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Cohen CL, Atkins KJ, Evered LA, Silbert BS, Scott DA. Examining Subjective Psychological Experiences of Postoperative Delirium in Older Cardiac Surgery Patients. Anesth Analg 2022; 136:1174-1181. [PMID: 36201368 DOI: 10.1213/ane.0000000000006226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is an acute syndrome including inattention and impaired cognition that affects approximately 42% of older cardiac surgical patients. POD is linked to adverse outcomes including morbidity, mortality, and further cognitive decline. Less is known about the subjective psychological experience of POD and its ongoing impact on well-being. METHODS We performed a qualitative analysis of the long-term psychological sequelae of older adults who experience POD after cardiac surgery. We sampled 30 patients aged 60 years and older who experienced at least 2 episodes of POD during a prior hospital admission. We administered semistructured interviews with participants via telephone 3 to 5 years postoperatively. Interviews were transcribed and thematically analyzed. Data were interpreted in accordance with the naturalist paradigm. RESULTS Three overarching themes emerged in our qualitative analysis. The first reflected the multifaceted presentation of POD, including distortion of time and reality; feelings of isolation; and a loss of self, identity, and control. The second theme reflected the psychological challenges associated with functional decline after surgery. Common examples of functional decline included cognitive difficulties, excessive fatigue, and a perceived loss of independence. The final theme captured the emotional sequelae of acute illness, which included low mood, reduced motivation, and social comparisons. CONCLUSIONS Our findings emphasize the multidimensional experience of POD and long-term effects on psychological wellbeing. Our research highlights the beneficial role multidisciplinary clinicians play in managing POD including strategies that may be embedded into clinical practice and helps anesthesiologists understand why patients who have experienced POD in the past may present with specific concerns should they require subsequent surgery.
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Affiliation(s)
- Caitlin L Cohen
- From the School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia.,Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Kelly J Atkins
- From the School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia.,Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - Lisbeth A Evered
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia.,Weill Cornell Medicine, New York, New York
| | - Brendan S Silbert
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - David A Scott
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
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Mudge AM, Lee-Steere K, Treleaven E, Cahill M, Finnigan S, McRae P. Cognitive impairment in older hospital inpatients: prevalence, care needs and carer perceptions. AUST HEALTH REV 2021; 46:244-250. [PMID: 34856117 DOI: 10.1071/ah20286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
ObjectivesThe aim of this study was to describe the prevalence of cognitive impairment in hospital inpatients, the associated need for assistance with activities of daily living (ADL) and carer perceptions of hospital care.MethodsA prospective cross-sectional observational study was conducted in a large metropolitan teaching hospital in Brisbane, Australia. Participants were inpatients aged ≥65 years and their carers. Cognitive impairment was measured by clinician auditors using the validated 4 'A's test (4AT), with a score >0 indicating cognitive impairment (1-3, probable dementia; >3, probable delirium). The need for supervision and/or assistance with ADL was recorded from daily nursing documentation. Carers were invited to complete a brief questionnaire.ResultsIn all, 92 of 216 older inpatients (43%) had cognitive impairment, including 52 (24%) with probable delirium. The need for supervision and/or assistance with ADL increased significantly with 4AT score. Fifty-two carers of patients with cognitive impairment reported feeling welcome and that care was safe. They identified opportunities for better information, greater support and more inclusion of carers.ConclusionsCognitive impairment is common in older inpatients and is associated with increased care needs. Workforce planning and health professional training need to acknowledge the needs of patients with cognitive impairment. There are opportunities for greater support and more involvement of carers.What is known about the topic?Cognitive impairment due to delirium and dementia increases with age, and is common in older medical and surgical inpatients. However, cognitive impairment remains under-recognised by healthcare staff. Australian guidelines now recommend routine screening using valid tools, and including carers, when appropriate, when assessing, caring for and communicating with people with cognitive impairment.What does this paper add?This cross-sectional study using the validated 4AT showed 43% of hospital inpatients aged ≥65 years had cognitive impairment. Participants with cognitive impairment had higher care needs and much longer hospitalisations. Carers of people with cognitive impairment reported unmet information needs in hospital and had limited involvement in assessment and care.What are the implications for practitioners?Cognitive impairment is common in older inpatients. Hospitals and healthcare professionals must be prepared and equipped to recognise cognitive impairment, and address the accompanying patient and carer needs.
