The effects of operations on those living with dementia in acute settings

[Isabella Grace]

Hello, My name is Isabella and I am a final year student nurse. We have recently begun a module at university which is aimed to help us understand and analyse problems within healthcare based around a specific area within our field of nursing (mine being adult). I have always been very interested in dementia and have had many placements where I have been able to care and look after persons with dementia. I also have a job on a dementia ward outside of university. For this module I have decided to investigate how carrying out operations e.g. hip operations effect a patient with dementia in an acute setting. I have read many articles and have been looking through lots of chat forums to analyse how operations effect those living with dementia e.g. I read that a person with dementia who undergoes a hip operation is twice as likely than a person without dementia to be in hospital far longer and have other health issues arise because of this. I was just wondering if anyone would be able to give me any advice (first hand experiences or professional medical advice) on why this may be the case and/or some of the effects that operations have upon those with dementia.
Kind regards.

 

[nitram]

There are two distinct problems.

• The effect of the anaesthetic on the progression of the dementia. This may be short term but can be permanent, Ask an anaesthetist for a opinion.
• The inability of the person with dementia to understand and carry out any post operative instructions.

 

[Isabella Grace]

Many thanks!

 

[marionq]

There is also the problem that surgeons don't want to do these operations because the PWD is unable to follow instructions e.g. About doing necessary exercises. They forget they've had the op and try to get out of bed or to walk causing falls.

So people with dementia are often denied or discouraged from getting ops which should help them.

 

[Kevinl]

I think Nitram has hit the main 2 issues, anaesthetics seem to hit people with AZ much more that they would normally and that the clinicians job is much harder when you don't get any patient feedback so it means they have to consider the implications of discharging someone before you're sure it's totally safe to do so.
With AZ you may be discharging someone in their 70's, 80's or older into the care of a similar aged partner so you may have to involve occupational or physiotherapists to assess the home environment and where necessary supply equipment or a care package, this all takes time.
In the past year I've seen 3 people in the nursing home hospitalised for broken hips and it surprised me how quickly they came back, just a few days, but they were being sent back to a nursing home so there's a qualified nurse available 24/7, trained staff and all the people handling equipment like hoists and lifts and everywhere has wheelchair access.
I think the logistics of discharging someone back to their own home where the only carer is one person with no help or equipment may be a big part of why people with AZ spend longer in hospital when the operation affects their mobility.
I have noticed that all the broken hip patients when they come back just want to get up an walk, someone has to be there all the time to stop them getting up, it's almost like they don't feel any pain. I've never had a hip operation but I imagine it's pretty painful, however, these people don't seem to be troubled by pain at all.
K

 

[canary]

Mum had 2 operations when she had Alzheimers. The first was for cataract surgerry in the early stages of her dementia and the second was for a hip repair after a fall in later stages of dementia.

The cataract surgery was done under local anaesthetic and did not seem to progress the dementia, but after the operation she could not remember that that was what she had had done and didnt understand why her eye hurt. She confabulated that staff had beaten her up and was distraught for days.

The hip surgery that was done in later stages sent her into delirium. She was trying to get up all the time and although she had a cushion which sounded an alarm every time she tried to get up the staff had trouble getting her to comply. She was being discharged back to her CH, but because of the delirium it took longer and they had to check with mums care home whether they would still be able to meet her needs. In mums case they could, but I could imagine that many care homes (especially ones that are not specifically dementia homes) would not be able to. Then there would be a delay while a home that could meet her needs could be found. BTW, the anaesthetic and surgery for mums hip led to a huge progression in her dementia and she stopped eating and drinking, so she ended up back in hospital to check that the surgery was OK. The surgery was, indeed fine, but this would have counted as a failed discharge. She went back to her care home, but passed away 2 weeks later.

 

[DeMartin]

Mum had 2 operations when she had Alzheimers. The first was for cataract surgerry in the early stages of her dementia and the second was for a hip repair after a fall in later stages of dementia.

The cataract surgery was done under local anaesthetic and did not seem to progress the dementia, but after the operation she could not remember that that was what she had had done and didnt understand why her eye hurt. She confabulated that staff had beaten her up and was distraught for days.

The hip surgery that was done in later stages sent her into delirium. She was trying to get up all the time and although she had a cushion which sounded an alarm every time she tried to get up the staff had trouble getting her to comply. She was being discharged back to her CH, but because of the delirium it took longer and they had to check with mums care home whether they would still be able to meet her needs. In mums case they could, but I could imagine that many care homes (especially ones that are not specifically dementia homes) would not be able to. Then there would be a delay while a home that could meet her needs could be found. BTW, the anaesthetic and surgery for mums hip led to a huge progression in her dementia and she stopped eating and drinking, so she ended up back in hospital to check that the surgery was OK. The surgery was, indeed fine, but this would have counted as a failed discharge. She went back to her care home, but passed away 2 weeks later.

Some dementia sufferers can't comprehend instructions, both written or verbal. My mum fried microwave foods, microwaved oven cook food. She has a knee problem, saw a physiotherapist, was given exercises to improve the situation, "rubbish" says mum," I get plenty of exercise doing house work". Mum was a nurse, worked orthopaedic wards, but failed to understand the difference between activities of daily living and specific muscle group exercises.
Also a lot of discharge information is vague, sometimes written in medicalease, "NAD", mum had forgotten what that meant, non medical families would also not understand. I also was a nurse and understand the pressure to clear beds, the closing of convalescence and community hospitals has not helped. There are few bridges between acute care and home care. Good luck with your research, talk to a lot of people, include friends of your parents and older relatives if you can.

