DEMENTIA

Dementia is a broad term used to describe a progressive disease with a broad group of symptoms. These include impairment in memory, intellect, judgment, language, insight and deterioration in social skills [Dementia Ireland, 2011]. Alzheimer's disease is the most common cause of dementia accounting for more than 50% of all cases. Other causes include vascular dementia, mixed dementia and Lewy body disease. The symptoms of dementia are caused by progressive nerve cell deterioration that results in decreased amounts of neurotransmission and altered cerebral function. The complex symptoms of dementia are characterised in the early stages by short-term memory impairment progressing to longer term impairment that interferes with normal activities of daily living. Behaviours can also change with a tendency for personality traits to become accentuated such as obsessiveness and compulsion [Fetzer, Reference Fetzer1999]. Other difficulties include non-recognition of familiar objects and difficulty with verbal communication such as the inability to find the correct words. Progress of the disease is usually gradual occurring over a number of years and through different stages as outlined in Table 1.

Table 1

Stages of dementia

MMSE = Mini Mental State Examination.

Adapted from Buckwalter and Buckwalter [2002].

Dementia is a debilitating and unpredictable disorder. An individual with dementia is likely to exhibit a high sensitivity to his or her environment and experience a high level of stress [Draper et al, Reference Draper, Karmel, Gibson, Peut and Anderson2011]. The clinical features of dementia also vary according to its physiological basis, the characteristics of the sufferer and their care environment [Redfern and Ross, Reference Redfern and Ross1999]. Cognitive and non-cognitive features co-exist. Among the non-cognitive features of dementia are disorders of mood such as loss of interest and decreased energy, psychotic symptoms such as hallucinations and behavioural disturbances such as aggression, wandering and changes to sleeping cycle. The condition and features of dementia may be exacerbated by the stress of surgery; therefore, failure to recognise the needs of patients with dementia and initiate appropriate care may increase the risk of morbidity and mortality [Buckwalter and Buckwalter, 2002].

THE IMPORTANCE OF PRE-OPERATIVE ASSESSMENT

In general, older patients are more at risk of adverse post-operative outcomes. The ageing process (physiological ageing) reduces metabolism, and decreases the body's ability to tolerate stress, infection or complications of surgery. A slower metabolism can also result in altered responses to medications and anaesthesia [Saufl, Reference Saufl2004]. The primary predictor of poor outcomes of surgery, however, is co-morbidity as opposed to chronological age [Harari et al, Reference Harari, Hopper, Dhesi, Babic-Illman, Lockwood and Martin2007]. In older people it is quite common to find a number of existing co-morbid conditions and a plethora of medications. Comprehensive medical and nursing assessment of the older person, as with any patient who is undergoing surgery is paramount. Where the patient has dementia, accurate information on their level of comprehension and orientation to time and place is very important. Patients with Alzheimer's disease, for example, will often give similar answers to contradictory questions; therefore, the involvement of a caregiver or family member who is very familiar with the patient's needs is advised [Williams, Reference Williams2009]. Specific information about behaviours will assist in the development of care strategies specific to the individual.

The special needs associated with older patients are also of concern in patients with dementia. For example, visual and auditory changes are not uncommon so any sensory deficits need to be identified and communicated to other staff [Saufl, Reference Saufl2004]. Skin integrity is of concern as there is increased potential for injury to fragile skin already compromised by age-related changes. Physical function in older people is viewed as a strong determinant of healthcare needs [Ng et al, Reference Ng, Niti, Chiam and Kua2006]; therefore, an assessment of the older patient's ability in activities of daily living will assist in the determination of potential for functional recovery. Older people and particularly patients with dementia are more sensitive to the effects of medication; therefore, reaction to anaesthetic agents may differ. Research has suggested that prolonged exposure to general anaesthetic agents can result in deterioration of cognitive function [Tvanderweyde et al, Reference Tvanderweyde, Bednar, Forman and Wolozin2010] and can result in delirium in the post-operative period. Comprehensive baseline information on the older patients’ physiological, psychological and social functioning will inform risk assessment and perioperative nursing interventions.

THE OPERATING THEATRE ENVIRONMENT

The environment of the operating theatre can appear strange and confusing to any patient. In the case of an older patient with dementia, these surroundings are likely to be frightening and may result in agitation. Stressors known to negatively affect people with dementia include changes in routine, changes in their environment, multiple and competing stimuli, pain and medications [Gerdner et al, Reference Gerdner, Buckwalter and Reed2002]. These stressors cause the individual to become anxious and may trigger challenging behaviour. Unfamiliar noises, lighting and numerous voices can exacerbate the situation. It is important for nurses to calmly orient patients to their surroundings and to remain with the patient as their behaviour may be unpredictable. Sensory aids such as hearing aids and glasses should be retained to assist with communication. Orientation may only be possible for a short time or not at all, as the patient with dementia enters a world of his or her own interpretation [Williams et al, Reference Williams, Roe and Morris2009]. From the patients’ perspective, the operating theatre environment may be interpreted as a very different place and it is advisable that the patient's perspective is acknowledged rather than contradicted. If patients with dementia are fearful and confused they can often respond by agitation and other behavioural changes. In the unfamiliar surroundings of the operating theatre, variable behaviour should be anticipated and plans put in place to manage behaviour effectively and ensure patient safety.

