| 1. |
- Burman, Maria, 1983-
(författare)
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Malnutrition and obesity among older adults, assessed by Mini Nutritional Assessment and the body mass index, respectively : prevalence and associations with mortality and urinary tract infection
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- INTRODUCTION: Malnutrition and obesity are health concerns among older (aged ≥ 65 years) adults, but the combination of them have not been studied thoroughly nor have they been thoroughly investigated in very old (aged ≥ 85 years) adults. The aims of this thesis were to investigate the prevalence, trends in prevalence and associations with mortality of malnutrition and obesity, assessed by Mini Nutritional Assessment (MNA) and the body mass index (BMI), respectively, and to examine the combined effects of these conditions on mortality. Malnutrition as a risk factor for urinary tract infection (UTI) was also investigated. MATERIAL AND METHODS: The studies reported on in papers I and II were conducted with data from the Umeå85+/Gerontological Regional Database study, a population-based study of cohorts of very old adults. Data from all four Swedish cohorts (2000–2002, 2005–2007, 2010–2012 and 2015–2017), and from the 2000–2002 and 2005–2007 Swedish cohorts and a 2005–2006 Finnish cohort, respectively, were used. In the paper I study, trends in the prevalence of malnutrition (by MNA score) and obesity (by BMI) were investigated across cohorts. In the paper II study, the associations of MNA scores and BMI with 5-year mortality were investigated. The study reported on in paper III was conducted with data from the Senior Alert national quality registry; associations of Mini Nutritional Assessment–Short Form (MNA-SF) scores, BMI and 2-year mortality in older adults living in residential care facilities in Sweden were investigated. The study reported on in paper IV was conducted with data from the Frail Older People–Activity and Nutrition and Umeå Dementia and Exercise studies; risk factors for UTI among older adults in residential care facilities were investigated. RESULTS: In the paper I study, mean BMI increased between 2000–2002 and 2015–2017 and the prevalence of obesity were 13.4% and 18.3%, respectively; the prevalences of underweight were 7.6% and 3.0%, respectively. Mean MNA scores increased between 2000–2002 and 2010–2012 and were slightly lower in 2015–2017. The prevalence of malnutrition according to MNA scores in the four cohorts were 12.2%, 6.4%, 5.1% and 8.7%, respectively, and the prevalence of at risk thereof were 31.8%–37.2%. In the paper II study, 13.3% of participants were malnourished, and 40.3% at risk thereof according to MNA scores, and malnutrition was more common among women than men. Twenty-five percent of the population had BMIs ≥28.0 kg/m2. Of those with malnutrition according to MNA scores, 17.4% had BMIs ≥ 24.7 kg/m2; of those with good nutritional status according to MNA scores, 13.8% had BMIs < 22.2 kg/m2. Compared to malnutrition according to MNA, lesser mortality was found in individuals with good nutritional status. Compared to individuals with BMI <22.2 kg/m2, lesser mortality was found in those with BMI ≥28.0 kg/m2. In the paper III study, 14.6% of the population was malnourished, and 45.0% at risk of malnutrition according to MNA-SF scores and 16.0% were obese. Compared to individuals with good nutritional status, greater mortality was found in those with malnutrition according to MNA-SF. Mortality was greater among underweight than among normal-weight participants and lesser among participants with obesity, including severe obesity. Higher BMIs were also associated with reduced mortality in subgroups defined by MNA-SF scores. In the paper IV study, malnutrition according to MNA scores was not a risk factor for UTI in the whole sample or in women. In men, the MNA score was associated with UTI in univariate analysis. CONCLUSIONS: The results of this thesis highlight the importance of nutritional screening in older adults in residential care facilities and in very old adults, since malnutrition risk was common and associated with greater mortality among these populations. Malnutrition according to MNA was not a clear risk factor for UTI in older adults living in residential care facilities. Time trends indicated an increasing prevalence of obesity whereas no change in nutritional status according to MNA was observed among very old adults, although these trends need further investigation. The results also confirmed that higher BMIs were beneficial for survival in these populations, and in the residential care population this seems to apply also for BMIs reflecting severe obesity. Finally, in the residential care population, regardless of nutritional status according to MNA-SF, higher BMIs were associated with better survival.
