The Experience of PostOp Delirium for the Elderly Loyalist CollegeAlex AnsellNURS 1004As

The Experience of Post-Op Delirium for the Elderly Loyalist CollegeAlex AnsellNURS 1004As our population continues to age there are many health issues that will need to be addressed in order to continue providing quality care to our population. One major issue concerning the elderly is that of post-operative delirium (POD). As such, this paper will summarize and compare a portion of the academic literature regarding the topic in order to understand how the experience of POD effects the patient. Understanding the effects of POD is especially important given that it is the most common surgical complication in elderly patients, particularly when considering that more than a third of inpatient operations are performed on this population (Inouye et al., 2015). Furthermore, it is estimated that up to 40 percent of POD cases are preventable, with an annual cost of approximately 150 billion dollars (Inouye et al., 2015). As such, improving our ability to understand POD will allow us to further improve both the quality of care and life of the patient. While the specifics of these effects on the patient will be examined within this paper, it is important to know that the experience of POD has both short and long-term detrimental impacts upon the patient. Understanding the patient experience of POD will also demonstrate the importance of this issue, and the lasting effects that it can have for the patient. Unfortunately, according to the best practice statement issued by the American Geriatrics Society, which specifically addresses POD, both nurses and physicians are often unable to accurately diagnose POD using various bedside evaluations (Inouye et al., 2015). Moreover, despite the number of diagnostic tests available, their results vary widely and are highly dependent on the patient population (Inouye et al., 2015). Despite an acknowledgement that POD is a serious and often avoidable complication, there remains insufficient evidence for unified recommendations regarding regular POD screening to be made (Inouye et al., 2015). The Registered Nurses Association of Ontario (RNAO) best practice guidelines, which focuses on delirium more broadly, has similar concerns noting that in general delirium often goes unnoticed and therefore recommends that elderly patients be assessed both on the initial interaction and if the patients’ condition change (RNAO, 2016). Despite this lack of detection however, a number of preventative nonpharmacological interventions have been identified which includes; the use of sensory and mobility enhancements, cognitive activities and pain control (Inouye et al., 2015). Due to the effectiveness of these interventions, the American Geriatrics Society, has recommended that hospitals implement multifaceted nonpharmacological interventions for at risk patients (Inouye et al., 2015). As use of nonpharmacological interventions have been shown to effectively reduce the rates of delirium and are also recommended by the RNAO best practice guidelines (RNAO, 2016). The use of nonpharmacological based prevention is particularly important as the evidence regarding the use of pharmacological interventions to prevent POD is quite limited and contradictory (Inouye et al., 2015). This type of intervention often involves the administration of either antipsychotics or benzodiazepines and can should therefore be used only for the shortest possible timeframe as they can have a number of adverse effects for the patient (Inouye et al., 2015). Furthermore, this also consistent with the RNAO guidelines as while they may work to reduce the symptoms they do not address the fundamental causes of why the delirium has occurred and may in fact prolong the episode (RNAO, 2016). Therefore, while the diagnosis remains difficult, a number of nonpharmacological interventions have been uncovered to help prevent the onset of POD. Overall, nonpharmacological interventions can serve as a means to prevent POD, while pharmacological ones can be used in the short term to address serious occurrences. Broadly speaking delirium is described as an acute cognitive change from the patient’s baseline and includes a wide variety of symptoms such as and change in the patient’s level of consciousness (Inouye et al., 2015). Common symptoms of POD includes a wide range of issues such as; a decrease in cognitive functioning and speech, rapidly changing emotional states, sleep cycle changes and perceptual disturbances including both illusions and hallucinations (Inouye et al., 2015). POD is also often associated a number of complications including; prolonged hospitalization, a loss of functional independence, reduced cognitive functioning and can be fatal (Inouye et al., 2015). To best understand how these symptoms are experienced, Instenes et al (2018) interviewed patients between the ages of 81-88 who had undergone cardiac surgery. Both before the operations and both preoperatively and after six months each had their cognitive functioning assessed using the Mini-Mental Assessment. This was then followed up with in-depth interviews six to twelve months later. During these interviews it was found that the POD experiences were grouped around six major themes which consisted of being “Like dreaming while awake, Disturbed experiences of time, Existing in a twilight zone, Trapped in medical tubes, Moving between different surroundings and Meeting with death and the deceased”. Additionally, it was found that after 12 months had these patients reported “strong and distressing memories” of their delirious experience. Overall, these patients found their delirious episode was not only distressing at the time of occurrence but also for up to 12 months later. Additionally, work done by Nguyen, Uminski, Heibert, Tangri & Arora (2018) on patients who had experienced POD after undergoing either a coronary artery bypass graft or valve replacement, may help understand what impact POD has on mid-term cognitive functioning. To do this they assessed the baseline cognition and mood using two different cognitive assessments. After six to nine months telephone interviews were conducted and again the patients were assessed using a number of different assessments. These assessments were then compared between patients who had experienced POD and those who had not. It should also be noted that any factors deemed clinically relevant by the researchers were controlled for. Although no difference in cognitive functioning was found between these two groups of patients, those who had experienced POD were more likely to self-report increased anxiety and depression. The finding that patient where more likely to report higher levels of anxiety and depression is also consistent with the types of memories the patients experienced during their delirious episode. This research indicates that not only are the patients’ memories of POD themselves troubling but may also be linked to increased levels of anxiety and depression as well. Other research however, contradicts the finding by Nguyen et al (2018) that POD does not impact cognitive functioning. For instance, longitudinal study done by Li et al (2016), examined the impact of early POD through a two year follow up where both cognitive functioning and quality of life were assessed. Overall they found that a prolonged duration of POD was not only associated with and increased mortality risk but also worse cognitive functioning and quality of life than those who had not. One major limitation of this study, which was noted by the authors, however is that pre-operation quality of life was not assessed meaning the differences before and after the operation could not be addressed. Interestingly, more recent work done by Bagienski et al (2018) examined mortality rates after 30 days and 12 months along with quality of life. While they found similar results that patients who had experienced POD had a higher 30 day and 12 month mortality rate from all causes, they did not find any differences in the quality of life between patient who experienced POD and those who did not. Despite these contrasting findings however, it should be noted that this study had a much smaller sample size which was analyzed and over a shorter period of time. This serves to amplify the effects of outliers or to consider longer term effects. As such these results should be taken with much more caution, particularly when the other research presented is taken into consideration. Overall, patients who have experienced an episode of POD have a higher short and long term mortality rates, higher reported anxiety and depression, and tended to have a lower overall quality of life. Furthermore, research has been done through examining the electronic medical records of patient who had experienced POD, such as that done by Mangusan, Hooper, Denslow & Travis (2015). They demonstrated that these patients often had longer hospital stays, are more likely to be discharged into a nursing facility and use home health services. Additionally, they also tend to have a higher need for both inpatient physical therapy and an increased risk of falls. These patients also commonly associated with much worse general outcomes than their counterparts who did not. This is often because POD can begin as series of events leading to further complications including prolonged hospitalization, lower cognitive functioning, loss of functional independence and death (Inouye et al., 2015). From these findings the Mangusan et al (2015) recommend that patient centered care plans be developed to help in preventing the patient from losing their independence. The development of a focused care plan with not only those patients who are at risk, but also alongside their families is also one of the recommendations from the RNAO best practice guidelines regarding delirium (RNAO, 2016). Additionally, the loss of functional independence can itself have a number of negative effects and have a significant impact on the life of the patient. This can be well illustrated by research done by Araujo, Castro, Daltro & Matos (2016) who studied how the loss of functional independence on elderly patients with osteoarthritis of the knee can influence the patient’s overall quality of life. Using various assessments, they we able to demonstrate that there was as strong positive correlation between a patient’s functional independence and quality of life. Simply put this means that the more independent the patient, the higher quality of life was found to be. Furthermore, Kim, Liu, Nakaoka, Jang & Browne (2018) demonstrated that lower rates of in cognitive and physical functioning leading to a decline of independence are directly associated with a higher rate of depression. This was done using a descriptive analysis to reveal group differences of gender, age, marital status against activities of daily living (ADL), instrumental activities of daily living (IADL), cognitive functioning and depression. Interestingly, they also found that gender (men) and marital status were both protective factors against depression. The work done by both Araujo et al (2016) and Kim et al (2018) is important because POD is associated with overall poorer health outcomes including the loss of both cognitive and functional independence and this research demonstrates the effects this loss can have upon the patients, extending its impact beyond a single symptom. Furthermore, these symptoms are particularly worrying as depression along with both cognitive and functional impairment have also been identified as risk factors for POD (Inouye et al., 2015). This means that these