THE FOUR STAGES OF CARE
FIRST: PREOPERATIVE CARE TEAM: RISK ASSESSMENTS, CONVERSATIONS, CHOICES
Unfortunately, if emergency surgery is the only agreed upon reasonable treatment, that person, especially if unconscious, will have none of the benefits of this essential care section on risk assessments and choices. Postoperative care for that person can be initiated by using guidelines offered in the following intraoperative, postoperative, and post discharge care sections.
Hopefully, by your retirement age, in anticipation of the possible disabling consequences of aging, you took steps to address possible disability and dementia. Crucially, if a surgical candidate is unable to clearly understand the choices being presented prior to or after surgery, they need to have an Advance Directive and/or a “sound of mind” video of themselves clearly defining the healthcare decisions they want made on their behalf. Some warn that circumstances and the course of dementia can change beyond what can be anticipated when creating the document or video, placing clinicians and care partners in a difficult position if a new choice seems more compatible with the person’s original intent for care. Alternatively, there can be a provision included that allows designated care partners to be the final decision makers. These arrangements for postoperative decision assistance are necessary prior to risking PND effects that could be disabling to decisional capacity.
When surgery is recommended for an older adult, two categories of risks must be assessed to determine the best estimate of total risk. First is the risk posed by the type of surgery. Orthopedic and cardiac surgeries are considered high risk, but any surgery that is prolonged in time under anesthesia or causes considerable inflammation due to extensive surgical wounding and blood loss is also considered high risk for PND. The second category of risk that must be determined is the total for personal risk factors. The process of determining the severity of personal risks is the focus of this preoperative care section.
When surgical intervention is proposed for an older adult, a total health status assessment must be quickly scheduled to thoroughly evaluate risk factors for likelihood of serious untoward postoperative consequences. Research studies and major associations like the American Society of Anesthesiologists and the American Geriatrics Society urge that preoperative neurocognitive evaluations be done to uncover and respond to risk factors for PND. As previously noted, insisting on an evaluation of risk for PND may be necessary since these crucial evaluations are too often ignored in clinical practice.
Though the methods employed for PND risk evaluation are many, varied, and imperfect, they are being investigated for their ability to accurately predict outcomes. Still, using some available methods of evaluation are better than using none since no testing at all also means no discussion and warning of harm, leaving everyone with no stress protection and no plans for implementing the postoperative care the patient might have wanted. The Enhanced Recovery After Surgery (ERAS) is one well-known protocol addresses risk evaluation and many other stages of the surgical experience. The Perioperative Optimization of Senior Health (POSH) is another collaborative care model that features teams from geriatrics, surgery, and anesthesiology who do assessments and conduct patient-centered shared decision-making conferences with surgical candidates and their care partners.
What are the main currently identified predisposing PND risk factors for older adults? Being of older age tops the list. Also placing them at much higher risk for serious and long lasting PND, is having been diagnosed with mild or major neurocognitive disorders (NCD) or neurological frailty conditions such as current struggles with dementia, a history of brain injury, stroke, or experiencing other neurodegenerative diseases like Parkinson’s Disease and Alzheimer’s. The comorbidity risk list continues with pre-existing chronic severe pain hearing impairment, muscle weakness, diabetes, obesity, hypertension, heart disease, lung disease, kidney disease, a history of or present heavy smoking, alcohol or drug use, polypharmacy, chronic stress, depression or other psychiatric disorders, sleep disorders, sleep apnea, and low educational level all causing vulnerability. Unfortunately, the risk factor of a possibly or probably weakened blood-brain barrier in older adults that allows inflammatory substances produced by the surgical process to enter the brain as destructive neuroinflammation cannot be measured for the severity of risk in any particular surgical candidate. The greater the number of risks and longer-term chronicity of them forecasts an increased risk for PND.
Since polypharmacy is a risk factor, determining which medications and dietary supplements are risky for delirium or other PND and which are thought to be helpful is an important part of self-care. The prescriber and the preoperative evaluation team should review these. Also, the fasting time prior to surgery should be reduced to the fewest number of hours possible to decrease stress and maintain hydration and general physiological stability.
No total scoring can be done for these personal and surgical risk factors that would allow a final valid risk score for any given person. Whatever details apply to one person or another, you may want to be mindful of the overall percent occurrence of PND in the older adult population referenced earlier in this paper.
If your risk factors are in a range of moderately worrisome but might be improved upon if surgery can be delayed, that allows time to try to alter your risk profile by employing preoperative optimization (also called prehabilitation). This intervention gives you an opportunity to taper the cessation of smoking and drinking, eat very healthy food, exercise to build strength, lose weight if obese, develop stable sleeping hours, and plan details for postoperative care.
