Postoperative risks of stoma formation in patients with dementia

Abstract

Stoma formation for patients with dementia presents an increasing problem in a global ageing population. While potentially lifesaving, stomas impose significant, long-term postoperative burdens on patients, and may particularly challenge those with cognitive impairment.

In this case, a patient was considered for colostomy to manage a colovesical fistula. The patient’s cognitive status significantly influenced clinicians’ beliefs concerning suitability for stoma formation.

The relevance of dementia to stoma formation is underdiscussed within the literature. In this report, we outline the postoperative risks to which those with dementia undergoing stoma formation are particularly vulnerable. These include increased risk of psychological harm, of relocation to a nursing home, and of stoma-related complications.

We hope an increased appreciation of these postoperative challenges will inform decisions concerning suitability for stoma formation in this patient group.

Background

Stoma formation is undertaken to facilitate the external diversion of urine or faeces away from anatomy that might be blocked, missing or dysfunctional. These are common procedures, with over 13 000 and 100 000 performed in the UK and USA each year, respectively.^{1 2}

While potentially life-saving, gastrointestinal stomas are also associated with substantial postoperative complications including parastomal hernias (affecting 40% of patients), stoma prolapse (10%), stoma retraction (24%), stoma necrosis (7%), reduced well-being, poor nutrition and dehydration.^3–5 Crucially, the impact of these challenges on patients’ quality of life is variable.⁶ Patients with cognitive impairment may be particularly affected.⁷

Stoma maintenance can be a significant time burden to patients, requiring the use of a pouching system to collect waste products. These systems usually multi-part, comprising a removable bag to store waste, a protective baseplate applied to the peristomal skin, and water-resistant tape to secure each component. Inadequate care may prompt complications ranging from skin irritation and cellulitis to ulceration and significant infection.^{8 9}

While recognised as a risk factor for poorer surgical outcomes more generally,¹⁰ there is little discussion of the relevance of dementia to stoma formation specifically. Incidence of dementia is increasing due to the UK’s ageing population. As such, understanding the postoperative risks surrounding stoma formation for this patient group is essential to ensuring appropriate stoma construction and care.

Case presentation

An elderly male patient attended the Accident and Emergency department a year ago with abdominal pain accompanied by increased faecal discharge through a permanent urinary catheter. Previous medical history included anterior colonic resection and ileostomy formation a decade earlier for management of colorectal cancer with ileostomy reversal occurring (which was later reversed) and a cerebrovascular accident (CVA) 8 years earlier. A colovesical fistula, identified 2 years before admission, accounted for the patient’s feculent catheter discharge. The patient reported no notable family history of disease, lived at home with the support of a live-in carer and mobilised independently using a frame.

When reviewed on admission to our surgical ward, abdominal pain had spontaneously resolved. Physical examination and blood results were unremarkable.

Initially, it was thought that the patient suffered cognitive impairment, possibly associated with his previous CVA. This was considered to render him potentially unsuitable for a stoma to manage his colovesical fistula. Following this initial review; however, the patient’s cognitive function was formally assessed and found to be intact (Abbreviated Mental Test Score (AMTS)=10).¹¹ Cognitive assessment prompted revision of the patient’s suitability for a stoma, and he was offered a colostomy formation to manage his colovesical fistula.

Investigations

Initial investigations included full blood count, urea and electrolytes, liver function tests, inflammatory markers and venous blood gas. These were unremarkable except for a mild, normocytic anaemia (Haemoglobin=101 g/L, Mean Corpuscular Volume=95.3 fL), hyponatremia (127 mmol/L), raised urea (9.8 mmol/L) and a raised C reactive protein (36.5 mg/L). Blood glucose was normal.

Blood cultures and urine cultures were also obtained to investigate possible infective causes, but results were not reported before the patient’s discharge. A normal white cell count, however, was considered to make infection unlikely. A COVID-19 lateral flow test was also performed, which was negative. A CT abdomen/pelvis with contrast identified a colovesical fistula.

Differential diagnosis

Initial differential diagnoses included infection, particularly gastroenteritis or urinary tract infection, diabetic ketoacidosis, hyponatremia, abdominal bleed and bowel obstruction. In addition to causing abdominal pain and vomiting, these differentials were considered plausible explanations for the patient’s confusion. Long-standing, undiagnosed psychiatric causes of the patient’s apparent confusion, including depression or an adjustment disorder, were also considered.

Following the spontaneous resolution of the patient’s vomiting and abdominal pain, and the determination that he was not cognitively impaired, it was concluded that the patient’s colovesical fistula represented the most significant identified pathology.

