A DOCS Education member writes:
A 78-year-old requires multiple restorations and posterior crowns. My patient's history includes bruxing and multiple falls. The woman has Parkinson's disease and, as a result of her involuntary movements, clinical treatment, can be very difficult. This is true even after variation in the timing of her Sinemetâ„¢ and amantadine doses.
The woman's current regimen of medications includes 25/100 mg Sinemet CRâ„¢, 25/100 mg Sinemetâ„¢, 100 mg amantadine, 81 mg aspirin, 6 mg RequipXLâ„¢, 200 mg DSS, 25 mg Seroquelâ„¢, 5 mg amlodipine, 0.4 mg tamsulosin, 50,000 u/week Vitamin D, MiraLaxâ„¢, folic acid, occasional Xanaxâ„¢ and Restasis.â„¢
Here is the metabolic panel: BUN 29, BUN/Creat 31, eGFR59. So far I have not received a CBC report.
I have two questions about this patient's care. First, will light sedation control her involuntary muscle movements? Secondly, please clarify red flags regarding the risk of respiratory depression.
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
This patient should be classified as a high-risk ASA III. Not only is the woman elderly, she also appears to be suffering from an advanced case of Parkinson's disease.
Light sedation will not completely control involuntary muscle movements. The temptation exists to sedate the patient more deeply in an effort to accomplish this. However, given the patient's advanced age, the risk of oversedation is concomitantly increased.
This patient would be better served through IV sedation. In this way sedation can be titrated to effect, or through means of an anesthesiologist trained to manage the sedation and related monitoring and if necessary the airway.
Dr. Leslie Fang, DOCS Education Faculty responds:
I agree with Dr. Feck; IV sedation is more appropriate for this patient. The following aspects of the woman's situation suggest this:
- Her Parkinson's disease is poorly controlled, despite the fact she takes four medications.
- Again, despite the drug regimen, she is still prone to falling and involuntary movements. No, the involuntary movements will not go away with light sedation.
- The woman is on amlodipine for hypertension.
- She is 78.
- Her renal function is compromised.