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| 2. |
- Claesson Lingehall, Helena, 1965-
(författare)
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Delirium in older people after cardiac surgery : risk factors, dementia, patients’ experiences and assessments
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background:Delirium is common in older people undergoing cardiac surgery. Delirium is an acute or subacute neuro-psychiatric syndrome, characterized by a change in cognition, disturbances in consciousness; it fluctuates, develops over a short period of time and always has an underlying cause. It is associated with a disturbance in psychomotor activity, and is classified according to different clinical profiles such as hypoactive, hyperactive and mixed delirium. Delirium after cardiac surgery is not harmless, it increases the risk of complications such as prolonged stay in hospital, falls, reduced quality of life, reduced cognitive function and increased mortality.Aim:The overall aim of this thesis was to investigate postoperative delirium in older people undergoing cardiac surgery with Cardiopulmonary Bypass (CPB), focusing on risk factors, dementia and patients’ experiences; and to evaluate an assessment for screening delirium.Methods:This thesis compromises four studies. All participants (n=142) were scheduled for cardiac surgery with use of CPB at the Cardiothoracic Surgery Department, Heart Centre, Umeå University Hospital, Sweden, between February and October 2009. Six structured interviews were conducted preoperatively, day one and day four postoperatively, and in home visits, one, three and five years after surgery (2010, 2012 and 2014). The assessment scales used in Studies I, II and IV were: the Mini-Mental State Examination (MMSE) for cognition, the Organic Brain Syndrome Scale (OBS) for delirium, Geriatric Depression Scale 15 (GDS-15) for depression, Katz staircase with Activities of Daily Living (ADL) for participants’ functional status and the Numerical Rating Scale (NRS) for pain. During the hospital stay, nursing staff used the Swedish version of the Nursing Delirium Screening Scale (Nu-DESC) to assess delirium. Semi-structured interviews were also carried out (III) in the one-year follow up. Delirium, dementia and depression were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR).Results: Out of 142 participants 54.9% (78/142) developed delirium after cardiac surgery (I). Independent risk factors, predisposing and precipitating, associated with delirium were: age, diabetes, gastritis/peptic ulcer, volume load during operation, longer time on ventilator in intensive care, increased temperature and plasma sodium concentration in the intensive care unit. Out of 114 participants thirty (26.3%) developed dementia within the five years of follow-up. It was shown that a lower preoperative MMSE score and postoperative delirium were factors independently associated with development of dementia (II). One year after cardiac surgery, participants diagnosed with postoperative delirium described in detail feelings of extreme vulnerability and frailty. Despite this, the participants were grateful for the care they had received (III). Hypoactive was the most common symptom profile for delirium. The Swedish version of Nu-DESC showed high sensitivity in detecting hyperactive delirium, but low sensitivity in detecting hypoactive delirium (IV).Conclusion:Delirium was common among older patients undergoing cardiac surgery. Both predisposing and precipitating factors contributed to postoperative delirium. Preventive strategies should be considered in future randomized studies. It might also be suggested that cognitive function should be screened for preoperatively and patients who develop delirium should be followed up to enable early detection of symptoms of dementia. Whether prevention of postoperative delirium can reduce the risk of future dementia remains to be studied. To minimise unnecessary suffering, patients and next of kin should be informed about and prepared for the risk of delirium developing during hospitalization. The Swedish version of Nu-DESC should be combined with cognitive testing to improve detection of hypoactive delirium, but further research is needed. Healthcare professionals need knowledge concerning postoperative delirium in order to prevent, detect and treat delirium so as to avoid and relieve the suffering it might cause.
