CPD
CONTINUING PROFESSIONAL DEVELOPMENT
Improving surgical outcomes for people with dementia NS794 Loughlin D, Brown M (2015) Improving surgical outcomes for people with dementia. Nursing Standard. 29, 38, 50-58. Date of submission: January 19 2015; date of acceptance: February 20 2015.
Abstract
Aims and intended learning outcomes
Surgical intervention in older people with dementia is becoming increasingly common as the population ages and the number of people with dementia continues to rise. People with dementia have unique needs that require sensitive management at all stages of hospitalisation for surgery. This article sets out a suggested pathway for the care of these patients, in the form of a flow chart. It discusses recognition and assessment of dementia and delirium, issues of capacity and consent, interventions required for optimum care of older people with dementia and peri-operative management. It explores the role of family and friends in achieving integrated care.
This article examines the care of older people with dementia who are undergoing surgical interventions. It discusses recognition and assessment of dementia and delirium, capacity and consent, caring for carers and the specific needs of and interventions required by older people with dementia. After reading this article and completing the time out activities you should be able to: Discuss how to recognise and assess dementia and delirium in surgical patients. Identify the specific needs of people with dementia, their families and carers during hospitalisation for surgery. Describe the nursing interventions required by people with dementia throughout the surgical pathway.
Authors Diane Loughlin Lecturer, Adult Health, School of Health, Nursing and Midwifery, University of the West of Scotland, Hamilton, Scotland. Margaret Brown Senior lecturer, Institute of Older Person’s Health and Wellbeing, University of the West of Scotland, Hamilton, Scotland. Correspondence to:
[email protected]
Keywords
Introduction
Alzheimer’s disease, dementia, general surgery, health services for the aged, integrated delivery of health care, nursing assessment, nursing care, patient-centred care
Many surgical interventions involve older people (Murray and Dodds 2004). It is suggested that up to 50% of people receiving anaesthetics by 2050 will be aged 65 or over (Evered 2013). People in this age group occupy 65% of beds in acute hospitals, and many may have cognitive impairment caused by dementia or delirium (Royal College of Physicians 2012). There was an estimated 44.4 million people with dementia worldwide in 2013, and this figure is expected to increase to 75.6 million by 2030 (Alzheimer’s Disease International 2015). In the UK, there are about 850,000 people with dementia, including one sixth of people aged 80 or older (Alzheimer’s Society 2015). Older adults are considered to have more complex needs than younger people, and may require an enhanced care pathway when undergoing surgery (Fodale et al 2006). Older people with dementia are likely to experience greater challenges than other older people if they require surgical intervention.
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CPD topic Dementia is defined as ‘a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not clouded’ (World Health Organization 2010). There are a number of different diseases that can cause dementia, including Alzheimer’s disease and vascular dementia (Knapp and Prince 2007). The course of dementia is variable and can range from a few years to more than ten years (Rahman 2014). Although dementia can affect a person at any age, it is essentially a disease of old age and the risk of developing it doubles every five years after age 65 (Alzheimer’s Society 2015). Most people with dementia are older – 97.8% are aged over 65, and 68% of these are aged over 80 (Knapp and Prince 2007). Specific information on the care required by people with dementia who are undergoing or scheduled for surgery is sparse, however some guidance is available on the management of older people undergoing surgery. Continued improvements in peri-operative care, surgical procedures and anaesthesia have made elective procedures safer for older people (Watters 2002). Improvement in peri-operative care offered to older people is particularly required in areas such as cognitive assessment, improved nutrition, rapid mobilisation and pain assessment (Dodds et al 2013). This article discusses a surgical care pathway for older people with dementia, using the stages shown in Figure 1. While the focus of the pathway is on improving outcomes for older people with dementia who are having planned surgical procedures, the principles described apply to those undergoing unplanned or urgent procedures. Positive surgical outcomes for older people with dementia require practitioners who are knowledgeable and who work in partnership with patients, their families and friends. Practitioners must have an understanding of dementia, mental capacity and consent, appropriate assessment tools and communication. In an unpublished local audit undertaken by the authors, the main challenges identified by surgical practitioners caring for people with dementia were: deficits in the recognition of dementia and cognitive impairment, lack of knowledge of appropriate assessment tools, lack of specific information
FIGURE 1
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Good surgical nursing care of older people with dementia Stage 1. Recognition Does the person have a formal diagnosis of dementia? No
Yes
Does the person have any signs or symptoms indicative of dementia or delirium? Consider: 4AT (rapid assessment test) to screen for delirium and cognitive impairment. Confusion assessment method tool to screen for delirium. Abbreviated mental test score.
