"Eight Days of Nightmares … " - Octogenarian Patients' Experiences of Postoperative Delirium after Transcatheter or Surgical Aortic Valve Replacement

Detection of delirium in older patients-A point prevalence study in surgical and non-surgical hospital wards

AIMS AND OBJECTIVES

To (i) determine the prevalence of delirium and identify delirium subtypes in surgical and non-surgical patients aged ≥65 years, (ii) determine whether certain precipitating factors affect the prevalence of delirium and (iii) review patients' medical records for description of delirium symptoms and the presence of International Classification of Diseases (ICD-10) coding for delirium in discharge summaries.

METHODOLOGICAL DESIGN AND JUSTIFICATIONS

Despite being a robust predictor of morbidity and mortality in older adults, delirium might be inadequately recognised and under-reported in patients' medical records and discharge summaries. A point prevalence study (24-h) of patients ≥65 years from surgical and non-surgical wards was therefore conducted in a tertiary university hospital.

ETHICAL ISSUES AND APPROVAL

The study was approved by the Data Protection Officer at the university hospital (2018/3454).

RESEARCH METHODS, INSTRUMENTS AND/OR INTERVENTIONS

Patients were assessed for delirium with 4AT and delirium subtypes with the Delirium Motor Subtype Scale. Information about room transfers, need and use of sensory aids and medical equipment was collected onsite. Patients' medical records were reviewed for description of delirium symptoms and of ICD-10 codes.

RESULTS

Overall, 123 patients were screened (52% female). Delirium was identified in 27% of them. Prevalence was associated with advanced age (≥85 years). The uncharacterised delirium subtype was most common (36%), followed by hypoactive (30%), hyperactive (24%) and mixed (9%). There were significant associations between positive screening tests and the need and use of sensory aids. Delirium symptoms were described in 58% of the patients who tested positive for delirium and the ICD-10 code for delirium was registered in 12% of these patients' discharge summaries.

CONCLUSIONS

The high prevalence of delirium and limited use of discharge codes highlight the need to improve the identification of delirium in hospital settings and at discharge. Increased awareness and detection of delirium in hospital settings are vital to improve patient care.

Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review

OBJECTIVES

Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults.

METHODS

Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed.

RESULTS

These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition.

CONCLUSIONS

The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.

A standardized clinical pathway for hip fracture patients is associated with reduced mortality: data from the Norwegian Hip Fracture Register

PURPOSE

A standardized clinical pathway is recommended for hip fracture patients. We aimed to survey standardization of treatment in Norwegian hospitals and to investigate whether this affected 30-day mortality and quality of life after hip fracture surgery.

METHODS

Based on the national guidelines for interdisciplinary treatment of hip fractures, nine criteria for a standardized clinical pathway were identified. A questionnaire was sent to all Norwegian hospitals treating hip fractures in 2020 to survey compliance with these criteria. A standardized clinical pathway was defined as a minimum of eight criteria fulfilled. Thirty-day mortality for patients treated in hospitals with and without a standardized clinical pathway was compared using data in the Norwegian Hip Fracture Register (NHFR).

RESULTS

29 out of 43 hospitals (67%) answered the questionnaire. Of these, 20 hospitals (69%) had a standardized clinical pathway. Compared to these hospitals, there was a significantly higher 30-day mortality in hospitals without a standardized clinical pathway in the period 2016-2020 (HR 1.13, 95% CI 1.04-1.23; p = 0.005). 4 months postoperatively, patients treated in hospitals with a standardized clinical pathway and patients treated in hospitals without a standardized clinical pathway reported an EQ-5D index score of 0.58 and 0.57 respectively (p = 0.038). Significantly more patients treated in hospitals with a standardized clinical pathway were 4 months postoperatively able to perform usual activities (29% vs 27%) and self-care (55% vs 52%) compared to hospitals without a standardized clinical pathway.

CONCLUSION

A standardized clinical pathway for hip fracture patients was associated with reduced 30-day mortality, but no clinically important difference in quality of life compared to a non-standardized clinical pathway.