Since PND types are a difficult spectrum to treat, attempting to reduce their neurocognitive damage quickly and intensively is of utmost importance as the best option for postoperative brain health. Any waiting period prior to surgery offers you not only time for prehabilitation and avoiding infections, but for other preparations specifically designed to anticipate reducing the time and intensity of the experience of some postoperative delirium. Accurate recognition of time, place and of yourself and others is essential in the urgent and continuous management of delirium. While preparing for surgery with a care partner, practicing speaking caring words to each other and devising physical prompts for your recognition of self and others can be achieved by spending time imagining being together after surgery while holding hands or stroking head and arms in a familiar pattern that would likely be recognizable if you were confused.
Selecting familiar objects to be shown immediately for reorientation if delirium is active postoperatively is a very important intervention. Gathering recent familiar pictures or videos of yourself with people who are usually seen or lovingly thought of every day, yourself in the most often inhabited spaces of your home, yourself dressed as usual carrying out daily activities at home or at work, and yourself at a computer if that is a usual activity can be helpful in reorientation during delirium. Also, collecting familiar objects like favorite clothing, favorite tea or coffee cup, or any other daily use objects that will help you feel known to yourself again. This waiting period would also be a fine time to make a personal video message to yourself to say whatever might be helpful by way of advice about what to do to overcome delirium. The later section on Postoperative Care may contain useful information on what advice to give yourself in the “to self” video.
There are two additional preoperative categories of concerns to be clearly identified. First is your own listing of the personality qualities and abilities you value most and would not recognize yourself to be the same person if these qualities were markedly altered by PND. For instance, knowing yourself to essentially be a very bright, kind, emotionally steady person with a quick-witted sense of humor are traits often verbalized by older adults and these crucially important personality traits could be seriously diminished by PND.
The second imperative preoperative evaluation category is your account of your current abilities to fully participate in their “purpose-in-life” activities, especially if these, like personal qualities, are intensely cherished and irreplaceable. Being available to help others by your professional or volunteer work, enjoying forms of socializing in groups or being able to be a loyal long-term friend to family members and neighbors are common activities that help older adults define and enjoy being themselves.
Ethical clinical practice demands that the patient truthfully be informed about how much the estimated PND risk level could attenuate or even obliterate the patient’s ability to resume being recognizable to themselves and participate in the usual essential parts of their life. Massive grieving the loss of your life’s essentials can easily, rather rationally, transform into depression and loss of the will to continue living a life perceived as painfully empty of self and usual activities. The challenge of rebuilding self and life is often overwhelming for young people and is obviously more overwhelming for older adults who also may be challenged by some normal effects of aging and need the comforts of familiarity of home, neighbors, friends, and the usual enjoyable activities.
If a risk assessment indicates a likelihood of significant loss of self, abilities, and activities, declining the surgery and living with those consequences rather than losing the preciousness of your recognizable self to PND may be a rational and perfectly understandable decision that should be respected. A review of likely consequences of declining surgery then should be offered without a tone of pushing for surgery as the must do only reasonable choice since the question is no longer simply a surgical question but has shifted to a quality-of-life question that can only be answered by the surgical candidate and their care partners. Health care professionals in end-of-life clinical practice are familiar with the sometimes-singular focus of oncology and surgical colleagues who feel they must keep the patient “alive” by whatever means without consideration of the possible extraordinary suffering that predictably can result.
Geriatric and end-of-life healthcare clinicians are familiar with patients who much prefer quality of life over quantity of life. Many are unafraid of dying and welcome that option over pointless suffering they may have witnessed over the years in family and friends. Often, people are comforted by their religious beliefs or a clear sense that they did their best and are ready to declare their life finished and perhaps even well done. Others may have had an extraordinary near-death experience that left them unafraid of making a consciousness transition they have already experienced. Palliative and hospice care can be initiated at any time if the person would prefer that level of care.
A risk evaluation can indicate that personal and surgical risks are high enough that the consequences of surgery are likely to be significant lasting PND that would severely alter quality of life. In that case, options to consider treatments other than surgery or a briefer less invasive surgical approach if possible should be considered as well as discussing delaying or cancelling the surgery with the option to reconsider at any time.
Some PubMed Keywords: patient-physician communication, comprehensive geriatric assessment (CGA), frailty assessment, decisional capacity assessment, preoperative neurocognitive risk assessment, best case/worst case protocol, shared decision-making surgery, concordant care, preoperative cognitive optimization, Perioperative Optimization of Senior Health (POSH), Enhanced Recovery After Surgery (ERAS).
SECOND: INTRAOPERATIVE CARE
In addition to the PND risks discovered in the preoperative assessment, the following factors apply during surgery: the analgesics and anesthetics used; monitoring devices employed for very close watch of brain activity, depth and length of anesthesia, temperature, and blood pressure; length of time for and complexity of the surgical procedure; degree of cerebral metabolic stress in supply of oxygen and glucose to the brain, and the inflammation caused by anesthesia and surgical trauma that can become a dangerous source of neuroinflammation, especially if the blood-brain barrier is likely weakened by aging or other factors.