Stage 2. Capacity and consent Is the person able to consent to treatment? No Enhance the person’s ability to make decisions. Consider: Power of attorney. Guardianship. Anticipatory care plan. Advanced directive. Advocacy.
Yes Normal rules for informed consent apply.
Stage 3. Interventions Person-centred pre-operative care and preparation. Consider: Explore optimum communication strategies with the family and/or carer. The environment. Encourage the family and/or carer to stay with the person.
Stage 4. Peri-operative care Integrated surgical pathway. Consider: Effect of anaesthesia on cognition. Physical issues – nutrition and mobility. Specific pain assessment tools for the person who does not speak, for example the Abbey pain scale. Recovery ward support from the family and/or carer. Discharge planning and transitions.
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CPD dementia care for this staff group, and lack of time to spend with patients and families. Complete time out activity 1
Stage 1: recognition and assessment of dementia and delirium
1 Read the case study in Box 1 and consider how a healthcare professional would decide whether Joan has dementia. Is Joan able to consent to treatment? What role would her granddaughter have in the process of assessment? 2 List the challenges you think exist in caring for a person with dementia who has undergone surgery.
Surgical procedures such as cataract removal and hip replacement can improve quality of life by promoting independence. Some procedures may also be life saving, for example, excising cancerous tumours. However, older people are at greater risk of iatrogenic events in hospital, more likely to have poor outcomes and have a higher risk of mortality, compared with younger patients (Watters 2002). Early recognition of emerging complications, such as urinary tract infection, stroke and acute kidney injury, is essential to reduce distress and avoid an extended hospital stay. One of the complications in older patients with dementia is an exacerbation of cognitive impairment. The pre-surgery assessment appointment offers an opportunity to identify potential care issues and to prepare the person and their family for the procedure. There are significant issues relating to cognition and the surgical experience, including a risk of worsening existing dementia or causing delirium. Evered (2013) identifies pre-existing dementia as one of the strongest predictors of delirium. Post-operative delirium is associated with greater morbidity and mortality and a longer stay in hospital; it also carries greater risk of subsequent placement in care. Levels of post-operative delirium fluctuate and alter the person’s level of consciousness (Bodolea et al 2008). Even in the absence of a diagnosis of dementia, some older people are at risk of post-operative cognitive decline (Bodolea et al 2008, Chow et al 2012). Prompt and ongoing assessment of dementia and delirium ensures that peri-operative care addresses the person’s changing needs (Dodds et al 2013). A pre-operative cognitive
BOX 1 Case study: Joan Joan, aged 74, has been admitted to a minor surgical procedure area. Her 22-year-old granddaughter is with her. Joan does not appear to have communication difficulties, but says: ‘I don’t know this place. I don’t know how I got here, but I don’t like it. There are people sitting nearby that don’t speak to me.’
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assessment provides a baseline to identify any post-operative changes, whether or not the older person has a history of dementia (Chow et al 2012). A cognitive evaluation should be performed routinely (Fodale et al 2006). This should be part of the assessment process and is as important as a cardiac and pulmonary review (Evered 2013). Healthcare Improvement Scotland (2014) has developed a comprehensive care improvement package for older people and discusses a variety of assessment tools for delirium. Such tools are not diagnostic but can indicate that there is a degree of impairment in memory, thinking and planning. In acute care settings, the most useful tool is the abbreviated mental test score (AMTS), a ten-item scale that can be completed in less than five minutes (Hodkinson 1972). Delirium may also be assessed using the 4AT (rapid assessment test) (MacLullich et al 2014) or the confusion assessment method (CAM) (Inouye et al 1990), and managed according to National Institute for Health and Care Excellence (NICE) (2010) guidance. Complete time out activity 2
Stage 2: capacity and consent All practitioners have a responsibility to understand legislation on capacity and consent and should apply it in an informed and person-centred way. In England and Wales this legislation is embodied in the Mental Capacity Act 2005, and in Scotland in the Adults with Incapacity (Scotland) Act 2000. Both acts are intended to support and protect adults who lack capacity to make decisions. The key principles of the acts include the right of the individual to make their own decisions and that any decisions made on behalf of an individual should be in their best interests and be the least restrictive possible. The person’s ability to make decisions should be regularly reassessed. Capacity is the ability to make a decision about oneself. The person must understand the nature of the decision as well as the implications and possible consequences of that decision (NHS Education for Scotland 2012). In other words, a person must be able to understand the information required to make the decision, to remember this information long enough to make the decision, to understand the implications and consequences of the decision, and to be able to make their decision known to others (Alzheimer’s Society 2005).