Adverse clinical events during the first 24 h of bedrest following cardiac electronic device implantation: a prospective observational study

AIMS

To describe the incidence and impact of adverse clinical events (ACEs) during first 24 h of bedrest of patients after cardiac implantable electronic device (CIED) implantation.

METHODS AND RESULTS

We conducted a prospective observational study of patients aged over 18 years undergoing elective placement of permanent bicameral pacemaker (PM), cardiac resynchronization therapy (CRT) PM, CRT defibrillator, or implantable cardioverter-defibrillator. Patients were maintained on bedrest post-operatively for 24 h and delirium, post-operative urinary retention, severe post-operative pain, pressure ulcer, and sleep disturbance were recorded using standardized assessments. Of 90 patients, 66 (73.3%) were male and average age was 76 ± 10 years. The median time to first mobilization was 23 (21-24) h. The adverse clinical events occurred in 48/90, with severe pain (38/90), sleep disturbance (12/90), delirium (9/90), and urinary retention requiring urinary catheterization (8/90) most frequent. Patients receiving implantable cardioverter-defibrillator or CRT defibrillator experienced ACEs significantly more frequently than those receiving PM. Adverse clinical event was associated with prolonged hospital stay [odds ratio (OR) 2.5; 95% confidence interval (CI) 1.16-6.17]. Patients with delirium were more dependent for daily living activities on admission (OR 8.0; 95% CI 1.55-41.3).

CONCLUSION

Adverse clinical events frequently occur post-insertion of a CIED and impact patient clinical course and experience. The progressive increase in ageing and frailty of CIED implant candidates requires special nursing attention to improve patients' satisfaction and to prevent increased healthcare resource use.

Alpha-2-adrenergic receptor agonists for the prevention of delirium and cognitive decline after open heart surgery (ALPHA2PREVENT): protocol for a multicentre randomised controlled trial

INTRODUCTION

Postoperative delirium is common in older cardiac surgery patients and associated with negative short-term and long-term outcomes. The alpha-2-adrenergic receptor agonist dexmedetomidine shows promise as prophylaxis and treatment for delirium in intensive care units (ICU) and postoperative settings. Clonidine has similar pharmacological properties and can be administered both parenterally and orally. We aim to study whether repurposing of clonidine can represent a novel treatment option for delirium, and the possible effects of dexmedetomidine and clonidine on long-term cognitive trajectories, motor activity patterns and biomarkers of neuronal injury, and whether these effects are associated with frailty status.

METHODS AND ANALYSIS

This five-centre, double-blind randomised controlled trial will include 900 cardiac surgery patients aged 70+ years. Participants will be randomised 1:1:1 to dexmedetomidine or clonidine or placebo. The study drug will be given as a continuous intravenous infusion from the start of cardiopulmonary bypass, at a rate of 0.4 µg/kg/hour. The infusion rate will be decreased to 0.2 µg/kg/hour postoperatively and be continued until discharge from the ICU or 24 hours postoperatively, whichever happens first.Primary end point is the 7-day cumulative incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Secondary end points include the composite end point of coma, delirium or death, in addition to delirium severity and motor activity patterns, levels of circulating biomarkers of neuronal injury, cognitive function and frailty status 1 and 6 months after surgery.

ETHICS AND DISSEMINATION

This trial is approved by the Regional Committee for Ethics in Medical Research in Norway (South-East Norway) and by the Norwegian Medicines Agency. Dissemination plans include publication in peer-reviewed medical journals and presentation at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT05029050.

PAINT I: the effect of art therapy in preventing and managing delirium among hospitalized older adults in the PAINT I study-a proof-of-concept trial

BACKGROUND

Delirium is common among older hospitalized patients and is regarded as a negative outcome parameter. Non-pharmacological strategies have been shown to be effective in the prevention and management of delirium. This study aimed to determine the effectiveness of art therapy as part of a multicomponent intervention in preventing and managing delirium in hospitalized older patients.

METHODS

138 patients at risk of developing delirium were included and received art therapy twice daily for 25 min using a mobile atelier. 107 participants were included in the final analysis (N = 53 intervention, N = 54 control). The primary outcome was the effectiveness of art therapy in preventing delirium. The secondary outcome was to determine its impact on duration of delirium in patients with existing delirium. Delirium was assessed using the Nursing delirium Screening Scale (Nu-DESC).