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| 3. |
- Eriksson, Irene, 1965-
(författare)
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Urinary tract infection : a serious health problem in old women
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Urinary tract infection (UTI) is a common bacterial infection in women of all ages but the incidence and prevalence increase with age. Despite the high incidence of UTI, little is known about its impact on morale or subjective wellbeing and daily life in old women. UTI in older people can be a complex problem in terms of approach to diagnosis, treatment and prevention because in these patients it frequently presents with a range of atypical symptoms such as delirium, gastrointestinal signs and falls. Even if UTI has been shown to be associated with delirium it has frequently been questioned whether UTI can cause delirium or if it is only accidentally detected when people with delirium are assessed. The main purpose of this thesis was to describe the prevalence of UTI, to identify factors associated with UTI among very old women and to illuminate the impact of a UTI on old women’s health and wellbeing. This thesis is based on two main studies, the GErontological Regional DAtabase (GERDA) a cross-sectional, population-based study carried out in the northern parts of Sweden and Finland during 2005-2007 and a qualitative interview study in western Sweden 2008-2009. Data were collected from structured interviews and assessments made during home visits, from medical records, care givers and relatives. UTI was diagnosed if the person had a documented symptomatic UTI, with either short- or long-term ongoing treatment with antibiotics, or symptoms and laboratory tests judged to indicate the presence of UTI by the responsible physician or the assessor. One hundred and seventeen out of 395 women (29.6%) were diagnosed as having suffered from at least one UTI during the preceding year and 233 of these 395 (60%) had had at least one diagnosed UTI during the preceding 5 years. These old women with UTI were more dependent in their activities of daily living, and had poorer cognition and nutrition. In these women, UTI during the preceding year was associated with vertebral fractures, urinary incontinence, inflammatory rheumatic disease and multi-infarct dementia. Eighty-seven of 504 women (17.3%), were diagnosed as having a UTI with or without ongoing treatment when they were assessed, and almost half (44.8%) were diagnosed as delirious or having had episodes of delirium during the past month. In all, 137 of the 504 women (27.2%) were delirious or had had episodes of delirium during the past month and 39 (28.5%) of them were diagnosed as having a UTI. Delirium was associated with Alzheimer’s disease, multi-infarct dementia, depression, heart failure and UTI. Forty-six out of 319 women (14.4%) were diagnosed as having had a UTI with or without ongoing treatment and these had a significantly lower score on the Philadelphia Geriatric Center Morale Scale (PGCMS), (10.4 vs 11.9, p=0.003) than those without UTI, indicating a significant impact on morale or subjective wellbeing among very old women. The medical diagnoses significantly and independently associated with low morale were depression, UTI and constipation. The experience of suffering from repeated UTI was described in interviews conducted with 20 old women. The interviews were analysed using qualitative content analysis. The participants described living with repeated UTI as being in a state of manageable suffering and being dependent on alleviation. Being in a state of manageable suffering was described in terms of experiencing physical and psychological inconveniences, struggling to deal with the illness and being restricted regarding daily life. Being dependent on alleviation was illustrated in terms of having access to relief but also experiencing receiving inadequate care. In conclusion, UTI is very common among old and very old women and is a serious health problem. UTI seems to be associated with delirium and to have a significant impact on the morale or subjective wellbeing of old women and those affected suffer both physically and psychologically and their social life is limited. UTI was also associated with vertebral fractures, urinary incontinence, inflammatory rheumatic disease and multi-infarct dementia which might raise the suspicion that UTI can have serious medical effects on health in old women.
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| 4. |
- Karlsson, Åsa, 1972-
(författare)
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Team-based home rehabilitation after hip fracture in older adults : effects, experiences and impact of dementia
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BACKGROUND: For an older adult a hip fracture may be a traumatic and life-changing event and has shown to be associated with reduced health-related quality of life, disability and increased mortality. Previous rehabilitation studies have often excluded older adults with cognitive impairment and those living in residential care facilities, groups with an additional risk of poor outcome. Moreover, there are few randomized controlled trials that have evaluated interdisciplinary home rehabilitation after hip fracture. These studies did not include older adults with severe cognitive impairment or dementia, those with serious medical conditions, or those living in residential care.OBJECTIVE: The aim of the thesis was to investigate the effects of early discharge followed by geriatric interdisciplinary home rehabilitation (GIHR) for older adults with hip fracture, and specifically among those with dementia, compared to in-hospital geriatric care according to a multifactorial rehabilitation program. An additional aim was to explore how older adults experienced their rehabilitation and recovery during the year following the fracture.METHODS: The thesis evaluated a randomized controlled trial that included 205 participants with hip fracture, 70 years or older, living in ordinary housing or residential care facilities. In hospital, both the GIHR and control groups received care and rehabilitation according to a multifactorial rehabilitation program, but with the aim of early discharge for the GIHR group. The individually designed GIHR intervention focused on walking ability indoors and outdoors, independence