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A diagnosis of dementia does not necessarily mean that a person no longer has capacity, since dementia is not necessarily an ‘all or nothing’ state and may fluctuate. It should be presumed, but not assumed, that the person has capacity. Assessment of capacity is vital before any decisions are made (Mental Welfare Commission for Scotland 2014). Consent to treatment is an important element of care and should be gained through an informed process. There are general principles to follow when considering consent. The treatment should offer clear benefit to the person, they should be involved fully in the process, any previously expressed wishes should be taken into account and appropriate individuals, such as family members, should be consulted. If the person is unable to give consent because of cognitive impairment resulting from pain or infection, it is good practice to wait for their consent if this will not create unnecessary risk. A person with dementia may have made an advance decision or advance statement, and may have a ‘healthcare proxy’ document in place. Information relating to this should be gathered at admission and should be discussed with the person. A trusted person should be asked to support the patient’s decision making throughout the process, therefore allowing them to be involved fully. Good communication and excellent patient information underpins much of this process (Dodds et al 2013).
Stage 3: interventions to improve the surgical experience To produce good outcomes for older people with dementia, effective integrated, interdisciplinary care is necessary throughout the peri-operative pathway (Dodds et al 2013). Therefore, the planned surgical pathway should begin with the GP and health and social care professionals who already know the patient, working with family and other carers. Good communication between primary and secondary care is required.
Communication
Communication is integral to positive surgical experiences for older people with dementia. In the early stages of dementia, the patient may have difficulty finding the right words, and speaking and listening takes more effort and time. Speaking clearly, in a gentle tone, and using short sentences will increase the
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patient’s understanding and reduce anxiety (Haak 2002). As the condition progresses, the patient’s verbal skills may be reduced and use of non-verbal communication, such as gestures or facial expressions, may be helpful (NHS Education for Scotland 2011). The assessment process will involve the practitioner asking questions of the patient, and this may be challenging for a person with dementia. Watching and listening carefully to responses allows the practitioner to identify when the person is no longer attentive or responding. It is important to take time to engage with the person (Clissett et al 2013). Sometimes a short break or a change of environment can allow recuperation, and the person may then be able to continue. Encouraging family or friends to be with the person can help since they may be able to frame questions differently. There may also be occasions where answers are not forthcoming, and family and friends may be the most useful sources of information. The person may also have useful written information describing their usual routine and preferences, such as the This Is Me Tool (Alzheimer’s Society 2013), or Getting to Know Me (Scottish Care 2013). A strategy to help people with impaired ability to think, remember and communicate is to reduce the number of decisions required in their daily routine. Keeping questions and instructions to a minimum, providing reminders about where the person is and what is happening, and giving information repeatedly will reduce stress for the person and those who care for them.
