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Delirium in older people after cardiac surgery: risk factors, dementia, patients’ experiences and assessments
Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.ORCID iD: 0000-0002-0549-8544
2016 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Akut förvirringstillstånd (delirium) hos äldre personer som genomgått hjärtkirurgi : riskfaktorer, demens, patienternas erfarenheter och skattningsinstrument. (Swedish)
Abstract [en]

Background:

Delirium is common in older people undergoing cardiac surgery. Delirium is an acute or subacute neuro-psychiatric syndrome, characterized by a change in cognition, disturbances in consciousness; it fluctuates, develops over a short period of time and always has an underlying cause. It is associated with a disturbance in psychomotor activity, and is classified according to different clinical profiles such as hypoactive, hyperactive and mixed delirium. Delirium after cardiac surgery is not harmless, it increases the risk of complications such as prolonged stay in hospital, falls, reduced quality of life, reduced cognitive function and increased mortality.

Aim:

The overall aim of this thesis was to investigate postoperative delirium in older people undergoing cardiac surgery with Cardiopulmonary Bypass (CPB), focusing on risk factors, dementia and patients’ experiences; and to evaluate an assessment for screening delirium.

Methods:

This thesis compromises four studies. All participants (n=142) were scheduled for cardiac surgery with use of CPB at the Cardiothoracic Surgery Department, Heart Centre, Umeå University Hospital, Sweden, between February and October 2009. Six structured interviews were conducted preoperatively, day one and day four postoperatively, and in home visits, one, three and five years after surgery (2010, 2012 and 2014). The assessment scales used in Studies I, II and IV were: the Mini-Mental State Examination (MMSE) for cognition, the Organic Brain Syndrome Scale (OBS) for delirium, Geriatric Depression Scale 15 (GDS-15) for depression, Katz staircase with Activities of Daily Living (ADL) for participants’ functional status and the Numerical Rating Scale (NRS) for pain. During the hospital stay, nursing staff used the Swedish version of the Nursing Delirium Screening Scale (Nu-DESC) to assess delirium. Semi-structured interviews were also carried out (III) in the one-year follow up. Delirium, dementia and depression were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR).

Results:

Out of 142 participants 54.9% (78/142) developed delirium after cardiac surgery (I). Independent risk factors, predisposing and precipitating, associated with delirium were: age, diabetes, gastritis/peptic ulcer, volume load during operation, longer time on ventilator in intensive care, increased temperature and plasma sodium concentration in the intensive care unit. Out of 114 participants thirty (26.3%) developed dementia within the five years of follow-up. It was shown that a lower preoperative MMSE score and postoperative delirium were factors independently associated with development of dementia (II). One year after cardiac surgery, participants diagnosed with postoperative delirium described in detail feelings of extreme vulnerability and frailty. Despite this, the participants were grateful for the care they had received (III). Hypoactive was the most common symptom profile for delirium. The Swedish version of Nu-DESC showed high sensitivity in detecting hyperactive delirium, but low sensitivity in detecting hypoactive delirium (IV).

Conclusion:

Delirium was common among older patients undergoing cardiac surgery. Both predisposing and precipitating factors contributed to postoperative delirium. Preventive strategies should be considered in future randomized studies. It might also be suggested that cognitive function should be screened for preoperatively and patients who develop delirium should be followed up to enable early detection of symptoms of dementia. Whether prevention of postoperative delirium can reduce the risk of future dementia remains to be studied. To minimise unnecessary suffering, patients and next of kin should be informed about and prepared for the risk of delirium developing during hospitalization. The Swedish version of Nu-DESC should be combined with cognitive testing to improve detection of hypoactive delirium, but further research is needed. Healthcare professionals need knowledge concerning postoperative delirium in order to prevent, detect and treat delirium so as to avoid and relieve the suffering it might cause.

Abstract [sv]

Akut förvirringstillstånd (delirium) hos äldre personer som genomgått hjärtkirurgi –riskfaktorer, demens, patienternas erfarenheter och skattningsinstrument.