in activities of daily living (ADL), and multifactorial fall prevention during a maximum period of 10 weeks. Participants were assessed in-hospital and at 3- and 12-month follow-up visits. Independence in walking and use of walking aids was assessed via an interview along with gait speed tests. Independence in ADL was measured using the Barthel ADL Index, and the ADL Staircase including the Katz ADL Index, and hospital length of stay (LOS) was recorded from medical charts. The effects of GIHR intervention among participants with dementia were investigated in a post hoc subgroup analysis where additional outcomes were falls, mortality and readmissions between discharge and 12 months. Individual interviews were conducted with 20 selected participants just after the 12-month follow-up. Data were analysed using qualitative content analysis.RESULTS: The postoperative hospital LOS was significantly reduced by a median of six days in the GIHR group compared to the control group, although not significantly reduced in the GIHR group for participants with dementia. Binary logistic regression analyses revealed no significant differences between the GIHR and control groups regarding independent walking ability, the ability to walk without a walking device, or independence in ADL at 3 and 12 months. Gait speed was comparable between the two groups at 3 and 12 months. At 12 months, 56% in the GIHR group and 58% in the control group had recovered their prefracture walking ability, and 41% vs. 42% in GIHR and control groups, respectively, had regained their prefracture Barthel ADL Index score. Interaction analyses showed that the GIHR group vs. the control group had comparable effects on walking ability and ADL at 3 and 12 months, and on falls and mortality between discharge and 12 months, regardless of whether the participants had dementia or not (P≥0.05 for all). The number of readmissions and hospital days after discharge was comparable between GIHR and control groups for participants with dementia. Overall, dementia was associated with significantly impaired walking ability and greater dependence in ADL at 3 and 12 months and with increased risk of falling and increased mortality between discharge and 12 months compared to participants without dementia. The interviews revealed that access to rehabilitation, provided by skilled staff, and support from others were important for participants’ well-being and recovery. Participants experienced a fundamental change in their self-image after the fracture, and faced a number of difficulties, but strove for independence and used adaptive strategies to find contentment in their lives.CONCLUSIONS: In older adults with hip fracture, early discharge followed by interdisciplinary home rehabilitation significantly reduced postoperative hospital LOS. Functional recovery during the year following the fracture was nevertheless comparable to in-hospital geriatric care according to a multifactorial rehabilitation program. The GIHR intervention seems to be appropriate also for older adults with dementia since the effects were not different in this subgroup, except for postoperative hospital LOS, which was not significantly reduced in the GIHR group for participants with dementia. Further studies with larger samples are needed to validate these results. Overall, dementia was associated with a substantial negative impact on the outcomes. According to participants’ experiences, receiving rehabilitation and support after the hip fracture seems crucial for successful recovery. Negative psychological reactions were common, suggesting that future interventions should consider both physical and psychological aspects. Different rehabilitation alternatives were appreciated by the participants. Rehabilitation should thus be customised to suit wishes and needs of older adults and may accordingly be carried out in different settings, where rehabilitation in the home can be one suitable alternative. The findings of this thesis indicate that geriatric interdisciplinary home rehabilitation after hip fracture can be an alternative and a complement to in-hospital care and rehabilitation for older adults with and without dementia.
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| 5. |
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| 6. |
- Herkner, Birgitta, 1951-
(författare)
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Läsutveckling i årskurs 2–6 belyst genom standardiserade test och nationella provet i svenska i årskurs 3
- 2011
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this study is to analyse and describe reading ability from the second to sixth year of schooling in Sweden (ages 8–13). An introductory study presents the pupils’ reading profiles and also the extent to which teaching in reading comprehension is given at their schools. In a second study, the results and effects of the national test in Swedish in grade three (age 9) are studied and compared with other recognised test data on the development of children’s reading. A total of 428 pupils at four schools participated in the study. Each child was tested once a year during two consecutive school years. In addition to collecting results on the national test for all the pupils in their third year, standardised tests of word decoding ability and reading comprehension were administered to all students in the study. A questionnaire dealing with teaching reading and skills development was answered by 23 teachers. The study reveals that there are stronger links between phonological tasks and reading comprehension for pupils in their first three years than for those in years 4–6. The study also shows that the national test identifies some pupils with reading difficulties but not all of them. A number of pupils who have problems with word decoding nevertheless attain the national test threshold for reading comprehension tasks in the third year. There are also pupils who cannot manage the age-adapted reading comprehension tasks but who still pass the national test in their third year. The findings reveal that teachers work with reading comprehension exercises to only a small extent in both the first three years and second three years of schooling. The study indicates the importance of using a diagnostic approach, so that early and effective measures can be adopted to prevent the emergence of reading comprehension problems.