RESULTS

8 patients (7.5%) developed new onset delirium after admission, equally distributed among control and intervention group. Therefore, no valid statistical analysis could be performed. There was a statistically non-significant decrease in the duration of delirium in the intervention group (4 days, IQR 2.25-8.75) compared to the control group (7 days, IQR 5-10), Mann-Whitney-U-Test p-value = 0.26. After stratifying by dementia diagnosis on admission, the non-significant decrease in duration of delirium in the intervention group was more apparent in patients without dementia.

CONCLUSION

Findings from this study showed that the integration of art therapy as part of a multicomponent intervention in delirium management is feasible, and can reduce duration of delirium among hospitalized older adults.

Patients' experiences of delirium: A systematic review and meta-summary of qualitative research

AIMS

The purpose of this systematic review and meta-summary was the aggregation of the empirical qualitative literature on patients' experiences of delirium in order to support the development and implementation of patient-oriented delirium management and to guide future research.

DESIGN

We conducted a systematic literature review of qualitative research published between January 1980 and June 2019.

DATA SOURCES

In June 2019, we searched in Medline, CINAHL, SSCI and PsycInfo to identify relevant reports. In addition, we conducted searches in three dissertation databases (BASE, DART and ProQuest) and Google Scholar.

REVIEW METHODS

We used methods developed by Sandelowski and Barroso to construct a meta-summary of the findings by extracting them from the reports, abstracting them into meta- findings and calculating their manifest interstudy frequency effect sizes.

RESULTS

Out of the 742 identified records, 24 reports based on delirium experience accounts of 483 patients met our criteria and were included. One thousand ninety-seven findings were extracted from these reports and abstracted into 92 meta-findings. These were grouped to the five emerging themes 'perception', 'emotions', 'interaction with others', 'dealing with delirium' and 'influence on further life'.

CONCLUSION

Delirium is commonly perceived as an overall distressing condition, which can accompany and influence patients even after hospital discharge.

IMPACT

This systematic review and meta-summary is the most comprehensive aggregation of qualitative research of the patient delirium experience to date. It allows us to better understand, extract meaning from, and weigh the qualitative findings in their context by calculating their manifest frequency effect sizes. This can be used to support the development and implementation of delirium management concepts.

Octogenarian patients' sleep and delirium experiences in hospital and four years after aortic valve replacement: a qualitative interview study

OBJECTIVES

Sleep disturbances and delirium are frequently observed complications after surgical aortic valve replacement (SAVR) and transcutaneous aortic valve implantation (TAVI), especially in octogenarian patients. However, a knowledge gap exists on patient experiences of sleep and delirium. In particular, patients' long-term sleep and delirium experiences are unknown. This article explores and describes how octogenarian patients suffering from delirium after aortic valve replacement experience their sleep and delirium situation.

DESIGN

An explorative and descriptive design with a longitudinal qualitative approach was applied. Qualitative content analysis following the recommended steps of Graneheim and Lundman was performed.

SETTING

Patients were included at a tertiary university hospital with 1400 beds. Delirium and insomnia screening was performed at baseline and five postoperative days after aortic valve treatment. For qualitative data, 10 patients were interviewed 6-12 months after treatment with focus on delirium. Five of these patients were reinterviewed 4 years after treatment, with focus on their sleep situation.

PARTICIPANTS

Inclusion criteria; age 80+, treated with SAVR or TAVI and had experienced delirium after treatment.

RESULTS

For the initial interview, we included five men and five women, four following TAVI and six following SAVR, mean age 83. One overarching theme revealed from the content analyses; Hours in bed represented emotional chaos. Whereas three subthemes described the patients' experiences with sleep and delirium, a cascade of distressful experiences disturbing sleep, the struggle between sleep and activity and elements influencing sleep. Four years after the treatment, sleep disturbances persisted, and patients still remembered strongly the delirium incidences.

