 Early identification of geriatric patients with cognitive impairment is, hence, recommended. Dentists providing care for elderly patients are encouraged to become familiar with cognitive screening tests and consider their routine application to enhance overall patient management.²⁷

Dental sedation

Dental sedation is a valuable tool for managing stress and enabling treatment in geriatric patients, particularly those with anxiety or dementia. Sedation ranges from minimal (anxiolysis) to moderate to deep sedation and extending to general anesthesia. As sedation depth increases, more comprehensive peri-operative preparation is required (Table 5).

Table 5: Characteristics of the Levels of Sedation and General Anesthesia

	Minimal Sedation	Moderate Sedation	Deep Sedation	General Anesthesia
Consciousness	maintained	maintained	obtunded	unconscious
Responsiveness	to either verbal command or tactile stimulation	may require either one of or BOTH verbal command and tactile stimulation	response to repeated or painful stimuli	unarousable, even to pain
Airway	maintained	no intervention required	intervention may be required	intervention usually required
Protective Reflexes	intact	intact	partial loss	assume absent
Spontaneous Ventilation	unaffected	adequate	may be adequate	frequently inadequate
Cardiovascular Function	unaffected	usually maintained	usually maintained	may be impaired
Required Monitoring	basic	increased	advanced	advanced

Practical perioperative considerations include reducing aspiration risk through fasting protocols and water control, managing potential medication interactions, and mitigating postoperative complications such as falls and delirium.

Airway: frail elderly patients are particularly vulnerable to aspiration due to weakened cough reflexes, reduced muscle strength and decreased sphincter tone, making dental treatments involving water spray challenging.^3,28 Proper fasting preparation, intraoperative suction, and fluid management are essential to prevent pooling, coughing and subsequent aspiration, which could lead to hypoxia and hypoxemia (Table 1).

Polypharmacy: Existing medications require thorough review to assess potential of sedative interactions and adverse effects. For instance, while beta-blockers and statins are usually continued, medications such as ACE inhibitors or Angiotensin Receptor Blockers (ARBs) may need adjustment to prevent intraoperative hypotension.^3,29,30 Similarly, diabetic medications such as insulin and glucagon-like peptide 1 (GLP-1) agonists, require careful consideration³¹ and possible consultation with a medical specialist. Due to age-related cardiovascular and adrenergic system changes, elderly patients are susceptible to pronounced blood pressure swings from surgical stimulation and sedative administration. They are also at heightened risk of hypoglycemia with preoperative fasting and fluid restriction. Both conditions can increase the risks of cardiovascular event and postoperative delirium.

Postoperative care: elderly patients require extended recovery monitoring and physical support. With changes in hepatic, renal and nervous systems, older patients are at increased risk of prolonged sedation after treatment, postoperative delirium, and falls (Table 1). Preoperative discussions with patients and caregivers must address these risks and emphasize the importance of establishing adequate postoperative support systems.

Key risk factors for falls in the sedated geriatric patient include the following ⁶:

1. altered mental status;
2. dehydration (e.g., fasting status, duration of appointment, intraoperative hemodynamics);
3. frequent toileting;
4. a history of falls;
5. impaired gait or mobility;
6. medications (e.g., sedatives); and
7. visual impairment.

To enhance safety, intraoperative intravenous fluid support requires careful titration to match the patient’s sedation level, physiologic need, and cardiovascular reserve. The postoperative care environment should be calm, with frequent reorientation of patient with voice, familiar persons and objects (e.g., glasses, hearing aids) in close proximity; as well, the importance of adequate pain control cannot be understated.^6,7

By customizing care across preoperative, intraoperative, and postoperative phases, dental sedation can be safely provided to geriatric patients while minimizing risks and enhancing treatment outcomes.

Evidence from research – Safety and efficacy

Two studies, one from Japan and another from Israel, provide valuable insights into the safety, efficacy and considerations required for dental sedation in this vulnerable population.

Study 1 – Observations from Japan

Sugimura et al. (2015)²⁸ conducted a retrospective study on geriatric patients with dementia undergoing outpatient intravenous (IV) sedation at a Japanese hospital over an eight-year period (2004-2012). The study aimed to evaluate the effectiveness of IV sedation in elderly patient with dementia; identify intraoperative complications and highlight management precautions during dental treatment under sedation.

Findings and results

• Demographics: The study involved 25 patients with dementia (mean age = 79.9 years) who underwent 65 IV sedation sessions. Sedatives used include midazolam and propofol, and the depth of sedation ranged from moderate to general anesthesia. All scheduled dental treatments were completed. Most patients had significant pre-existing comorbidities, including cardiovascular conditions (56%) and diabetes mellitus (8%).