Bakgrund:

Delirium är vanligt hos äldre personer som genomgår hjärtkirurgi. Delirium är ett akut eller subakut neuropsykiatriskt syndrom, som kännetecknas av förändrad kognitiv förmåga samt en förändad medvetande nivå. Delirium utvecklas under en kort tidsperiod, tenderar att fluktuera och har alltid en bakomliggande orsak. Delirium kan klassificeras som hypoaktivt, hyperaktivt eller en blandform av båda dessa. Delirium efter hjärtkirurgi kan öka risken för andra komplikationer som tillexempel; förlängd vårdtid, fall, försämrad livskvalité, nedsatt kognitiv förmåga samt mortalitet.

Syfte:

Det övergripande syftet med denna avhandling var att undersöka postoperativt delirium bland äldre personer som genomgått hjärtkirurgi med hjärt-lungmaskin med fokus på riskfaktorer, demens, patienters erfarenheter samt utvärdering av skattningsinstrument för delirium

Metod:

Denna avhandling består av fyra studier. Alla deltagare (n = 142) genomgick rutinmässig hjärtkirurgi med hjärt-lungmaskin vid Thoraxkirurgiska kliniken, Hjärtcentrum, Umeå Universitetssjukhus, mellan februari till oktober 2009. Sex intervjuer genomfördes; preoperativt, dag ett och dag fyra postoperativt, samt vid hembesök ett, tre och fem år efter operationen (2010, 2012 och 2015). Skattningsinstrument som användes i studie I, II och IV var; The Mini-Mental Test (MMSE) för kognition, The Organic Brain Syndrome Scale (OBS) för delirium, Geriatric Depression Scale (GDS-15) för depression, Katz ADL trappa-Katz-index aktiviteter för dagliga livet och Numerisk Rating Scale (NRS) för smärta. Under vårdtiden använde vårdpersonalen Nursing Delirium Screening Scale (Nu-DESC) tre gånger dagligen för att skatta delirium. Nu-DESC jämfördes med en sammanvägning av MMSE och OBS-skalan. Vid uppföljningen år 2010 genomfördes dessutom semistrukturerade intervjuer. Delirium, demens och depression diagnostiserades enligt Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).

Resultat:

Studie I visade att 54.9% (78/142) av patienterna utvecklade delirium efter hjärtkirurgi. Oberoende riskfaktorer (bakomliggande och utlösande) för delirium var; ålder, diabetes, gastrit/magsår, volymbelastning under operation samt respiratortid, förhöjd kroppstemperatur och förhöjd natriumkoncentration i plasma på intensivvårds avdelning. Studie II visade att 26.3% (30/114) av deltagarna utvecklade demens under en femårs uppföljning. En nedsatt preoperativ kognitiv förmåga (indikerad av lägre MMSE-poäng) och förekomsten av postoperativ delirium var faktorer som ökade risken för att utveckla demens. Ett år efter operation kunde deltagarna som diagnostiserats med postoperativt delirium i detalj beskriva sin sårbarhet och skörhet under vårdtiden. Deltagarna beskrev också sin tacksamhet över den vård de fått (Studie III). Den vanligaste formen var hypoaktivt delirium. Den svenska versionen av Nu-DESC kunde upptäcka hyperaktivt men inte hypoaktivt delirium (Studie IV).

Slutsats:

Delirium var vanligt bland äldre patienter som genomgått hjärtkirurgi. Både bakomliggande och utlösande faktorer utgjorde ökad risk för att utveckla postoperativt delirium. Förebyggande strategier bör övervägas i framtida randomiserade studier. Kognitiv funktion bör skattas preoperativt och patienter bör skattas för delirium under vårdtiden och följas upp efter hemgång för att upptäcka tidiga demenssymtom. Huruvida förebyggandet av postoperativt delirium kan minska risken för demens senare återstår att studeras. För att minska onödigt lidande bör patienter och anhöriga bli informerade och förberedda på risken att utveckla delirium under vårdtiden. Den svenska versionen av Nu-DESC behöver förmodligen kombineras med ett kognitiv test för att upptäcka hypoaktivt delirium. För att lindra det lidande som syndromet kan orsaka behöver vårdpersonal fördjupad kunskap i syfte att förebygga, upptäcka och behandla postoperativt delirium.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2016. , 79 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1783
Keyword [en]
Cardiac surgery, Cardiovascular disease, Delirium, Dementia, Nursing, Older people, Patients’ experiences, Perioperative period
National Category
Nursing
Research subject
Caring Sciences
Identifiers
URN: urn:nbn:se:umu:diva-118347ISBN: 978-91-7601-423-3.OAI: oai:DiVA.org:umu-118347DiVA: diva2:912869
Public defence
2016-04-15, Vårdvetarhuset, Aula, Umeå universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-03-24 Created: 2016-03-16 Last updated: 2016-03-24Bibliographically approved
List of papers
1. Delirium after cardiac surgery: incidence and risk factors
Open this publication in new window or tab >>Delirium after cardiac surgery: incidence and risk factors
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2013 (English)In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 17, no 5, 790-796 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Delirium after cardiac surgery is a problem with consequences for patients and healthcare. Preventive strategies from known risk factors may reduce the incidence and severity of delirium. The present aim was to explore risk factors behind delirium in older patients undergoing cardiac surgery with cardiopulmonary bypass.

METHODS: Patients (≥70 years) scheduled for routine cardiac surgery were included (n = 142). The patients were assessed and monitored pre-/postoperatively, and delirium was diagnosed from repeated assessments with the Mini-Mental State Examination and the Organic Brain Syndrome Scale, using the DSM-IV-TR criteria. Variables were analysed by uni-/multivariable logistic regression, including both preoperative variables (predisposing) and those extracted during surgery and in the early postoperative period (precipitating).

RESULTS: Delirium was diagnosed in 78 patients (54.9%). Delirium was independently associated with both predisposing and precipitating factors (P-value, odds ratio, upper/lower confidence interval): age (0.036, 1.1, 1.0/1.2), diabetes (0.032, 3.5, 1.1/11.0), gastritis/ulcer problems (0.050, 4.0, 1.0/16.1), volume load during operation (0.001, 2.8, 1.5/5.1), ventilator time in ICU (0.042, 1.2, 1.0/1.4), highest temperature recorded in ICU (0.044, 2.2, 1.0/4.8) and sodium concentration in ICU (0.038, 1.2, 1.0/1.4).

CONCLUSIONS: Delirium was common among older patients undergoing cardiac surgery. Both predisposing and precipitating factors contributed to delirium. When combined, the predictive strength of the model improved. Preventive strategies may be considered, in particular among the precipitating factors. Of interest, delirium was strongly associated with an increased volume load during surgery.

Place, publisher, year, edition, pages
Oxford University Press, 2013
Keyword
cardiac surgery, delayed, early, hemispheric, stroke survival
National Category
Surgery Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-86091 (URN)10.1093/icvts/ivt323 (DOI)23887126 (PubMedID)
Available from: 2014-02-17 Created: 2014-02-17 Last updated: 2016-03-24Bibliographically approved
2. Dementia after postoperative delirium in older people who have undergone cardiac surgery: a longitudinal cohort study
Open this publication in new window or tab >>Dementia after postoperative delirium in older people who have undergone cardiac surgery: a longitudinal cohort study
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Nursing Geriatrics
Identifiers
urn:nbn:se:umu:diva-118450 (URN)
Available from: 2016-03-18 Created: 2016-03-18 Last updated: 2016-03-24
3. Experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium: one year follow-up
Open this publication in new window or tab >>Experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium: one year follow-up
2015 (English)In: BMC Nursing, ISSN 1472-6955, Vol. 14, 17Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Cardiovascular disease is common among old people and many undergo cardiac surgery. Scientific knowledge is available on cardiac surgery from several perspectives. However, we found few studies focusing on older patients' experiences of cardiac surgery. The aim of this study was to illuminate experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium, a one year follow-up.

METHODS: Qualitative interviews were conducted with 49 participants (aged ≥70 years) diagnosed with delirium after cardiac surgery. Data were collected in Sweden during 2010 through individual, semi-structured interviews in participants' homes one year after surgery. The interviews were analyzed using qualitative content analysis.

