Dementia, delirium, polypharmacy, a...

Dementia, delirium, polypharmacy, and pain management are everyday considerations when caring for older adults. Perioperative pampers play an important role in identifying and managing patients with delirium and preventing delirium when possible. The case consideration provided in this article moves an opportunity to apply universals about dementia, delirium, polypharmacy, and pain management as they relate to the perioperative care of an older adult patient.

CASE STUDY

Mr A is an 87-year-old man with dementia who unexpectedly was place to have a right upper lobe mass in succession his chest x-ray. Mr A is referr to a pulmonologist for evaluation. He has no associated history of dyspnea, cough chest pain, agitation or weight loss. He lives at family with his wife and is able to perform activities of daily living (ADLs) with minimal supervision. He has no focal neurological deficits; however, no formal testing of cognitive functioning has been performed. Mr A's past medical history is significant for gastrointestinal bleeding, although, generally he denies nausea, vomiting, abdominal pain, constipation, diarrhea, or melena. A urologist also is treating him for intermittent bladder cancer. He denies symptoms of hematuria, dysuria, oftenness hesitancy, or incontinence. He is legally blind, and his wife reports that he has difficulty hearing conversational voices. He has no cardiac history. Electrocardiogram(ECG) reveals a normal sinus metre without evidence of ischemic changes. Medications include 5 mg olanzapine and 25 mg trazodone each day. The physical examination is unremarkable excepting for disorientation. History from previous health care providers, including a previous dementia workup, is unavailable.

Mr A and his wife agree to proce with surgery to resect the lung mass onward the recommendation of the pulmonologist and thoracic surgeon Mr A has a complicated postoperative course, including atrial fibrillation with rapid ventricular answer and ST depressions. He is confused, does not recognize family members, does not tread close upon commands, and is agitated as evidenced according to his pulling at his IV lines and the chest tube. Postoperative medications include IV cefazolin sodium, ketorolac tromethamine, ranitidine HCl diltiazem HCl and morphine. After stabilization of his cardiac status, Mr A is discharged residence He is confused but able to perform ADLs with his wife's assistance. His discharge medications are paroxetine HCl trazodone, and diltiazem HCl There is no order for pain medication.

single in kind week later, Mr A is brought to the crisis department by his wife for decreased responsiveness and appetite, incontinence, and no bowel emotion since discharge. Medications are the same as at discharge, save that aspirin has been added for pain. Mr A is admitted for gastrointestinal bleeding that requires gastric surgery He remains confused and agitated in every part this hospitalization. Medications during this admission include metoclopramide HCl diltiazem HCl acetaminophen, risperidone, haloperidol, valproic acid, levofloxacin, and methylphenidate. He is discharged to a subacute rehabilitation facility.

THE RISK OF DELIRIUM

Like Mr A, many older surgical patients are more likely to near with more comorbidities, cognitive and functional impairment, and chronic pain. They also guard to take more medication than their younger counterparts. These factors predispose older adults to perioperative delirium and other complications. Delirium is an acute charge of cognitive impairment with altered consciousness, impaired attention, and hyperactivity or hypoactivity. (1) It may take place in 10% to 61% of surgical patients age 65 or older and it increases with advancing age. (2) Mr A instanted for surgery with several preexisting risk factors for delirium, including advanced age, dementia managed with psychotropic medications, visual and auditory impairment, and a history of gastrointestinal and genitourinary disease. The course itself, a noncardiac intrathoracic surgery imposes him at risk for delirium.

Age is a risk factor for delirium and other perioperative complications, particularly in the personality of comorbidities, including dementia and impaired renal, hepatic, and cardiac function. The genuine impact of age on physiological function may be evident single during times of stress. A sedentary older someone may maintain cardiac output with a lower peak heart rate, and serum creatinine may be normal despite significant renal insufficiency. The stres of anesthesia and surgery can cause alteration in cardiac function, turn and electrolyte balance, which may be manifested at delirium. (3) Mr A had a normal preoperative ECG yet no stress testing or preoperative laboratory data were available. Mr A also has a history of gastrointestinal bleeding and bladder cancer. Stres medications, and immobility associated with surgery can contribute to pustules gastrointestinal bleeding, constipation, urinary retention, and incontinence. Many of these gastrointestinal and genitourinary disorders may precipitate delirium in the somewhat advanced in life (4)