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- 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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| 2. |
- Lundgren, Minna
(författare)
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Boundaries of displacement : Belonging and Return among Forcibly Displaced Young Georgians from Abkhazia
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This dissertation explores the implications of borders and boundaries for how forcibly displaced young Georgians from Abkhazia understand issues of belonging and return. My theoretical framework draws from theories on home and belonging as well as theories on border and boundary making, and locates them in geographies of uncertainty – or riskscapes – areas characterized by conflict and/or inequality. Empirical data was collected through two sets of interviews in Zugdidi near the border to Abkhazia and a questionnaire survey in Zugdidi and the capital Tbilisi. These data have been analysed through both qualitative and quantitative methods. The young respondents providing material for this research do not constitute a homogenous group. Some of the respondents have family still living in Abkhazia or even partly grew up in the area; others have never been there. The primary goal of the Georgian government has been that the displaced population should return to their homes, and the government’s efforts for local integration has long been insufficient. Since no peace accords have been signed, a lack of security prevents a large-scale return. Notwithstanding increased border controls that have made it difficult to visit former homes, some young people still cross the de facto border. By doing this they contest both the Abkhazian de facto authorities and the border as a symbol of separation and differentiation, while claiming a right to belong in Abkhazia. Property and social relations in Abkhazia contribute to stronger connections and an imperative to return. On the other hand, experience of hardship in contemporary Abkhazia has resulted in some young people not considering return as a viable option. Youth who never visited Abkhazia depend mainly on other peoples’ memories and political discourse to create emotional bonds to the area their parents fled and to form their ideas of return. Results from the quantitative survey indicate that youth living in Tbilisi, closer to the political centre, to a higher extent intend to return than their peers in Zugdidi. Meanwhile young people’s experiences of everyday life in current dwellings in relative stability create emotional bonds to their present place of living. These experiences challenge both collective processes and experiences from Abkhazia when it comes to maintaining the desire to return. This research offers insights into the human consequences of war and conflict. More specifically, this dissertation sheds light on how young internally displaced persons (IDPs) are living in a borderland (in both temporal and spatial terms) characterized by uncertainty-- between the past and the future as well as between Georgia and Abkhazia. Practices of exclusion and segregation are constitutive of the borders and boundaries that permeate life experiences of the forcibly displaced youth. Furthermore, these borders and boundaries are situated in riskscapes of disputed belongings, which makes this borderland more or less stable for different groups of IDPs. This dissertation contributes to an increased understanding of how political aspirations and personal desire to return preserves instability and uncertainty as long as return is not possible.
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