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Affiliation(s)
- Alison M Mudge
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Karen Lee-Steere
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Elise Treleaven
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Margaret Cahill
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - Simon Finnigan
- Centre for Functioning and Health Research, Metro South Hospitals and Health Service, Buranda, Qld, Australia
| | - Prue McRae
- Internal Medicine Research Unit, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Qld, Australia
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Evered LA, Goldstein PA. Reducing Perioperative Neurocognitive Disorders (PND) Through Depth of Anesthesia Monitoring: A Critical Review. Int J Gen Med 2021; 14:153-162. [PMID: 33469352 PMCID: PMC7813450 DOI: 10.2147/ijgm.s242230] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/05/2021] [Indexed: 11/24/2022] Open
Abstract
General anesthesia has been administered for over 150 years, and in that time, has become progressively safer. Improvements in outcomes have been driven by multiple advances, including the use of non-invasive monitors to assess cardiovascular and respiratory status. More recent advances have included the development and use of monitors to measure neurologic status by means of “processed” electroencephalography (pEEG), wherein the frontal EEG signal is analyzed by proprietary algorithms to produce a dimensionless number (scaled from 0 to 100), wherein low values are associated with deepening levels of sedation that progresses to loss of consciousness. Such monitors have been shown to enable anesthetic titration so as to expedite emergence and early recovery, and their use is advocated for the prevention of intraoperative awareness in the setting of administration of total intravenous anesthesia and neuromuscular blockade. Whether their use can minimize, or prevent, longer term adverse events is a matter of debate. In this narrative review of the most recent literature, we provide an assessment on the use of pEEG monitors in the prevention of a notable, and important, postoperative adverse outcome – delirium – in elderly patients. As we will discuss, the existing data do not support its routine use for the prevention of postoperative delirium in this, or any other, patient population.
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Affiliation(s)
- Lisbeth A Evered
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.,Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.,Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Peter A Goldstein
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.,Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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Buijs-Spanjers KR, Harmsen A, Hegge HH, Spook JE, de Rooij SE, Jaarsma DADC. The influence of a serious game's narrative on students' attitudes and learning experiences regarding delirium: an interview study. BMC MEDICAL EDUCATION 2020; 20:289. [PMID: 32873285 PMCID: PMC7465326 DOI: 10.1186/s12909-020-02210-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/25/2020] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- Kiki R Buijs-Spanjers
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, HPC: AA43, Groningen, 9700 RB, The Netherlands.
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Anne Harmsen
- Strategic Communication Group, Wageningen University, Wageningen, The Netherlands
| | - Harianne H Hegge
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, HPC: AA43, Groningen, 9700 RB, The Netherlands
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jorinde E Spook
- Strategic Communication Group, Wageningen University, Wageningen, The Netherlands
| | - Sophia E de Rooij
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, HPC: AA43, Groningen, 9700 RB, The Netherlands
- Medical School Twente, Medical Spectrum Twente, Enschede, The Netherlands
| | - Debbie A D C Jaarsma
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Buijs-Spanjers KR, Hegge HH, Cnossen F, Jaarsma DA, de Rooij SE. 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. JMIR Serious Games 2020; 8:e18479. [PMID: 32723710 PMCID: PMC7424470 DOI: 10.2196/18479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/14/2020] [Accepted: 05/20/2020] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Kiki R Buijs-Spanjers
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Harianne Hm Hegge
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Fokie Cnossen
- Bernoulli Institute of Mathematics, Computer Science and Artificial Intelligence, Department of Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Debbie Adc Jaarsma
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sophia E de Rooij
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Medical Spectrum Twente, Medical School Twente, Enschede, Netherlands
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