Self-care for this stage takes place in a serious preoperative conversation with the anesthesiologist and surgeon to be as certain as possible that their knowledge and practice is up to date from research about PND and that their intention is to monitor closely to spare as much harm as possible to your brain’s structure and function. Taking a copy of a recent research review study to share with each of them can indicate seriousness of your own intention for least harm.
Some PubMed Keywords: intraoperative monitoring elderly, intraoperative delirium prevention in elderly.
THIRD: POSTOPERATIVE CARE
Delirium is the immediate and most common type of postoperative PND to occur. It ranges in both severity and length of time it is experienced. The acute phase can last for hours or days and the persistent form lasts weeks or months. Patients experience delirium as a distortion and perhaps blocking of reality caused by disruption of normal sensory and cognitive brain function. If disorientation is severe, it may take the active form of fear and panic and other powerful emotions that can lead to a combativeness that risks self-harm or harm of others. It can also take the form of being sleepy and unable to be active. Some people experience fluctuating between the two. Delirium can cause a lengthy hospital stay and lasting PTSD upon discharge. It is extremely important to do whatever is possible to curtail the severity and the length of time delirium is being experienced since those two factors determine continuation of damage that leads to the longer lasting forms of neurocognitive impairment like dementia and an increased risk of mortality.
This is the moment for urging use of the correct kinds and doses of medications for controlling nausea and using opioid-sparing strategies to adequately control pain to reduce the possibility of increasing delirium. Antipsychotic drugs and benzodiazepines for sedation must not be used since they are known to worsen delirium. Minimal use of anticholinergics also is important to avoid worsening delirium. Adequate hydration is important soon as possible and throughout all phases of delirium or other PND. Watching for signs of infection causing acute widespread inflammation that triggers more neuroinflammation and worsens delirium is also very important.
A major goal of postoperative care is to help the person move as quickly as possible from any experiences of delirium to regaining the ability to perceive consensual reality and restore brain function close to preoperative levels if possible. Immediate provision of warm blankets to restore normal temperature to the body for normal functioning and comfort is essential. Quickly providing access to glasses, hearing aids, and dentures may be of help to correctly perceive self and reality. Assessment of vital signs and cognitive functions is necessary for early detection of delirium or other postoperative complications. Breathing exercises, standing, and walking as soon as is safely possible are important for strengthening and becoming reoriented to one’s body.
If there are no notable signs of delirium observed in the postoperative recovery room (also known as the post-anesthesia care unit or PACU), the patient may be discharged to their home. If that is a peaceful place offering the possibility of comforting and restorative sleep, early discharge may go well. On the other hand, if delirium develops and becomes serious, professional care in an Intensive Care Unit is likely to be needed, so careful determination of the advisability of early discharge is essential.
For a patient in the postoperative ICU, arranging for a familiar care partner to be with the person, especially during normal daytime waking hours and through the night, can help prevent the confusion, fear, anxiety, and panic of delirium that could trigger the need for the use of control by physical restraints that can cause much more panic. Saying the person’s name frequently in the usual way of speaking, wearing familiar clothing, and supplying familiar words of connection and affection can help with reorientation. Speak in simple short sentences. Gently holding hands in the usual way or offering other soothing typical physical contact can also help with relaxation and reorientation.
Repeating information on where the person is and why is vital as is taking a walk to orient to the space when that can be tolerated. Displaying a calendar of the day and often stating the date, day of week, and time of day is important. Placing at bedside the person’s favorite pictures and showing them videos of familiar times of enjoying the company of others may spur connection with that part of their identity. Having paper and pen available for communication and for taking notes on staff names, advice given, and results of the twice a day delirium screening done by staff serves as a diary of events to reference when perception of times and events can become imprecise for everyone.
For stress management, being present to protect the person as much as possible from uncontrolled stressful events like environmental noise and unidentified people suddenly entering the room is helpful. Earplugs and earphone or earbuds that can to some extent block hospital noise while delivering relaxation recordings, familiar music, or familiar podcasts may be helpful if the person has used those sources to relax or feel mood improvement. Supplying a brief recording of a conversation made prior to surgery about recovering from delirium just after surgery may be helpful for hearing yourself describing the current situation and recovery methods.
A few research studies of electroacupuncture energy treatment of PND indicate some promise. If a care partner can offer a calming form of relaxation and possible energy flow restoration such as Therapeutic Touch or Reiki already pleasantly familiar to the person, that may be helpful as well.