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| 7. |
- Herkner, Birgitta, 1951-
(författare)
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Studier av läsrelaterade språkliga förmågor i förskola och läsutveckling i grundskola
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The purpose of this doctoral thesis was to explore relationships that impact language development, and how reading ability develops during the compulsory school years. The thesis includes four studies, study I (licentiate thesis), with students from grades 2–5, from 24 classrooms (N = 428), study II examined whether the National test (NP) was able to identify students with word decoding problems from a sample of third graders from study I (n= 112). In study III a small number of students (n = 8) from Study II were followed-up to the ninth grade. The students’ and their parents’ perception of special education support is described.In Study IV the correlation between socioeconomic status (SES) and language development was examined in preschool children (N= 231) from three municipalities in the middle of Sweden. Furthermore, the language ability among these preschool boys and girls is described. Students’ language abilities are examined in these four studies, where the participants are students in preschool (N= 231), and compulsory school (N=428).The results indicated that the student’s reading profiles (the correlation between phonological decoding and reading ability) based on Simple View of Reading showed difficulties in reading ability for students in the fourth grade to a larger extent than in the third grade. National tests (NP) in Swedish for the third grade do not identify students with decoding difficulties.The students that had difficulties with decoding in the third grade also had difficulties with decoding in the ninth grade and scored low on all reading and writing tests. In interviews with parents and students, the respondents described that the students did not engage in leisure reading in their free time and that when they did, they read using their computer or their mobile phone. The respondents also described school experiences where special education support had been provided too late, and to an unsatisfactory extent. Between the fourth and sixth grade, special support was provided as reading in a small group, and between the seventh and ninth grade, special support was provided from a paraprofessional; receiving support from a special educational needs teacher was uncommon. Study IV does not indicate differences between preschool boys’ and girls’ results on tests in language abilities, letter knowledge, and rapid automatized naming. Children from areas with lower SES performed worse on the language tests than children from areas with higher SES. The results from these studies indicate the importance of early language interventions for preschool children in areas with low SES. Taken together, the studies indicate that the early identification of children with delays in language abilities is feasible in preschool, as well as the early identification of children with difficulties with decoding in primary school. The follow-up suggests that without early and effective interventions the difficulties may last for the following school years, and may affect negatively the students’ educational achievement.
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| 8. |
- Olofsson, Birgitta, 1963-
(författare)
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Old people with femoral neck fracture : delirium, malnutrition and surgical methods - an intervention program
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Hip fracture is a global and a growing public health problem. More women than men sustain hip fractures, the incidence increases exponentially with age and mean age is above 80. About one third of hip-fracture patients suffer from dementia and are prone to develop acute confusional state (delirium). Delirium is one of the most common complications after hip-fracture surgery, and seriously impacts on morbidity and mortality. Malnutrition is also common in hip-fracture patients and is associated with postoperative complications, such as delayed healing of the wound, infections and decubitus ulcers. Arthroplasty is usually preferred procedure in displaced femoral neck fractures but is, however, controversial in patients with dementia due to the fear of dislocation of the prosthesis. The aims of this thesis are to identify risk factors for delirium and the impact of delirium on rehabilitation outcome, to evaluate whether a postoperative multi-factorial intervention program could reduce delirium, to investigate the effect of a nutritional intervention and to evaluate complications, functional outcome and mortality regarding two surgical methods, hemiarthroplasty (HAP) and internal fixation (IF), in old patients with femoral neck fracture. Thirty-eight out of 61 consecutive patients (62%) were delirious on admission to hospital or developed postoperative delirium. An increased risk of postoperative delirium was found among hip-fracture patients with dementia and/or depression. Delirious patients were hospitalized longer, were more dependent in their activities of daily living, had poorer psychological well-being and suffered more complications than non-delirious patients. A postoperative multi-factorial and multidisciplinary intervention program reduced the incidence, at 55% vs 75% (p=0.003), and number of days with delirium, 5 vs 10 days (p=0.009). Postoperative complications were also reduced; decubitus ulcers 9% vs 22% (p= 0.010), urinary tract infections 31% vs 51% (p=0.005), falls 12% vs 27% (p=0.007), and the mean hospitalization period was 10 days shorter in the intervention group (p=0.030). Malnutrition was common among all these patients (53 %) and associated with postoperative complications such as decubitus ulcers and delirium. However, the nutritional intervention had no effect on nutritional parameters at four months, nevertheless men had better nutritional outcomes than women. A higher proportion of patients with dementia operated on using HAP had regained their pre-fracture ability to walk independently at the one-year follow up compared with those operated on using IF. Six of 83 patients dislocated their HAP during hospitalization and during an episode of delirium, none had dementia. No difference in mortality between the surgical methods was seen. Dementia per se should not be a reason to disqualify patients from being treated with the most appropriate surgical method. It is clinically important to discriminate between dementia and delirium, since delirium can be prevented and treated even in patients with dementia. Old patients undergoing surgery have special needs that are not always catered for in ordinary orthopaedic or surgical wards. The special care for these patients should include: a combined nursing and medical care based on comprehensive geriatric assessments, systematic prevention, detection and treatment of postoperative complications such as delirium, hypoxemia, urinary tract infections, pain, malnutrition and an active rehabilitation. It is obvious that improved quality of care reduces patient suffering and seemingly the costs for society.