 

[philamillan]

Interesting question Isabella.

What you are probably specifically looking at is the increased risk of delirium associated with surgery in a patient with dementia.

This is one that no has no clear answers.

In terms of hip surgeries, I would suggest that you look at the risk of delirium between spinal and general anaesthesia. My view would be that only spinal anaesthesia should be used in the at risk patients for delirium even if it takes longer to do the operation.

Also looking at bowel habits post operatively could be interesting as constipation is associated with delirium.

Finally, what about pain relief in the dementia patient as they cannot express their discomfort as well. Increased pain is also associated with delirium as well as the pain medication.

Hope that helps.

 

[AlsoConfused]

Not relevant to your research, I fear, but I'm aware of what seems like a dangerous obsession with cost-cutting NHS top bods preferring that "Home First" care, rather than hospital care, should be provided regardless of whether it's safe and practicable for the specific patient being sent home.

"Home First" is the mantra of NHS Sustainability Transformation Partnerships (the name's morphed from the Sustainability & Transformation Plans in the same way that Windscale Nuclear Power Station was rebranded to make it sound cleaner and improve its dire reputation).

Thanks to "Home First" far too soon after an op, my aunt is now facing the possibility of a leg amputation (though she doesn't know it yet). She lasted less than 12 hours out of hospital before falling. She's already had 3 further operations to try to repair the damage due to the fall.

 

[DMac]

I was just wondering if anyone would be able to give me any advice (first hand experiences or professional medical advice) on why this may be the case and/or some of the effects that operations have upon those with dementia.
Kind regards.

Hello Isabella

My father-in-law, with dementia (undiagnosed in his lifetime) had what should have been a routine operation to repair an inguinal hernia. He was given a spinal block and sedative instead of a full anaesthetic, which I understand should have got around the problem of anaesthetics making a dementia patient worse. Unfortunately it was hard to communicate with him after the operation, as he became virtually incoherent, so it was impossible to say whether the modified anaesthetic worked or not.

He was also unable to process any instructions about his care, so was unable to co-operate with medical staff and carers. On more than one occasion, he pulled out his urinary catheter when he attempted to get up and walk away from his bed when the catheter bag was attached to the side of the bed. Whilst receiving IV fluids, he would also bend his arm so that the intake line got trapped. I asked the nursing staff if they could put his arm in a splint to keep it straight, but that was against the rules, I was told. Events took over, his catheter bag filled with blood, and infection overwhelmed him. He died of sepsis about 6 weeks after the operation. His death certificate quoted dementia as a cause of death, together with the sepsis.

I do know that the doctors were debating whether or not to carry out the operation on him in the first place. If they had left things alone, I understand his hernia could have strangulated, which would have resulted in a medical emergency. I really don't know which outcome would have been worse for him.

I'm not sure if any of this is helpful to you, but I'm glad that you are taking an interest in this subject. Good luck with your studies, and thank you for all that you are doing to care for some of the most vulnerable patients in society today.

 

[love.dad.but..]

My father also had an inguinal hernia which became an emergency. He was 84 at that time, late moderate dementia and high post op risk due to heart etc. First anaesthetist declined to operate due to to risk but surgeon and 2nd anaesthetist agreed with us...the dementia was only heading one way, we should get him pain free and remove the risk of hernia strangulation. We were fully warned of the op risks and risk of making his dementia worse. Coming round from the anaesethic was terrible for him due to lack of understanding....pulling out.canula, resistant and frightened of anything even having his temp taken so I had too hold him down many many times and help him with more intimate functions. But what was interesting...for 4 or so hours as he was coming round from the anaesthetic but not enough to resist much interventions, pre op verbally very incoherent due to dementia....we had 4 hours of very clear speech, everything seemed to make sense and he named names we hadn't heard in a couple of years, it was like having dad back for a while. Gradually the fog came down and we were back with incoherent dad. The surgeon said a couple of drugs in the anaesthetic cocktail can produce this short term clarity as new pathways clear in the brain but it doesn't last. Hospital is extremely difficult for those dementia patients like dad who are medic frightened, on that occasion I stayed in with him for 2 weeks and at end of life with sepsis and a stroke I stayed in with him ....would do it again for any other loved one with dementia who cannot coherently communicate or is frightened

Unlike when Mum died suddenly, the trauma and shock caused an immediate and noticeable mental decline...after his op the decline was not accelerated, he recovered physically well and whilst his illness carried on its downwards path into advanced stage he had 2.5 more years pain free....and pre op he was in continual pain which he couldn't verbalize but we could see so would have made the same decision again.

 

[Lawson58]

Interesting question Isabella.

What you are probably specifically looking at is the increased risk of delirium associated with surgery in a patient with dementia.

This is one that no has no clear answers.

In terms of hip surgeries, I would suggest that you look at the risk of delirium between spinal and general anaesthesia. My view would be that only spinal anaesthesia should be used in the at risk patients for delirium even if it takes longer to do the operation.

Also looking at bowel habits post operatively could be interesting as constipation is associated with delirium.

Finally, what about pain relief in the dementia patient as they cannot express their discomfort as well. Increased pain is also associated with delirium as well as the pain medication.

Hope that helps.

Unfortunately, epidural anesthetics are not appropriate for dementia and other patients if they have particular cardiac issues. My husband has had several surgeries in the last few years and has been unable to have an epidural as he has had a mitral valve repair, a cardiac arrest and now has heart failure.

Just another thing to complicate the care we give.