Family and friends
The hospital setting can be bewildering for people with dementia. At home, patients have their own routine and everything is familiar and easily accessible. The confusion or anxiety caused by this change in routine and environment is compounded by the increased number and range of people with whom they are in contact in hospital. Family and friends are valuable resources in establishing the patient’s usual routines and habits. While many routines may be difficult to replicate in the hospital setting, simple adjustments can help. For example, it is useful to know the name by which the patient prefers to be called, their usual routine and what upsets or calms them. Details of the prescription and use of medication – in particular, the times medication is taken and by what route – is may 20 :: vol 29 no 38 :: 2015 53
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CPD dementia care required. This information can help the practitioner to develop a relationship with the patient, address their needs appropriately, understand their behaviour and manage risk. The relationship with family and friends is considered to be vital. Communication and relationships between patients’ carers and staff are often viewed by carers as being unhelpful and negative (Jurgens et al 2012). Complete time out activity 3
The environment
Modifications may reduce the stress caused by those aspects of the environment that cannot be changed. Attempting to provide an environment with some dementia-friendly aspects can reduce stress for people with dementia, their families and friends, other vulnerable groups of patients and staff providing their care and treatment. There are two main aspects of the hospital environment that are amenable to change: noise and lighting (Dewing 2009). Windows that allow good natural light are the most helpful to the older eye. An older person might require two to three times the amount of light needed by a younger person (Dewing 2009). Low levels of interior light can cast shadows, leading to misperception and distress. Some patients may become confused about what they see in such environments.
Strong, bright light reflecting off shiny surfaces can cause glare and temporary ‘blindness’. People with dementia may also have problems discerning colour contrast; when objects close to each other, such as a chair and the floor, are similar in colour, they may not be able to distinguish where one ends and the other begins. This may lead to falls or refusal to sit on a chair that is hard to see. During the night, sound and lighting can have an increased effect. Lighting is lower at night, and any sound may be exacerbated. Patients who wake suddenly following anaesthesia and analgesia to find themselves in a strange place may react strongly. Reducing noise and increasing light may help to limit any distress. Visual problems can also occur with signage, tableware, bedcovers and handrails. Appropriate signage, along with good lighting, is being introduced in many care settings to help people with dementia find their way around these environments. Signage should contrast with the background wall or surface and be easily read from wheelchair height. This is particularly important in guiding patients to the toilet or back to bed (Waller 2012).
Stage 4: peri-operative care Several age-related physical and lifestyle factors may affect older people with dementia. These
TABLE 1 Physiological changes related to age System Nervous
Reduced volume of blood flow to the brain, with decreased oxygen consumption. Higher incidence of cognitive impairment. If dementia is present, decreased ability to assess pain. Fewer neurotransmitters and receptors.
Cardiovascular
Reduced cardiac output and response to cardiac demand. Blood vessels are narrowed and less elastic. Perfusion of other organs is less effective.
Respiratory
Decreased blood flow to the lungs and decreased sensitivity to hypoxia. Chest muscles deteriorate and the chest wall becomes rigid; muscle atrophy occurs in the pharynx and larynx. Breath is distributed to the apex rather than to the base of the lung. Increased incidence of sleep apnoea.
Renal
Decreased cardiac output reduces glomerular filtration rates. Renal mass decreased by about 25%.
Gastrointestinal
Reduced blood flow to the liver can affect drug metabolism. Intestinal motility reduces – constipation is common.
Integumentary
Decreased perspiration, and the extremities become cooler.
Musculoskeletal
Loss of muscle mass; joints are less mobile and have a reduced range of movement.
3 Find an unobtrusive
area of your care environment, sit down there and close your eyes for five minutes. Be aware of all that you hear. Consider your responses after this short period in an environment that is familiar to you, and then what it might be like for a disoriented person in this environment. Identify the noises in your clinical area that may be irritating or too loud, and develop some strategies to reduce them.
(Adapted from McLean and Le Couteur 2004, Hallingbye et al 2011)
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Age-related physiological change
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include long-term conditions, undiagnosed diseases, polypharmacy and poor dietary and fluid intake. The reduction in muscle mass that occurs in older age may increase the effect of muscle relaxants, and impaired thermoregulation may lead to hypothermia, further increasing the need for oxygen. Adequate oxygenation before and throughout the surgical procedure is essential. Other physiological effects are listed in Table 1.