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| 9. |
- Smulter, Nina, 1972-
(författare)
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Delirium after cardiac surgery : risk factors, assessment methods and costs
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Cardiac surgery is considered safe, but postoperative delirium (POD) remains frequently reported. Delirium is characterised by fluctuations in consciousness and cognition, and can be subdivided into disturbed psychomotoric activity (hyperactive and hypoactive) and psychiatric symptom profiles (psychotic and emotional). Delirium has an underlying cause that can be prevented and treated, provided the condition is detected. Undetected delirium could lead to serious consequences for the patient.Aim: This thesis aims to understand the underlying risk factors of delirium, to compare different assessment methods and documentation, and to understand its effects on hospitalisation costs after cardiac surgery.Methods: Two cohorts of patients undergoing cardiac surgery at the Heart Centre, Umeå University Hospital, Sweden were analysed. Cohort-A (Studies I-IV) enrolled 142 patients, ≥70 years of age, scheduled in 2009 for surgery with cardiopulmonary bypass (CPB). POD was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders 4th ed, text rev (DSM-IV-TR), based on repetitive assessments with the Mini-Mental State Examination (MMSE) and the Organic Brain Syndrome (OBS) scale. This method was considered as reference. Predisposing and precipitating risk factors were explored (Study I), and a separate analysis was conducted with focus on CPB parameters (Study II). Patients were also assessed for POD with the Confusion Assessment Method (CAM), which was validated versus the reference method (Study III). Additionally in Study IV, data about how nurses assessed patients for POD symptoms using the Nursing Delirium Screening Scale (Nu-DESC) were analysed together with information extracted from the clinical database. Moreover, discharge summaries from both nurses and physicians were retrospectively reviewed for key words and expression associated with delirium. Cohort-B (Study V) included 1879 routine cardiac surgery patients (2014-2017) retrospectively extracted from the clinical database with concomitant Nu-DESC scoring. The association between the Nu-DESC and postoperative hospitalization costs was analysed.Results: In cohort-A, 54.9% (78/142) patients developed POD. Both predisposing and precipitating risk factors were significantly associated with POD, of which the ‘volume load during operation’ had the strongest predictive influence (Study I). Among CPB variables the ‘duration of mixed-venous oxygen saturation <75%’ predicted POD (Study II). Hypoactive was more common than hyperactive delirium. Those with hypoactive delirium were less likely to be detected by the CAM method (Study III), an observation also demonstrated from information found in the clinical database and in discharge summaries. Nu-DESC did not detect all patients with POD, but significantly increased the detection rate (Study IV). The major hospitalisation costs associated with Nu-DESC ≥2 occurred in the ICU and independently of the surgical procedure performed. There were no significant differences in costs among patients with Nu-DESC ≥2, between age groups (70-year cut-off) or genders (Study V).Conclusions: Both predisposing and precipitating risk factors contributed to POD and should be considered in future guidelines to prevent delirium after cardiac surgery. Hypoactive delirium was most common, but was the most difficult to detect without screening scales. Systematic assessment with Nu-DESC improved the detection rate of POD. Delirium after cardiac surgery has consequences on healthcare and is associated with increased costs.