COMMUNICATING WITH THE PATIENT

Patients undergoing surgery may be at different stages of the dementia and have different types of dementia; therefore, the ability to communicate will vary from no communication to some difficulty with language. The interpretation of dementia patients’ needs can therefore be challenging for healthcare professionals. To assist in correct interpretation of patient needs and to avoid frustration, it is important to include family or caregivers who are very familiar with the patient's interactions and reactions at this stage. Even when it seems that patients cannot comprehend or are unable to communicate, all interventions should be explained directly to them. As Williams et al [Reference Williams, Roe and Morris2009, P 346] asserted ‘there is no way to know what is locked in a person's mind that is not communicated’. Talking ‘with the patient’ is important and not around him [Saufl, Reference Saufl2004]. The dignity and personal integrity of the patient must be considered and communication should be tailored to the individual's needs and stage of dementia. In the early stages of dementia, for example, disorientation and mild cognitive difficulty can cause the patient irritation. Healthcare professionals should be prepared to communicate information slowly and clearly allowing adequate time for interpretation. Patients with moderate dementia may not have a clear insight into their situation and may have fluctuating cognitive function. Therefore, their understanding of information provided and ability to provide consent for procedures are issues of concern.

Nevertheless, information should be provided in a form that patients can potentially understand and patients should be encouraged to express their concerns or fears. Opinions and preferences should be sought with regard to whom they wish to be involved in care decisions and to what extent. Some patients are happy to have family members present and involved and others are not. In all cases the best interests of the patient must prevail.

In communicating with patients in late stage dementia, touch is often the most effective while observing for facial expression [Fetzer, Reference Fetzer1999]. Eye contact and gentle tone of voice can give comfort to patients.

PAIN AND DISCOMFORT

Post-operative pain management can be challenging in patients with dementia as assessment of pain can be difficult when communication is compromised. However, any condition that causes pain or discomfort in a patient without dementia should be assumed to cause pain in a patient who cannot report it [Fetzer, Reference Fetzer1999]. In these instances, there is a need to evaluate pain and discomfort using non-verbal cues such as restlessness and or grimacing facial expression. There is a danger that pain can go unrecognised and hence untreated because it cannot be communicated. Advanced dementia patients may be at substantial risk for undetected or undertreated pain [Morrison and Siu, Reference Morrison and Siu2000]. As disruptive behaviour and agitation are often manifestations of pain in dementia, it can often be difficult to interpret patient need. In addition to pain, other sources of discomfort should be considered, such as full bladder, body position or hypothermia. Nurses should also familiarise themselves with medications not recommended for use in patients with dementia, such as diazepam (Valium) and meperidine (Demerol; Fetzer, Reference Fetzer1999) and consider complimentary therapies that may be of value in treating discomfort such as hot or cold compresses or massage.

DEMENTIA-RELATED BEHAVIOUR

Changes in behaviour of patients can occur as a result of changes in their environment and sensory overload. Noise and sudden changes are poorly tolerated by patients with dementia and their response may be negative particularly when approached abruptly. According to Reed and Tilly [Reference Reed and Tilly2008], patients with dementia are very sensitive to non-verbal cues; therefore, the manner in which a nurse approaches the patient can influence the response. Patients may sense concern or hurry in a voice or manner and become agitated or sense calmness and remain calm themselves. In as much as possible patients with dementia should be cared for in a quiet environment with the least amount of external stimuli. It is understandable, however, that in the busy surroundings of an operating theatre, patients are exposed to ever changing circumstances; therefore, it is difficult to stabilise their environment [O'Connell et al, Reference O'Connell, Gardner, Takase, Hawkins, Ostaszkiewicz, Ski and Josipovic2007] and the potential for challenging behaviour should be considered.

RESPONDING TO DEMENTIA-RELATED BEHAVIOURS

According to the Alzheimer's Association U.S. [2011], it is best to remain flexible, patient and respond to the emotion, not the behaviour. The environment should be modified to reduce stressors, reassurance provided and distractions limited. This should entail a reduction in the number of personnel communicating and interacting with the patient, a reduction in the noise level and a dimming of lights. A family member or caregiver should be allowed to accompany the patient to maintain familiarity and security [Fetzer, Reference Fetzer1999]. The goal being the creation of a safe and stress-free environment for the patient.