RESULTS: Four themes with sub-themes were formulated: Feeling drained of viability includes having a body under attack, losing strength and being close to death. Feeling trapped in a weird world describes participants having hallucinations, being in a nightmare and being remorseful for their behavior. Being met with disrespect includes feeling disappointed, being forced, and feeling like cargo. On the other hand, Feeling safe, including being in supportive hands and feeling grateful, points to participants' experiences of good care and the gift of getting a second chance in life.

CONCLUSIONS: Even one year after cardiac surgery, participants described in detail feelings of extreme vulnerability and frailty. They also had felt completely in the hands of the health care professionals. Participants described experiences of hallucinations and nightmares during hospitalization. Cardiac surgery was a unique, fearful, traumatic and unpleasant experience yet could also include pleasant or rewarding aspects. It seems that health care professionals need deeper knowledge on postoperative delirium in order to prevent, detect and treat delirium to avoid and relieve the suffering these experiences might cause.

Keyword
Cardiac surgery, Delirium, Lived experience, Nursing, Older people, Patient’s experience, Perioperative period
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-101857 (URN)10.1186/s12912-015-0069-7 (DOI)25866476 (PubMedID)
Available from: 2015-04-23 Created: 2015-04-15 Last updated: 2016-03-24Bibliographically approved
4. Validation of the Swedish version of the Nursing Delirium Screening Scale used in patients 70 years and older undergoing cardiac surgery
Open this publication in new window or tab >>Validation of the Swedish version of the Nursing Delirium Screening Scale used in patients 70 years and older undergoing cardiac surgery
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2013 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 22, no 19-20, 2858-2866 p.Article in journal (Refereed) Published
Abstract [en]

AIMS AND OBJECTIVES: Validation of the Swedish version of the Nursing Delirium Screening Scale as a screening tool for nurses to use to detect postoperative delirium in patients 70 years and older undergoing cardiac surgery.

BACKGROUND: Delirium is common among old patients after cardiac surgery. Underdiagnosis and poor documentation of postoperative delirium is problematic, and nurses often misread the signs.

DESIGN: A prospective observational study.

METHODS: Patients (n = 142) scheduled for cardiac surgery were assessed three times daily by the nursing staff using the Nursing Delirium Screening Scale. Nursing Delirium Screening Scale was compared with the Mini Mental State Examination and the Organic Brains Syndrome Scale, evaluated day one and day four postoperatively. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders - DSM-IV-TR criteria.

RESULTS: A larger proportion of patients were diagnosed with delirium according to the Mini Mental State Examination and Organic Brains Syndrome Scale compared with the Nursing Delirium Screening Scale, both on day one and day four. The Nursing Delirium Screening Scale protocol identified the majority of hyperactive and mixed delirium patients, whereas several with hypoactive delirium were unrecognised.

CONCLUSIONS: The Swedish version of the Nursing Delirium Screening Scale was easily incorporated into clinical care and showed high sensitivity in detecting hyperactive symptoms of delirium. However, in the routine use by nurses, the Nursing Delirium Screening Scale had low sensitivity in detecting hypoactive delirium, the most prevalent form of delirium after cardiac surgery. Nursing Delirium Screening Scale probably has to be combined with cognitive testing to detect hypoactive delirium.

RELEVANCE TO CLINICAL PRACTICE: Nurses play a key role in detecting delirium. The Nursing Delirium Screening Scale was easy incorporated instrument for clinical practice and identified the majority of hyperactive and mixed delirium, but several of the patients with hypoactive delirium were unrecognised. Training of assessment and cognitive testing seems to be necessary to detect hypoactive delirium.

Place, publisher, year, edition, pages
Blackwell Publishing, 2013
Keyword
delirium, heart surgery, instrument validation, nursing diagnosis, postoperative care
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-86090 (URN)10.1111/j.1365-2702.2012.04102.x (DOI)24033713 (PubMedID)
Available from: 2014-02-17 Created: 2014-02-17 Last updated: 2016-03-24Bibliographically approved

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