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| 10. |
- Unneby, Anna, 1985-
(författare)
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Pain and pain management with femoral nerve block following hip fracture : effects and experiences: the perspective of older patients and staff
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Older people with hip fractures are often frail with several comorbidities and roughly half of them have dementia disorders. Pain is common among patients with hip fracture and pain management in these patients is a challenge. Opioids are known to relieve pain while at rest but are not as effective in movement. One alternative to opioids is a femoral nerve block (FNB). Previous studies have shown that FNBs can decrease pain and the need for opioids, but these studies excluded patients with dementia. Few studies have investigated whether FNBs decrease the incidence of complications in general, and delirium in particular. These studies were also based on different types of nerve blocks and methods. Few studies have described patients’ experiences of pain and pain management, and there are no studies on patients’ experiences of receiving or being treated with FNBs. In addition, there are no studies on staff´s experience of nursing care among patients with hip fractures who received an FNB. Objectives: The overall aim of this thesis is to investigate the effect of a preoperative FNB in patients with hip fracture in terms of pain and complications, and, further, to describe experiences of pain and pain management among patients with hip fracture who received FNBs as well as staff´s experiences of treating them. The first two papers (I and II) investigate the effect of an FNB compared to opioids, with a focus on pain and complications. To gain a deeper understanding, the final two papers (III and IV) describe experiences of pain and pain management in patients with hip fractures who received an FNB, and the staff's experiences of nursing care with patients with hip fractures who received an FNB. Methods: Papers I and II are based on a randomized controlled study which included patients aged 70 years or older with hip fractures, including those with cognitive impairment or dementia. Patients were randomized on arrival at the orthopaedic ward in terms of pain treatment to be administered; the options were FNB (with opioids if needed) or opioids alone. In paper I, 266 patients were included; the mean age was 84 years, 64% were women, and 45% had a dementia diagnosis. Paper II included 236 patients; the mean age was the same, 66% were women, and 46% had a dementia diagnosis. Pain assessment scales (self-rated VAS and VAS by proxy) was used preoperative to assess patients’ pain in rest. Nurses assessed the incidence of delirium using Nu-DESC, both pre- and postoperatively. In addition, a structural interview was performed with validated assessments 3 to 5 days after surgery by the author (AU). The assessments, nursing and medical records were subsequently evaluated by a specialist in geriatric medicine together with a trained research nurse in terms of complications, dementia, depression and delirium. Data collected in papers I and II were analysed using comparative and descriptive statistical analysis. In papers III and IV, semi-structured interviews were performed with patients (paper III) and with staff (nurses and assistant nurses, paper IV) based on interview guides with open-ended questions that offered opportunities for clarification and follow-up questions. In paper III, 23 patients with hip fractures aged 70 years or older who were treated with FNBs were interviewed, and in paper IV, staff working in the orthopaedic ward and emergency department with experience of caring for patients with hip fractures treated with FNBs were interviewed. The interviews were audio-recorded, transcribed and analysed using qualitative content analysis. Results: The results in paper I showed that patients who received an FNB assessed lower pain scores over a period of 12 hours. Patients required smaller amounts of opioids and the number of patients requiring opioids was reduced compared with the group that received opioids alone. Overall, in paper II was it a high incidence of complications, common complications in both groups were pre and postoperative delirium (44% and 73%), nutritional problems (71%), anaemia (66%), constipation (64%) and urinary tract infection (45%), but no statistical difference was found between groups of those complications. The results in paper II showed that 39% of the patients who received an FNB and 49% of those who received opioids developed delirium before surgery, with no statistical difference. In paper III, patients described how the pain before surgery was experienced from no pain, to the worst possible pain and everything in between. They described how they dealt with pain in their own way, but also how they felt dependent on the staff's willingness to relieve the pain. They described that the pain treatment could be lifesaving, but that it could also create the feeling of a near-death experience. Further, some patients experienced memory loss regarding the time before surgery, which made it difficult to remember the pain and pain treatment they received. Finally, in paper IV, the staff described that the FNB setting the agenda when caring for older patients with hip fracture in the preoperative phase. Nursing care required timing, with a need of staff orienting to time and customizing their communication. The outcome of the FNB affected nursing care, depending on if the FNB was successful or not successful. Further, staff faced ethical challenges regarding doing good and not harm and relieving pain and avoiding side-effects. Conclusion: This thesis shows that FNB is a feasible preoperative pain management for patients with a hip fracture, even among those with dementia. Evidence-based guidelines are necessary as a basis for assessing pain and providing pain management, but staff should add an individualized pain management approach. Staff should evaluate every patient and see each patient as a unique individual with different experiences of pain and pain management to successfully relieve pain among patients with a hip fracture.
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