Expert: Mary Gordon - 2/17/2009

Question
My 91 year old mother-in-law fell and broke her upper right arm/shoulder.  It's so bad that the bone is completely detached from the shoulder and she needs a partial shoulder reconstruction surgery to try to mend it.  She cannot use her right arm and is in significant pain.  Since she has great difficulty walking (even getting up from a chair) her broken arm makes it very difficult for her caregiver to help her, so the surgery seems to make sense on the surface.  We even waited for almost two months after she broke her arm to see if it would get "better", that is if it would be more manageable.  This is what the orthopedic surgeion suggested since he really would prefer not to operate.  But she's still in severe pain and it's really hard for her caregiver to work with her.  

However, she has signficant dementia and "floats" between several mental stages, one state having severe hallucinations and paranoia.  I am concerned about the after effects of the anethesia and her reaction to being in the hospital for post operative care.  I don't know if hospitals are really able to deal with dementia patients?  We have told them of here dementia, but I don't know if they really understand the situation or are prepared.  

Do you have any insight?  I appreciate your comments.

Thanks, June

Answer
Hi June,
I totally understand your dilemma - you really are between a rock and a hard place on this one. You've done what you can by giving her injury time to improve on its own. You must have a smart surgeon - a lot of them are more enthusiastic about taking on orthopedic work on the elderly with cognitive problems than they should be. As I'm sure you've read, all surgery is risky for the elderly, but cardiac and orthopedic work particularly so in terms of risks for cognition. The problem is so common, even for those who don't start off with a dementia/preexisting neuropathology, it has a name - POCD - Post Operative Cognitive Decline.

Two things happen - the first is a very temporary post surgical "delirium" - in older people even without dementia, drugs can last longer in their systems, and cause more side effects - including pain meds. They can be loopy for a few days after surgery. It's really startling. My mother in law had broke a hip very early in her Alzheimer's and was so totally out of it during her hospitalization, the hospital thought we were in deep denial about her condition. They would not believe she'd been doing quite well prior to surgery (living on her own, managing well with supports, shopping, cooking, cleaning)- they called a social worker in to talk to us, since they thought she should go straight to a nursing home.  A lot of it did clear up after a few days, but in the weeks and months that followed, it was clear she had experienced a major and permanent drop in cognition. She went from being a little addled and forgetful to being impaired in a very noticeable way.

She lost ground she never recovered. I know this is what you fear with your mother. If you do a search on POCD you will find lots of information. Is there anyway that the surgeon could work on her shoulder under regional rather than general anesthesia? At this point, I doubt very much that she will be really able to regain full use of her arm post surgery. They can't cooperate with therapy. It  hurts, they don't understand the point, and they avoid it. The outcome is rarely very good. My mother in law broke the OTHER hip in later AD, and no matter who tried or what was tried, we got nowhere getting her walking again. Be prepared to be very frustrated with attempts to get her to use her arm again.

The point of the surgery is really to get her out of pain. Have you discussed options with the surgeon that may involve less invasive and extensive procedures? Is there anything he can propose that would stabilize things enough that they don't cause her pain? If it involves a simpler and shorter procedure, can he do it under a local with some sedation? It is worth talking about because of the very real risk that she'll take a major drop mentally and never recover. It has to be all about quality of life.  It may not be possible to use a local because she can't cooperate and stay still, but at least you will have explored all the options. You certainly can't leave her in pain. Aside from surgery, is there any kind of brace that might keep things still? You've probably thought about all these ideas.  

No one really understands exactly why anesthesia seems to exacerbate dementia. There is a lot of debate about the cause - probably a combination of things - but it is a real effect.  The other thing to be prepared for is how hopeless hospitals are with dementia patients.

Some advice with that front:

A family member should provide an accurate medical and surgical history, including past response to drugs, and a current list of medications prescribed. I'd type one out and take several copies so you can hand it to the various staff who will ask you the same questions again and again (or worse, trying to ask HER again and again).

She's going to be totally confused and overwhelmed in a strange place. To avoid overtaxing the person with dementia, the number of staff dealing with her should be kept to a minimum. No matter what, someone should plan to stay with her from the moment she gets there.  Hospital staff really have no special training in dementia particularly on the orthopedic ward, and you CANNOT TRUST THEM to be smart about dealing with her and her unique issues. We found, for example, that staff would shout at my mother in law, not realizing she couldn't follow verbal instructions. They assumed she was deaf, even when they were told she had advancing dementia. She could no more have answered their questions or complied with their demands than flown to the moon flapping her ears, and they really didn't "get" it.  They just didn't have the training or the time.

Someone should stay with her as much as possible - 24/7 if possible - a paid sitter or duty nurse is a big help. Your mom will need supervision and reassurance and other supports the orthopedic ward won't supply.

One scary thing we found is that a staff member would shove a covered tray of food into a wheeled trolley in her room and leave, often not placing it in front of her. The food provided was often not suitable for a person with dementia - we had to speak to them several times about potential choking hazards (i.e. pork chops she couldn't have cut herself, never mind chewed and swallowed).  My mother in law also needed the tray put directly in front of her and the insulating lid removed, so she knew it was food. If we had not been there, the covered tray would have been casually removed by another staff member 1/2 hour later without her having a bite to eat, and no one would have paid any attention. She also needed assistance and prompts to eat and drink, so someone who knew her had to be there. She would have gone hungry if family had not been on top of her care.

You also have to be there to watch in the recovery phase to make sure she is kept
warm and well hydrated during the recovery phase because hypothermia and dehydration can contribute to post-operative confusion. She will need reorientation and supervision when coming out of anesthesia, or she'll end up pulling out tubes and catheters etc. and may end up in restraints or at risk of trying to get up and falling. If she starts to flail around, the hospital may just sedate her more, so someone who is there for her, sitting at her elbow, to protect and look out for her is key.  

We found with the second hip break that my mother in law did much better once she got back to the Alzheimer's ward - in other words, get her out of hospital ASAP, back to the place where your mother in law's deficits are known and there is appropriate care to deal with them.

Does your mom have Lewy Body Dementia - I ask because visual hallucinations and extreme fluctuations are a hallmark.

Hope this helps

Mary G.