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Delirium After Surgery is Common in the Elderly

A senior couple at home. (iStockphoto/Thinkstock)
A senior couple at home. (iStockphoto/Thinkstock)

A dictionary defines delirium as a temporary state of mental confusion resulting from high fever, intoxication, shock or other causes, and characterized by anxiety, disorientation, memory impairment, hallucinations, trembling and incoherent speech.

Delirium after surgery under general anaesthetic is common in the elderly. Approximately half of all operations performed in North America are in patients greater than 65 years of age. This number is expected to increase as the population of elderly increases. Older adults represent a unique challenge to the surgeon, often presenting with multiple medical illnesses and higher risk for post-surgical complications, says an article in the Journal of the American College of Surgeons (JACS).

The incidence of delirium in various studies varies from nine per cent to 87 per cent. The development of delirium is associated with increased death rate, increased length of stay in the hospital and an increased rate of discharge to long term care facilities. Delirium is also associated with increased risk of major medical complications including heart attack, build up of fluid in the lungs, pneumonia, and respiratory failure.

Studies have also found that post-surgical delirium predicts future cognitive (mental processes of perception, memory, judgment and reasoning) decline and an increased risk of dementia. Delirium is not always easy to recognize and may be confused with other conditions common among the elderly such as dementia or depression.

Delirium is a complex phenomenon, often involving multiple factors to trigger the problem and likely affecting multiple spheres of the central nervous system. Some of the common factors responsible for post-surgical dementia are lack of oxygen, low blood sugar level, electrolyte imbalances, body fluid depletion, infection and drug interactions.

A surgeon has to remember that pain is a common post-surgical complaint and delirious patients may not be able to effectively communicate with providers about pain. Both under treatment of pain and overuse of narcotics can make delirium worse and makes postoperative pain management a challenge.

Which elderly patient is at high risk of developing post-surgical delirium?

One study identified seven predictors that could be used preoperatively to assess an individual patient’s risk of delirium. These factors include age greater than 70 years, self-reported alcohol abuse, poor cognitive status, poor functional status, abnormalities of serum sodium, potassium or glucose, non-cardiac thoracic surgery or abdominal aneurysm surgery, says the JACS article.

The strongest predictors of postoperative delirium are the presence of preexisting cognitive dysfunction, advanced age and multiple medical comorbidities. To reduce the incidence of postoperative delirium, hospitals should identify patients at risk, have good geriatrics pre-operative consultation services and assign patients to multidisciplinary teams of providers with experience caring for elderly patients.

JACS article says that despite the best preventive efforts, a certain percentage of patients will become delirious in the postoperative period. It is important to identify and treat underlying causes, along with emphasizing non-pharmacologic interventions to decrease severity and duration of delirium.

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Can you blame problems of the child on the parents?

As a parent, do you blame yourself if your child does not grow up to your expectation? I am no expert on the subject but a recent article in American Scientific Mind asked, “Do parents matter?” made me do some research on the subject.

It all started with Sigmund Freud (1856-1939), a Viennese doctor, who stressed the importance of childhood events and experiences. Freud blamed the problems of the child on the parents. He was especially hard on mothers. According to Freud, child development is described as a series of psychosexual stages. He outlined these stages as oral, anal, phallic, latency period and genital. Each stage involves the satisfaction of a libidinal desire and can later play a role in adult personality.

Since then much research has been done on child development and this has yielded many
theories on children’s mental, emotional, and social development. The debate continues as researchers try to find answers to many questions.

The article I referred to earlier is based on an interview done by the American Scientific Mind with Judith Rich Harris, author of The Nurture Assumption: Why Children Turn Out The Way They Do. The book was published 10 years ago. In the book Harris argues that parents matter much less, at least when it comes to determining the behavior of their children, than is typically assumed. Instead, Harris argued that a child’s peer group is far more important.

Harris says in the interview, “One of the reasons of writing the book was to reassure parents. I wanted them to know that parenting didn’t have to be such a difficult, anxiety-producing job, that there are many different ways to rear a child, and no convincing evidence that one way produces better results than another.”

Harris also says that most developmental psychologists still do not agree with her, but they are acknowledging that there’s another point of view.

Harris says that there is a greater awareness of genetic influences on personality. Personality is the sum total of the physical, mental, emotional, and social characteristics of an individual. It’s no longer enough to show, for example, that parents who are conscientious about childrearing tend to have children who are conscientious about their schoolwork. She asks, “Is this correlation due to what the children learned from their parents or to the genes they inherited from them?”

According to Harris, there are three different mental modules involved in social development. The first deals with relationships, including parent-child relationships. The second handles socialization. A stage where a child’s behavior becomes more similar to that of their same-sex peers. The third enables children to work out a successful strategy for competing with their peers, by figuring out what they are good at.

Harris says she has put together a lot of evidence showing that children learn at home how to behave at home (that’s where parents do have power!), and they learn outside the home how to behave outside the home. So if you want to improve the way children behave in school for instance, by making them more diligent and less disruptive in the classroom, then improving their home environment is not the way to do it. What you need is a school-based intervention. That’s where teachers have power. A talented teacher can influence a whole group of kids, says Harris.

Some readers of the article argued that Harris’s theory just encourages irresponsible parenting by shifting the onus on the child’s peers and teachers. One reader questioned the effects of television on child development.

So, are you any wiser today than you were before? As a parent, do you have a magic (or any) formula to raise a child? How was your upbringing? Who influenced you the most to be what you are today? How did that influence you to raise your children? Interesting questions, eh!

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Good Sleep is Necessary for Losing Weight

A study published in the May issue of Psychoneuroendocrinology says that getting enough rest promotes weight loss. Without enough deep sleep, fat accumulates. Ok, this is not a joke. Read on….