CONCLUSIONS

For octogenarian patients, sleep disturbances and delirium are long-term burdens and need a greater attention in order to improve patient care.

The influence of a serious game's narrative on students' attitudes and learning experiences regarding delirium: an interview study

BACKGROUND

Delirium is a neuropsychiatric syndrome that affects patients' attention and awareness as a result of a physical condition. In recent years, persistent gaps in delirium education have led to suboptimal delirium care. Still, little is known about what are the most important aspects of effective delirium education. Serious games are both entertainment and an interactive, safe learning environment where players can experiment and create new knowledge. They have the potential to contribute to improved delirium education. We used a video-based serious games' narrative to explore aspects essential to enhance students' attitudes and learning experiences regarding delirium.

METHODS

We created a semi-structured interview guide and interviewed seven nursing and nine medical students about their attitudes and learning experiences, after they had played the game. A qualitative descriptive design and inductive content analysis with constant comparison were used.

RESULTS

The patient's and nurse's perspective, interactivity to experiment, realistic views on care options, and feedback on care actions were important for enhancing students' attitudes and learning experiences regarding delirium. Students felt these aspects encouraged them to get actively involved in and experiment with the study material, which in turn led to enhanced reflection on delirium care and education. Our findings highlight the importance of a more patient-oriented focus to delirium education to drive attitudinal change. Students' learning experiences were further enhanced through their affective responses provoked by the perspectives, interactivity, realism, and feedback.

CONCLUSIONS

Students considered the characters' perspectives, interactivity, realism, and feedback important aspects of the game to enhance their attitudes towards delirious patients and enrich their learning experiences. A patient-oriented narrative provides a clinically relevant experience in which reflection plays an important role. The serious game also serves as medium to actively experiment with care solutions to create better understanding of how healthcare professionals can influence a delirious patient's experience.

Reasons to Engage in and Learning Experiences From Different Play Strategies in a Web-Based Serious Game on Delirium for Medical Students: Mixed Methods Design

Background

Although many studies have recently been published on the value of serious games for medical education, little attention has been given to the role of dark play (choosing unacceptable actions in games).

Objective

This study aimed to investigate potential differences in the characteristics of medical students who have the opportunity to choose normal or dark play in a serious game. This study also aimed to compare their reasons for choosing a play strategy and their perceptions of what they learned from their game play.

Methods

We asked undergraduate medical students to play a serious game in which they had to take care of a patient with delirium (The Delirium Experience). After getting acquainted with the game, students could opt for normal or dark play. Student characteristics (age, gender, experience with caring for older or delirious patients, and number of completed clerkships) were collected, and the Delirium Attitude Scale and Learning Motivation and Engagement Questionnaire were administered. Reasons for choosing normal or dark play were evaluated with an open-ended question. Information on lessons they had learned from the game was collected using an open-ended question and self-reported knowledge on delirium.

Results

This study had 160 participants (89 normal play, 71 dark play). Male students (26/160, 56.5%) chose dark play significantly more often than female students (45/160, 39.5%; P=.049). We did not find significant differences in student characteristics or measurement outcomes between play strategies. Participants’ main reason for choosing normal play was to learn how to provide care to delirious patients, and the main reason for dark play was to gain insight into what a delirious patient has to endure during delirious episodes. All participants learned what to do when taking care of a delirious patient and gained insight into how a patient experiences delirium. We found no differences in self-reported knowledge.

Conclusions

When medical students have the opportunity to choose dark play in a serious game, half of them will probably choose this play strategy. Male students will more likely opt for dark play than female students. Choice of play strategy is not affected by any other student characteristic or measurement outcome. All students learned the same lessons from playing the game, irrespective of their learning strategy.

Measuring the distress related to delirium in older surgical patients and their relatives

OBJECTIVES

Delirium is a common postoperative complication with implications on morbidity and mortality. Less is known about the psychological impact of delirium in patients and relatives. This study aimed to quantitatively describe distress related to postoperative delirium in older surgical patients and their relatives using the distress thermometer, examine the association between degree of distress and features of delirium on the Delirium Rating Scale (DRS), and examine the association between recall of delirium and features of delirium on the DRS.

