Caring for older people having surgery

1
Caring for older people having surgery

• Bernie Keenan

2
Two thirds of Acute Hospital beds are currently
occupied byelderly people
3
61 of these have a psychiatric illness

• Depression
• Delirium (temporary confusional states)
• Dementia
• Others, e.g., schizophrenia

4
A typical district general hospital with 500 beds

• Will admit 5000 older people each year 3000 of
  these will suffer a mental disorder
• On average older people will occupy 330 of these
  beds at any one time 220 of these will have a
  mental disorder

5

• This means that the acute hospital will have 4
  times as many older people with mental disorder
  on its wards as the older peoples mental health
  service has on theirs, Who cares wins(2005)

6
Common problems

• Please discuss the following scenarios could
  they have been avoided and how would you handle
  these situations?

7
Scenario 1

• You are called to assist in the recovery room
  where a post operative patient is attempting to
  pull her intravenous line out. She is Mrs Green a
  70 year old lady who has had a minor operation
  but now appears to be extremely agitated and you
  are afraid that she will hurt herself.

8

• On reading her case notes you discover that she
  has a history of dementia, and also that she
  usually wears a hearing aid spectacles- neither
  of which are present.

9
Scenario 2

• Mr Brown had a craniotomy , following which he
  was very agitated attempting to remove his
  craniotomy sutures. To stop him hurting himself
  very badly staff have bandaged up his hands in
  boxing gloves". After several days the bandaging
  is removed to reveal spacicity of his hands and
  an infected sore on his right palm where his
  fingernails have broken the skin. His relatives
  threaten to sue the hospital.

10
Scenario 3

• Mrs White is an 80 year old lady who had a
  fractured neck of femur fixation under a general
  anaesthetic yesterday. She appeared to be
  recovering well but has suddenly become agitated
  and says that there are fairies trying to get
  into her bed so she is attempting to escape into
  bed with the lady next to her.

11
Restraint use

• Requires a formal risk assessment, a
  consideration of the best interests of the
  patient
• Capacity must be assessed, under the Mental
  Capacity Act (2005) capacity is assumed until
  proven otherwise
• Informed consent obtained- explanation of
  (evidence based) rationale to patient, or
  family/carer (particularly important if informed
  consent cannot be gained from patient)

12

• Have all other management options been explored,
  e.g., possibility of intervention from family,
  behavioural management, low profile beds
• Have all the factors that predispose the patient
  to become confused or agitated been addressed
• Use the least restrictive method possible
• Use commercially available products only (home
  made devices are dangerous

13

• Are staff trained in the use of the device
• Use must be reviewed regularly (daily, or more
  frequently)
• Must be fully documented in patients notes
  (legally, if it is not written it was not done)

14
Sedation is a last resort

• The effectiveness of pharmacological
  interventions are doubtful can be counter
  productive
• The drug of choice is usually restricted to
  Haloperidol, the emphasis should be on regular
  rather than PRN medication
• If using sedation use the smallest dose of the
  least harmful substance (start low, go slow)

15

• Review the need for the medication to continue
• Contra-indicated in Lewy Body Dementia Head
  Injury/Neuro surgery (potentially fatal
  consequences)

16


17
Older patients surgery

• Extremes of age (1999) where we have not got
  the crucial area of preparation for surgery right
  we greatly increase the post operative mortality
  rates amongst older people.
• Effects of starving on the vulnerable
• Effects of anaesthetic/analgesia dramatic
• Need for comprehensive screening preoperatively
  by ward staff, intensivists, psychiatric liaison
  staff

18

• Certain operative procedures in which older
  people predominate, e.g., cataract surgery,
  fractured neck of femur
• United they stand(1999)- highlighted the
  importance of having well planned coordinated
  care for patients from admission to discharge,
  e.g., fractured neck of femur pathway, specialist
  rehabilitation