Two hormones in our body, ghrelin and leptin, control our appetite. Ghrelin increases hunger and leptin promotes feelings of fullness. Researchers found that in chronic insomniacs there is a significant disruption of night time ghrelin levels and this increases their appetite during the day.

In addition, in chronic insomniacs, there is increase in the levels of stress hormone cortisol which increases cravings for high-carb, high-calorie foods. Furthermore, the brain secretes growth hormone during the deep-sleep phase, helping the body convert fat to fuel, according to a report in the Scientific American Mind.

It is estimated that 10 to 40 per cent of people suffer from some sort of insomnia. This is only an estimate as nobody has yet defined what constitutes normal sleep.

Most adults sleep seven to eight hours a night. Newborns and children may sleep up to 16 hours a day. Older people may sleep only six hours a night. There is no magic number. If you are tired the next day or are yawning all the time then you need more sleep.

The quality of sleep you get is also important. The quality and quantity of sleep depend on many factors like your health, your lifestyle and your environment.

In a survey done in the United States, it was found that many patients with insomnia have other medical problems. Thirty per cent of the patients have depression, 20 per cent have other mental disorders, and 19 per cent have other illnesses. But 31 per cent of the patients have primary insomnia (i.e. they have no medical condition contributing to insomnia).

“The prevalence of insomnia has also been reported to be higher in women, women in minority groups, people who are unemployed or separated, lower socioeconomic groups and in those with medical or psychiatric (particularly substance abuse) disorders,” says an article in the Canadian Medical Association Journal.

Workaholics spend many sleepless nights to accomplish their tasks. They ask, “Why do we need to sleep?” Experts say we need sleep to rest. Sleep allows the brain and the body to recover and restore itself. So we can be fresh for the next task. Now we know we can lose weight as well.

It is very important that you consult your doctor if you have trouble falling asleep or cannot remain asleep for an adequate length of time. The cause of your insomnia could be stress, depression, anxiety, panic attacks, spastic bladder, arthritis, hyperthyroidism, congestive heart failure, obstructive sleep apnea, restless leg syndrome or lung disease. You may be overindulging in caffeine or alcohol. Or there may some other cause.

Your physician can help you sort some of these problems by recommending regular daytime exercise, avoiding large meals at night, avoiding caffeine, tobacco and alcohol; reducing evening fluid intake; maintaining a consistent wake-up time; avoiding or limiting daytime napping and avoiding bright lights (including television), noise and temperature extremes. In some circumstances he may recommend medications.

Remember, there are three things required to lose weight: a low calorie healthy diet, regular exercise and enough sleep. Now you know, I wasn’t joking.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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What Do We Know About Artificial Sweetners?

An artificial sweetener is a sugar substitute which duplicates the effect of sugar in taste but has fewer calories. Some sugar substitutes are natural and some are synthetic. Those that are not natural are, in general, referred to as artificial sweeteners.

Certain sugar substitutes are known as high-intensity sweeteners. Sweetness of these compounds exceeds many times the sweetness of sucrose which is our common table sugar. As a result, much less sweetener is required, resulting in minimal calorie consumption. The taste of artificial sweetener is not as good as our regular sugar. So they are often used in complex mixtures that achieve the most natural sweet sensation.

Is it safe to use artificial sweeteners?

Six intensely-sweet sugar substitutes have been approved for use in the U.S. They are saccharin, aspartame, sucralose, neotame, acesulfame potassium, and stevia. Artificial sweeteners are considered food additives and hence regulated and approved in the U.S. by the Food and Drug Administration.

In Canada, food additives are also subject to rigorous controls under the Food and Drugs Act and Regulations. New food additives (or new uses of permitted food additives) are only permitted once a safety assessment has been conducted, says Health Canada website. Several artificial sweeteners have been approved for use in Canada (see Health Canada website).

Let us look at couple of examples where safety questions have been raised.

Does saccharin cause cancer? Saccharin is a man-made sweetener that is used in food products in many countries. Health Canada says that in the 1970s, scientific studies raised concerns that saccharin could be carcinogenic (cancer-causing) in laboratory rats. As a result of these studies, saccharin was not permitted as a food additive in Canada, although restricted use of saccharin as a table-top sweetener has been allowed.

Since that time, further studies have revealed that the carcinogenic effect of saccharin in rats does not have the same effect on humans. Health Canada says that their scientists have thoroughly reviewed the scientific information available and as a result are considering re-listing saccharin in the Canadian Food and Drug Regulations to allow its use as a sweetener in certain foods.

Is aspartame safe? Aspartame is a non-nutritive sweetener first approved for use in foods and as a table top sweetener in Canada in 1981. Health Canada’s scientists evaluated an extensive array of toxicological tests in laboratory animals, and more recently, a large number of clinical studies in humans. Aspartame is also currently permitted for use as a sweetener in food in many countries and its safety has been carefully examined by health authorities and international expert groups around the world.

Stevia is a herbal supplement and is used as a sweetener. But there is not enough research on stevia’s safety as a sugar substitute and there is some controversy about its approval.

According to the National Cancer Institute (U.S.), there’s no scientific evidence that any of the artificial sweeteners approved for use in the United States cause cancer. And numerous studies confirm that artificial sweeteners are safe for the general population.

Here are some examples of commercially available artificial sweeteners: Aspartame (NutraSweet, Equal), Saccharin (Sweet’N Low, SugarTwin), Acesulfame K (Sunett, Sweet One), Sucralose (Splenda).

Diabetics and weight watchers who use artificial sweeteners should know that if they consume “sugar-free” drinks and food that are high in carbohydrates and proteins then these products may contain calories that may undermine your ability to lose weight and control blood sugar. Remember, it is not only what you eat, it is also how much you eat.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!