METHODS

This prospective study recruited postoperative patients and their relatives following delirium. The distress thermometer was used to examine the degree of distress pertaining to delirium and was conducted during the hospitalization on resolution of delirium and then at 12-month follow-up. Associations between delirium-related distress in patient and relative participants and severity and features of delirium (DRS) were examined.

RESULTS

One hundred two patients and 49 relatives were recruited. Median scores on the distress thermometer in patients who recalled delirium were 8/10. Relatives also showed distress (median distress thermometer score of 8/10). Associations were observed between severity and phenotypic features of delirium (delusions, labile affect, and agitation). Distress persisted at 12 months in patients and relatives.

CONCLUSION

Distress related to postoperative delirium can be measured using a distress thermometer. Alongside approaches to reduce delirium incidence, interventions to minimize distress from postoperative delirium should be sought. Such interventions should be developed through robust research and if effective administered to patients, relatives, or carers.

Indwelling urinary catheters, aortic valve treatment and delirium: a prospective cohort study

OBJECTIVES

To determine whether an association exists between delirium and length of time indwelling urine catheters (IUC) are used in octogenarian patients treated with surgical aortic valve treatment (SAVR) or transcatheter aortic valve implantation (TAVI).

DESIGN

Prospective cohort study.

SETTING

Tertiary university hospital covering the western region of Norway.

PARTICIPANTS

Octogenarian patients undergoing elective SAVR or TAVI and willing to participate in the study were eligible. Patients unable to speak Norwegian were excluded. Between 2011 and 2013, 143 consecutive patients were included, and data from 136 of them are presented.

PRIMARY OUTCOME

Delirium.

RESULTS

Logistic regression analysis shows that lower cognitive function was positively associated with delirium (OR 0.86, CI 0.74 to 0.99, p=0.047). Besides, the interaction term in the model shows that IUC use and delirium differed between SAVR and TAVI patients (p=0.04). The difference corresponded to a weaker association between hours of IUC use and delirium for SAVR (OR 1.01, CI: 0.99 to 1.03, p=0.54) compared with that for TAVI (OR 1.04, CI: 1.01 to 1.08, p=0.004).

CONCLUSIONS

The association between IUC use and delirium is stronger for octogenarian patients treated with TAVI than for patients who received SAVR. Our results revealed a previously unknown association between the number of hours an IUC is used and postoperative delirium in octogenarian patients treated with TAVI.

‘I hope you get normal again’: an explorative study on how delirious octogenarian patients experience their interactions with healthcare professionals and relatives after aortic valve therapy

Background:

Delirium affects nearly half of octogenarian patients after aortic valve replacement, resulting in impaired cognition, reduced awareness and hallucinations. Although healthcare professionals and relatives are often present during episodes, the nature of interactions with them is scarcely studied, and little is known about their long-term experiences.

Purpose:

The purpose of this study was to explore and describe how octogenarian patients with post-aortic valve replacement delirium experience interactions with healthcare professionals and relatives within the first year and four years later.

Method:

An explorative design with qualitative content analysis was used. Delirium was assessed for five consecutive days after aortic valve replacement using the Confusion Assessment Method. Delirious patients ( n=10) were interviewed 6–12 months post-discharge and four years later ( n=5). We used an inductive approach to identify themes in transcribed interviews.

Findings:

An overarching theme emerged: ‘ Healthcare professionals’ and relatives’ responses made a considerable impact on the delirium experience postoperatively and in a long-term’. Three sub-themes described the patients’ experiences: ‘ the need for close supportive care’, ‘ disrespectful behaviour created a barrier’ and ‘ insensitive comments made lasting impressions’. Having healthcare professionals and relatives nearby made the patients feel secure, while lack of attention elevated patients’ emotional distress. Four years later, patients clearly recalled negative comments and unsupportive actions in their delirious state.

Conclusions:

Healthcare professionals and relatives have an essential role in the aortic valve replacement recovery process. Inconsiderate behaviour directed at older patients in delirium elevates distress and has long-term implications. Supportive care focused on maintaining the patients’ dignity and integrity is vital.