problems will not only become intensified should a patient experience POD but they can also lead to a vicious cycle whereby the symptoms and risk factors perpetuate each other, leading to a continuous deterioration of the patient. Similarly, a retrospective study of a large sample of patients across a number of hospitals done by Berian, Mohanty, Ko, Rosenthal & Robinson (2016), found that a loss of independence was also associated with both postoperative readmissions and death after discharge. This loss of independence included decrease functional capacities, mobility and a general increase in the amount of care needed. Furthermore serious postoperative complications, such as POD, were the most important factor associated with readmission to this hospital increasing the risk by an estimated 70 percent, although they were not significantly associated with death after discharge. Therefore, as nurses we have the ability to not only prevent POD but as a result help maintain the patient’s current level of functioning and independence which itself can reduce the patients’ risk of depression, chances of readmission and improve their quality of life.Overall, patients reported having upsetting memories of the actual experience of POD and have been found to report higher levels of depression and anxiety afterwards. Furthermore, despite the fact that delirium is an acute episode, it can have substantial long term impacts on the patient. For instance, those who experience POD were found to have higher mortality rates and poorer outcomes in general ranging from requiring more medical care to a loss of general functioning. This loss of functioning is particularly concerning at that in of itself has been linked to a lower quality of life, is a significant factor influencing depression, and may be associated with a higher chance of death after discharge. These patients are also more likely to be readmitted to the hospital after discharge and the loss of independence itself can become a serious complication for caused by POD. Fortunately, nurses can play a major role in preventing POD by being able to identify its various symptoms so interventions can be implemented as early as possible. By understanding the various preventative measures which have been identified, nurses can help stop POD of occurring at all using patient centered care, which can improve the overall health outcomes for the patient, their overall quality of life and reduce the number of hospital readmissions as well. Moreover, there was a prospective study that took place within two hospitals in Germany which had begun the implementation of a specialized delirium nurse on the surgical ward done by Kratz & Diefenbacher (2016). Overall, they found through the interventions of this delirium nurse, the rate of POD fell from 20.2 percent to 4.9 percent. Therefore, nurses may begin to play and even larger role in preventing POD in the future, potentially resulting in the creation of additional nursing specialties or potentially expanding our scope of practice.References:Araujo, I. L., Castro, M. C., Daltro, C., & Matos, M. A. (2016). Quality of Life and Functional Independence in Patients with Osteoarthritis of the Knee. Knee Surgery & Related Research. 28 (3), 219-24.Bagienski. M., Kleczynski. P., Dziewierz. A., Rzeszutko. L., Sorysz. D., Trebacz. J., Sobczynski. R., Tomala. M., Stapor. M., & Dudek, D. (2017). Incidence of Postoperative Delirium and its Impact on Outcomes after Transcatheter Aortic Valve Implantation. The American Journal of Cardiology, 120 (7), 1187-1192. Berian. R., Mohanty S., Ko. Y., Rosenthal. A. & Robinson. N. (2016). Association of Loss of Independence with Readmission and Death after Discharge in Older Patients after Surgical Procedures. Journal of the American Medical Association: Surgery. 151 (9)Inouye. S., Robinson. T., Blaum. C., Busby-Whitehead. J., Boustani. M., Chalian. A., Deiner. S., Fick. D., Hutchison. L., Johanning. J., Katlic. M., Kempton. J., Kennedy. M., Ko. C., Leung. J., Mattison. M., Mohanty. S., Nana. A., Needham. D., Neufeld. K., Richter. H. (2015). Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. Journal of the American College of Surgeons. 220 (5) Instenes. I., Gjengedal. E., Eide. L. S., Kuiper. K. K., Ranhoff. A. H., & Norekvål. T. M. (2018). “Eight Days of Nightmares” Octogenarian Patients’ Experiences of Postoperative Delirium after Transcatheter or Surgical Aortic Valve Replacement. Heart, Lung and Circulation. 27 (2), 260-266.Kim. B. J., Liu. L., Nakaoka. S., Jang. S., & Browne. C. (2018). Depression among older Japanese Americans: The Impact of Functional (ADL & IADL) and Cognitive Status. Social Work in Health Care. 57 (2), 109-125.Kratz. T., & Diefenbacher. A. (2016). Prevention of Postoperative Delirium – A Prospective Nurse-Led Intervention on Surgical Wards in a General Hospital. European Psychiatry. 33 (4).Li. N., Dong-Liang. M., Qin-Jun. Y., Chun-Xia. S., Dong-Xin. W., Li- Huan. L. (2016). Impact of Early Postoperative Delirium on Long- Term Outcome in Patients after Coronary Artery Bypass Graft Surgery: A 2- Year Follow-up Cohort Study. Journal of Anesthesia and Perioperative Medicine. 3, 70-77.Mangusan. R. F., Hooper. V., Denslow. S. A., & Travis. L. (2015). Outcomes Associated with Postoperative Delirium after Cardiac Surgery. American Journal of Critical Care. 24 (2), 156-163. Nguyen. Q., Uminski. K., Hiebert. B. M., Tangri. N., & Arora, R. C. (2018). Midterm Outcomes after Postoperative Delirium on Cognition and Mood in Patients after Cardiac Surgery. The Journal of Thoracic and Cardiovascular Surgery. 155 (2), 660-667.Registered Nurses Association of Ontario. (2016). Delirium, Dementia, and Depression in Older Adults: Assessment and Care. Clinical Best Practice Guidelines (2nd edition).

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