Using Qualitative Approaches to Understand the Subjective Experience of Postoperative Delirium

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Contributed by Kelly Atkins, DPsych (Clin Neuro), Melbourne Medical School, University of Melbourne.

Our Research Question

Postoperative delirium is the most common adverse outcome affecting older adults after surgery and is associated with a cascade of negative outcomes1, 2. While research activity in the field of postoperative delirium has exploded, the subjective experience of postoperative delirium remains poorly researched, particularly as it relates to the long-term mental health of patients and their engagement with health care systems. We can start to understand this experience by listening and speaking with postsurgical patients directly affected by delirium3.

Qualitative research studies, like quantitative methods, address a particular research question, define a sample of interest, and use specific methods to collect and analyse data. However, unlike quantitative research, qualitative studies aim to understand, interpret, and describe a phenomenon within a particular group of people. Importantly, there is no hypothesis testing and no ‘control’ group.

In our qualitative study4, we asked two questions: 1) what is the psychological impact of postoperative delirium as recalled by patients? and 2) what are patients’ perceptions of the care they received in hospital after experiencing postoperative delirium?

What We Did

We sampled 30 patients, from a large parent study, aged 60 years or older who had undergone elective cardiac surgery and experienced at least two days of 3D-CAM5 -defined delirium following their surgical procedure. Participants ranged from 60 to 89 years of age, with most (63%) between 70 and 79 years. Males made up 83% of the sample, reflecting the high proportion of men undergoing cardiac surgery in Australia. The median length of hospital admission was 7 days, with a range of 5-35 days. We administered a semi-structured phone interview three to five years after surgery, realizing a duration this long was not ideal. All interviews were recorded for subsequent transcription and analysis.
Among the many qualitative approaches, we used thematic analysis for our study. Thematic analysis involves several recursive stages of coding, categorizing and interpreting the data. In the first stage, we became familiar with the data by reading and re-reading interview transcripts and generating codes and themes. We then selected and coded relevant text and sorted the codes into themes that captured patterns in the data that related to our research questions. We repeated these stages several times to refine and condense the data. Finally, we defined the themes using descriptors that meaningfully conveyed their content 6.

What We Found

In the group of older adults we interviewed, despite at least 3 years passing since their delirium episode, many described the experience of postoperative delirium as isolating and distressing. Specifically, patients described not being able to engage with their environment or communicate with their families and health care teams. Many patients expressed the need for more reassurance and better communication from health care staff to reduce the distress associated with postoperative delirium.
We also found that postoperative delirium was linked to poor mental health outcomes in the years following surgery such as fatigue, apathy and depressive symptoms. These findings emphasize the importance of providing follow-up psychological support for older adults who experience delirium, considering their environment, social supports and previous mental health.

Finally, the patients who described having distressing episodes of postoperative delirium expressed hesitancy to re-engage in healthcare settings. Some even reported masking signs of injury or illness from their friends and family to avoid new medical interventions. This disengagement is concerning as it may lead to inadequate treatment and a subsequent exacerbation of poor health or disability7.

Conclusions

Our study helped us understand how people perceive their experience of delirium acutely and in the years following surgery. In taking this approach, we were able to understand how people viewed their experience with postoperative delirium, and how it affected their subsequent mental health and long-term engagement with the health care system.

By using a qualitative design, we were able to gain perspectives from patients without the constraints of standardized questionnaires or structured forms. Participants could speak freely about their attitudes, preferences and personal experiences. Qualitative methods have important potential to strengthen research focused on preventing and treating postoperative delirium.

What We’re Doing Next

Multi-modal interventions that focus on modifiable risk factors are the best way to mitigate delirium in the hospital8. Our research group has developed and is now implementing a model of care to prevent postoperative delirium9, and we are actively asking patients about their experience of this care. Critically, we want to know what they valued from their care, and what needed to be different. In obtaining the lived experience of patients, we hope to ensure that our models of care place the patient at the centre.

As well as for the patient, delirium can be distressing for caregivers and family members. We would like to see future work that focuses on the experience of caregivers and their perceptions of delirium care.

This Guest Blog was prepared in collaboration with Caitlin Cohen (Graduate Student in Clinical Psychology, Swinburne University).

References

  1. Boone MD, Sites B, von Recklinghausen FM, Mueller A, Taenzer AH, Shaefi S. Economic burden of postoperative neurocognitive disorders among US medicare patients. JAMA Network Open. 2020;3(7):e208931. doi:10.1001/jamanetworkopen.2020.8931
  2. Inouye SK, Marcantonio ER, Kosar CM, et al. The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients. Alzheimer’s Dementia. Jul 2016;12(7):766-75. doi:10.1016/j.jalz.2016.03.005
  3. Baguley SI, Pavlova A, Consedine NS. More than a feeling? What does compassion in healthcare ‘look like’ to patients? Health Expectations. 2022;25:1691-1702. doi:10.1111/hex.13512
  4. Cohen CL, Atkins KJ, Evered LA, Silbert B, Scott D. Examining subjective psychological experiences of postoperative delirium in older cardiac surgery patients. Anesthesia & Analgesia. 2022; doi:10.1213/ANE.0000000000006226
  5. Marcantonio ER, Ngo LH, O’Connor M, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study. Annals of internal medicine. Oct 21 2014;161(8):554-61. doi:10.7326/M14-0865
  6. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  7. Walters K, Iliffe S, Orrell M. An exploration of help-seeking behaviour in older people with unmet needs. Family Practice 2001;18(3):277-282. doi:10.1093/fampra/18.3.277
  8. Berger M, Schenning KJ, Brown CH, et al. Best practices for postoperative brain health. Anesthesia & Analgesia. 2018;127(6):1406-1413. doi:10.1213/ANE.0000000000003841
  9. Atkins KJ, Scott DA, Silbert BS, Pike K, Evered L. Preventing delirium and promoting long-term brain health: A clinical trial design for the perioperative cognitive enhancement (PROTECT) trial. Journal of Alzheimer’s Disease. 2021;83(4):1637-1649. doi:10.3233/JAD-210438

Suggested Citation:

Atkins, Kelly. Using Qualitative Approaches to Understand the Subjective Experience of Postoperative Delirium, Network for Investigation of Delirium: Unifying Scientists (NIDUS); April, 2023, Available at: https://deliriumnetwork.org/qualitative-approaches-subjective-experience/ (accessed today’s date)

Citing a published NIDUS blog post on your CV

When citing a NIDUS blog post on your CV, list it in a section entitled Other Non-Peer Reviewed Scholarship. For the actual citation, list your name, blog title, organization (NIDUS), and the link to Blog. At the end, add ‘invited blog’ in brackets. This is the format suggested on the Harvard Med School CV template.

Example
Sam Jones, My Delirium Blog Post, NIDUS, www.deliriumnetwork/my-delirium-blog-post.org (invited blog)

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