To assist with the crucial re-establishment of normal circadian rhythm, especially the critical restoration of a healthy pattern of sleep at the person’s normal hours, careful management of light and darkness is crucial. Most helpful is a single room with a window letting in daylight to help stay awake at the usual daylight hours. If the room unfortunately has no window, use of a portable light therapy lamp that simulates sunlight may be helpful. Dimming the room light in the evening and blocking outside sources to create darkness at night and use of a night mask to protect from environmental lighting may allow for the necessary sleep at the appropriate time that hopefully won’t be interrupted. Pain must be adequately controlled to allow for the possibility of sustained sleep.
Preparing for sleep in the usual manner may help if someone assists with warm milk, and massages of the hands, feet, and back if those are accepted. Melatonin use helps some but makes delirium worse for others. If the person has been enjoying reading a particular book as a way to fall asleep, having that book available to read as usual or being read to from it can help with reorienting to the usual pattern of sleeping.
Orientation to other parts of a typical day like TV shows or news broadcasts viewed at specific hours can help define time of day. If the person enjoyed word games or other forms of cognitively stimulating games as phone apps that may still feel enjoyable and calming, presenting them at the usual time of day they were typically played may serve a double purpose.
Also important is eating familiar food at usual times and constipation care to restore bowel movements to their typical time. Encouraging some familiar form of exercise to its usual time is another helpful attempt at reorientation to being oneself again. Stretching and light exercise are important to do several times a day and physical therapy may be prescribed to help regain strength and balance.
Showing pictures taken together just prior to surgery of the person in the living space where they were most comfortable and talking about going back to that space as soon as possible can help. Hopefully, the staff has been conducting frequent delirium assessments to chart notes on the status of the patient’s delirium. Before discharge, the staff member should show a care partner which assessment tool they used and how to do that assessment and record results as a guide to gauging progress while at home that will be valuable to share as follow-up reports.
Some PubMed Keywords: As noted, this paper would need to become a holistically oriented book to any more thoroughly address all the complicated PND issues, but fortunately, many studies offering excellent delirium prevention and care information continue to be available, making updated searches worthwhile. For the perspective of detailed effective guidance from protocols used for bedside nursing care of those with delirium, see the keywords: nursing care delirium, nonpharmacological delirium interventions, delirium in ICU, HELP hospital elder life program, postoperative delirium elderly, postoperative delirium treatment and prevention, pain management and delirium, circadian rhythm postoperative, circadian rhythm sleep-wake disorders, electroacupuncture.
FOURTH: POST DISCHARGE CARE
Ideally, discharge as soon as possible from a noisy postoperative clinical unit to one’s own quiet familiar home where care partners can continue delirium assessments and take time to kindly assist with the reorientation process can offer the best opportunity for recovery. Receiving help with trying to stay awake during the day and sleep at night, safely exercising, and enjoying favorite foods and pleasant conversations about familiar topics is ideal.
If returning home to a care partner, a very important care consideration is for that person to have avoided “straightened up” in any way the person’s familiar living space while they were absent since reorientation to that space will rely on whatever is retained of the preoperative knowledge and visual memory about details of where objects are always kept. Any changes to the preoperatively familiar living space will cause harmful challenges rather than be helpful for clearly reorienting to familiar objects by their locations and feeling at home in the space. Avoid triggering any experiences of causing a distressing, “Where’s my…?” when the person is in the reorienting process.
If home aftercare continues to be required, an option for additional help with managing delirium may be found by attending online support group meetings with others facing similar challenges. Meetings are available for the patient and for both patient and family and for family members. Guidance from geriatric professionals or members of the presurgical assessment team may be the best sources to locate this kind of specialized support.
Unfortunately, not everyone can return to a helpful home situation, so may not recover as well as might have been possible and may need placement in some sort of facility rather than returning home. That decision requires the perioperative discharge care team to be involved in choosing the best option available. If the person has been living alone, it is necessary to determine whether they have the cognitive abilities and reorientation to manage activities of daily living (ADL’s) on their own or the kinds of help they need from whom and when. If at some point the hoped-for recovery has not happened and the person’s condition has stabilized as PND that has become the longer lasting major delayed neurocognitive disorder (DNR), its characteristics may resemble conditions like dementia, Alzheimer’s disease, stroke, and other brain injuries and diseases. Though there could be hope for some slow improvement, the basic condition is unlikely to be reversed. Sadly, this is the time to consult geriatric professionals and neurologists who specialize in the care of persons with those conditions. That care must be individually tailored and would become a clinical research report of its own so extends beyond the scope of this paper. Since many kinds of brain disorders have been treated for decades, there are reliable organizations that offer specific help depending upon the symptom details and diagnosis.
Helpful Resources are: https://www.alz.org/ and https://www.alzheimers.gov/. Both sites offer trustworthy information, support, and care partner guidance for Alzheimer’s and dementia.