Anaesthesia
The surgical experience may exacerbate and accelerate the progress of dementia in some older people (Fodale et al 2006). Older people are at greater risk of adverse medication events as a result of impaired renal and vascular systems (Chow et al 2012). Changes in the ageing brain will increase the effect of many anaesthetic drugs (Dodds et al 2013). In addition, dementia is associated with cholinergic deficits, and several anaesthetic drugs interact with the cholinergic system. This can affect memory and learning, leading to increasing confusion and loss of understanding, particularly in older people with dementia (Fodale et al 2006). The high number of adverse drug events in older patients are considered to be a result of increased comorbidity, age-related changes and previous medications taken over the long term (Permpongkosol 2011). Complete time out activity 4
Nutrition and hydration
Many older people are at risk of malnutrition and/or dehydration. To reduce this risk post-operatively, appropriate nutritional assessment should be recorded at baseline and during the peri-operative period. Extended surgical waiting times can lead to increased periods of fasting and exacerbate nutritional problems (Dodds et al 2013). A nutritional assessment should record height and weight, calculate body mass index (BMI), record serum albumin levels and highlight any recent unintentional weight loss (Chow et al 2012). Watters (2002) suggests that, where necessary, peri-operative nutritional support should be introduced early, for example 10-14 days before major surgery, particularly where recovery is complex. There are two forms of malnutrition: under and over-nourishment. Both involve inadequate levels of nutrients, resulting in greater post-operative risks (Hughes et al 2013) (Box 2).
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Mobilisation and assessment of pain
Musculoskeletal disorders such as osteoarthritis and late-life reduction in bone density can lead to greater risk of injury and complex post-operative pain (Hehir 2005). Passive movements can help with joint flexibility in the immediate post-operative phase, and early mobilisation is essential to reduce complications of immobility. Weight-bearing exercises increase vascular tone and reduce the potential for deep vein thrombosis and pulmonary embolism. Sui et al (2006) found immobility to be associated with higher mortality rates, particularly in patients who were older, had reduced mobility before admission and had comorbidities. Early mobilisation is also seen as a way of reducing time to discharge, with some people also showing psychological improvement (Dodds et al 2013). It is essential that pain management is appropriate and instigated early to assist mobility (Watters 2002). Acute pain, such as post-operative pain, stimulates the sympathetic nervous system, producing a physiological stress response: sweating, increased heart rate, increased blood pressure, increased respiratory rate, nausea and pallor. These effects are initiated mainly in response to demands for oxygen for the vital organs and to prevent further damage (Hallingbye et al 2011). Many older people have concurrent chronic pain. In contrast to what occurs with acute pain, the sympathetic nervous system variables of blood pressure and heart rate are likely to be within normal limits, and are rarely considered in chronic pain assessment (Stannard and Booth 1998). Changes in the hepatic and renal systems in older people may lead to pharmacokinetic and dynamic changes in the metabolism of drugs, particularly morphine. In contrast to pain in younger people, which may be considered abnormal, prompting all
BOX 2 Post-operative risks associated with malnutrition Cachexia. Mortality. Poor wound healing. Pressure ulcers. Anaemia. Fatigue and weakness. Susceptibility to infection. Thromboembolism. Restricted mobility. Electrolyte imbalance. Increased hospital stay and readmission. (Adapted from Moats and Hoglund 2012)
4 How would you assess the nutritional status of an older adult? Do you consider this assessment to be adequate? What effect do you think this could have on surgical outcome?
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CPD dementia care
5 Read the case study in Box 3 and write notes on the following: It is likely that Jim has pain from his back and leg and perhaps elsewhere, however is it possible that there are other reasons for his discomfort? If he is given pain relief, is it likely that his behaviour will change? What other interventions might be useful?