• Complications: From the 65 IV sedations:

– 46.2% experienced circulatory complications (e.g., hyper/hypotension, arrhythmias).

– 52.3% experienced respiratory complications (e.g., coughing spells, partial airway obstruction).

– Overall, 67.7% of cases had at least one complication.

• Complications: Of the 30 cases where depth of sedation were measured by BIS monitor

– 89.5% of complications occurred at deep sedation or general anesthesia state.

– 10.0% of complication occurred at conscious to moderate sedation state.

• Impact of treatment factors:

– Treatments requiring local anesthesia, such as extractions and pulpectomy, had shorter durations but similar sedation and recovery times compared to less invasive procedures.

– Procedures involving water usage (e.g., restorations) were associated with longer sedation times, greater use of sedatives, and higher rates of respiratory complications compared to those without water usage (e.g., extractions).

– Tooth extraction cases, compare to all other treatment, were associated with more airway complications (81.8%), and circulatory complications (63.3%), highlighting the need for vigilant airway support and attention at hemodynamic fluctuations caused by invasive procedures despite local anesthesia.

• Complications correlated strongly with deeper sedation levels, with some patients showing prolonged postoperative sedation effects.

Practice implication

Cardiovascular and respiratory complications are common during IV sedation in geriatric patients. Effective management requires strict attention to water use, anticipation of temporary interruption of treatment for airway management (e.g., tongue thrust or jaw lift) and careful attention to physical pressure during invasive dental procedures. Sedatives should be diligently titrated to achieve the lightest effective depth of sedation.

Study 2 – Insights from Isreal

Rettman et al. (2021)³² conducted a retrospective analysis at the Hadassah Medical Center, focusing on dental sedation sessions performed over five years (2016–2020). Unlike Sugimura et al.²⁸, this study included a broad range of sedation modalities and patient conditions.

Findings and Results

• Demographics and Scope:

– Of the 389 sedation sessions recorded, 4.1% involved patients aged 65 and older. All elderly patients received moderate (conscious) sedation using IV midazolam, either alone or in combination with ketamine.

• Outcomes:

– 100% of planned treatments for elderly patients were completed successfully, though some interruptions in patient management occurred.

– No adverse effects were reported during recovery.

• Success Factors:

– Poor success rates (3.9% of sessions) were linked to indications such as “special needs” rather than patient age or type of sedation.

Practice implication

The study underscores the necessity of tailoring sedation techniques to individual patients, considering factors like medical history, procedural complexity, and anxiety levels. The exclusive use of moderate sedation for elderly patients aligns with the increased risks associated with deeper sedation, reflecting a cautious approach that prioritizes safety and postoperative recovery.

Conclusion

Managing sedation for dental care in the geriatric population presents unique challenges due to age-related physiological-functional changes, a high prevalence of systemic comorbidities, and the risk of pharmacological interactions. Evidence underscores the relative safety and efficacy of conscious and moderate sedation techniques, particularly when combined with diligent intraoperative measures. In situations where deeper sedation or general anesthesia is required, careful consideration must be given to the individual’s overall health status and goal of treatment, with procedures ideally performed in hospital-based facilities that offer specialised monitoring and care.^2,24,32

This paper highlights the critical role of preoperative assessments, including frailty and cognitive-delirium screenings, in optimizing patient management perioperatively. Such evaluations will allow for the early identification of at-risk individuals, and where possible, timely modification of risk factors or treatment plans; enabling tailored approaches that optimize the benefits of dental treatment versus the potential risks of adverse outcomes such as cardiovascular event, postoperative delirium, prolonged recovery, or loss of independence.

Furthermore, a patient-centered and interdisciplinary approach is essential. Dentists and other healthcare providers must work collaboratively to address the medical, emotional, and logistical needs of geriatric patients. Such a strategy not only ensures safer perioperative care but also enhances the quality of life for elderly individuals undergoing dental treatment.

As the national population continues to age, the importance of evidence-based, compassionate, and holistic approaches to geriatric dental care cannot be overstated. Through continuing education and the integration of knowledge and collaboration, dental practitioners can contribute significantly to preserve older patients’ overall well-being, independence, and dignity. 

Oral Health welcomes this original article.

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About the author

Dr. Elise Wong is a dentist-anesthesiologist with a private practice in Richmond Hill, Ontario. She is a clinical instructor at the University of Toronto’s Faculty of Dentistry, and a diplomat with the American Dental Board of Anesthesiology.