possible treatment options to be explored, pain in older people may be perceived as part of the ageing process and not necessarily as a symptom that can be treated or resolved. Brown et al (2011) found that more than 90% of older people living in the community had experienced pain in the previous month, mainly musculoskeletal, with 41% reporting discomforting, distressing, horrible or excruciating pain. The relationship between poor pain management, morbidity, mortality and quality of life is well established (Wood 2004). Without thorough assessment of pain, this situation is unlikely to change. It is better to pre-empt pain than to respond to it, and this requires knowledge of pain assessment and pain management. Causes of pain include: Pain associated with disease – for example, rheumatoid arthritis or cancer. Pain caused by therapy – for example, venepuncture, investigations. Pain caused by care – for example, movement, hygiene activities. Pain associated with the patient’s decision to forgo treatment – for example, refusal of medication. Most people in the early stages of dementia can describe their pain quite accurately. However, many older people respond better to a standardised assessment tool than to vague enquiries that may be misunderstood (McLennon 2007). As people progress through the stages of dementia, they require more time to respond to questions and difficulties
BOX 3 Case study: Jim Jim, aged 81, is on the ward two days after having a prostatectomy under general anaesthesia. He has a diagnosis of dementia and has been in a mental health unit for a few years. He has a frontal lobe type of presentation. This type of dementia mainly results in changes in behaviour and he can be impulsive and difficult; he frequently shouts and strips off his clothes. Before his diagnosis he was a devout Christian and devoted family man. Staff realise he cannot control his behaviour, but some patients are afraid of him and they sometimes shout back. The ward area can become very noisy. He is assessed outside the nursing station, avoiding the stimulation of other patients. Staff place him in a reclining chair and turn on the television, playing a wildlife programme that Jim likes, and sit beside him. However, when reclining in the chair, he is looking upwards into a bright overhead light that he cannot avoid, and there is pressure on his coccyx, which is red and sore on examination. He has a urinary catheter that is causing friction along his leg; the sound of the television is competing with a loud radio in the room of another patient who is hard of hearing; the staff area is manned and people are chatting, telephones ringing and doors opening and closing (he has his back to this noisy area); and the television is positioned opposite a window and the light is reflecting on the screen, making it difficult to see what is on the screen. The staff want pain relief to be prescribed since he scored highly on a behavioural assessment for pain.
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with memory may affect assessment of their pain history. It may be necessary to encourage patients to move during assessments to help them recognise their pain. In the later stages of dementia, it becomes increasingly difficult to tell whether patients are experiencing pain or another form of distress. People with dementia may experience pain differently, they may not react to it immediately, they may not exhibit behaviours that are recognised by their carers, or their behaviours may be interpreted only in the light of their dementia (Hallingbye et al 2011). Communication problems can affect the patient’s ability to self-report their needs, and many carers rely on self-reporting of pain to decide if the patient requires pain relief. There are many observational pain tools, such as the Abbey pain scale (Abbey et al 2004). Practical advice to help with assessment of pain includes: Getting to know as much as possible about the person’s history. Involving those who know the person well from the early stages of care. Avoiding diagnostic overshadowing (when the person’s diagnosis is perceived as the cause of any symptom or behaviour they exhibit); assessment and treatment should not always be based on the diagnosis of dementia. Using appropriate tools to discern distress, discomfort or pain and addressing the cause. If behaviour has changed and words such as ‘challenging’ or ‘difficult’ are used by carers or healthcare staff, then consider pain first. Administering pain relief medication before considering psychoactive or sedative medication. Complete time out activity 5
Discharge from hospital
Discharge planning should begin at the pre-surgery assessment appointment. The involvement of family and carers is crucial to a successful outcome. The majority of delayed discharges occur in people with dementia, and it is reported that their needs are not well understood (Department of Health 2003). As a result of central nervous system complications following anaesthesia and the stress of the surgical experience, people with dementia may not be able to return to their previous state of health and wellbeing (Fodale et al 2006). This can lead to higher dependency on others or transition to a care home. This should not be considered as inevitable for all patients: careful and
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considered baseline measures and optimum management throughout the peri-operative period may improve these outcomes considerably.
Conclusion This article describes the management of older people with dementia who are undergoing surgery, using a surgical nursing pathway. Assessment of cognition and delirium at an early stage in the process, and care interventions including the management of pain are vital in this vulnerable group. As the
population ages and the number of people with dementia continues to rise, surgical intervention in people with dementia will become more frequent. Knowledge of dementia and the care intervention that can enable positive surgical care outcomes is essential for practitioners in this field. The involvement of family and carers is crucial throughout the experience. There is a lack of integrated guidance for staff delivering care to people with dementia though the surgical pathway. This is of concern, and further development is required NS Complete time out activity 6
6 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 62.
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Call for papers Nursing Standard is welcoming submissions from experienced or new authors on a variety of subjects, including:
• • • • • •
Management of infected wounds Bariatric pressure injury Necrotic wounds Pressure injury due to tracheostomy tubes Paediatric wound care Management of fungating wounds
Contact the deputy Art & Science editor Noreen Begley at
[email protected]
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