Treatment

The patient refused stoma formation and his fistula was instead managed conservatively. He was discharged 48 hours after initial admission with a 20fr catheter to reduce risk of faecal catheter obstruction.

Outcome and follow-up

Following discharge, the patient was referred to the community care team for continuing management. A telephone follow-up 7 days following discharge found the larger catheter to have successfully prevented faecal obstruction. A single instance of faecal obstruction was then reported in May by the community care team, which spontaneously resolved.

Discussion

This patient’s cognitive capacity significantly influenced clinicians’ decision-making. Sadly, their assumption of cognitive impairment is one commonly made of elderly patients.¹² This was reflected in clinicians’ use of only the relatively brief AMTS to assess this patient, a 10-item cognitive measure developed to rapidly screening the elderly for dementia.¹¹ AMTS questions include ‘What is your age?’, ‘Who is the Prime Minister?’ and ‘Where are you at the moment?’.

Other tools, such as the Montreal Cognitive Assessment (MoCA) or Addenbrooke’s Cognitive Examination, include a larger number of items and explore a greater range of cognitive domains, thus providing more thorough assessment.^{13 14} Had this patient been younger, they may have received assessment using more detailed tools before any treatment decisions were made.

Reticence to undertake stoma formation in those with dementia likely reflects concerns about the patient’s ability to adequately manage their stoma postoperatively, and the quality of nursing care available to patients in these circumstances. This may lead to higher rates of postoperative complications and psychological distress. Importantly, while particularly pertinent in the case of stoma formation, the impact of cognitive capacity on patients’ operative experience and postoperative quality of life should be considered when undertaking any surgical intervention.

Stoma care

Complications such as peristomal dermatitis, stomal ulceration and soiling of clothes affect 70% of patients within a year of their stoma’s formation.⁵ Preventing these complications requires attentive stoma care, which is cognitively complex. Care includes regular stoma bag emptying (2–3 times daily for colostomies and up to 10 times for ileostomies), frequent replacement of the stoma baseplate and regular stoma and peristomal washing. Risk of complication may be increased in those with cognitive impairment due to their performance of poor stoma care.¹⁵

Cognitive impairment may also increase risk of complications progressing to more severe pathology, such as stoma breakdown or systemic infection, due to inappropriate patient management (eg, scratching of peristomal skin). Patients may also be less likely to seek appropriate medical care when experiencing symptoms of complication, increasing their vulnerability to time-sensitive stomal complications (eg, stoma ischaemia) requiring urgent surgical attention.¹⁶

Nursing home admission

Cognitively impaired patients with stomas frequently require nursing home care, often to receive support with their stoma.⁷ Admission is associated with significant deterioration in mental health¹⁷ and risk of neglect due to poor staffing levels.^{18 19} Furthermore, nursing home staff frequently receive no formal training in stoma management,²⁰ placing patients at risk of poor quality care. Improved stoma awareness and education is key to improving outcomes for these patients.

Poor stoma fit

Achieving a close seal between stoma bag and abdomen through good stoma positioning is key to preventing complications.^{21 22} This requires thorough physical examination as the patient holds various positions to ensure the chosen site avoids bony prominences, scar tissue and skin folds. Cognitive impairment may increase risk of non-compliance with this examination.

Dementia’s association with weight loss, and accompanying abdominal surface changes, may also result in poor stoma fit.²² This weight loss is frequently refractory to nutritional management via percutaneous endoscopic gastrostomy (PEG) insertion, likely as a result of its multifactorial aetiology.²³

Psychological distress

Stoma formation negatively impacts mental health, with as many as 50% and 42% of patients experiencing clinical depression and anxiety, respectively.⁴ Poor outcomes are particularly common for those patients unable to adapt to life with a stoma.^{6 24} The loss of cognitive flexibility and reliance on routine typically associated with dementia makes these patients particularly likely to experience reduced well-being following stoma formation.²⁵

Conclusion

This case offers an opportunity to consider the postoperative challenges of stoma formation faced by those with cognitive impairment. While further work is needed to fully explore and quantify these challenges, it is nonetheless clear that careful consideration of these additional risks is essential when assessing the suitability of a patient with dementia for stoma formation. However, in cases where formation is unavoidable, care can be optimised by:

• Net undergarments, worn under clothing, to prevent fiddling with the stoma.

• One-piece or flushable stoma devices to improve ease of care.

• Opaque devices, which attract less patient attention.

• Offering calming sensory items (eg, twiddle muffs) or encouraging performance of other tasks during bag changing (eg, hair brushing) to redirect patient attention.

• Inclusion of all staff and close family members in stoma care education, facilitating collaborative patient care.

Learning points.

• The number of patients with cognitive impairment presenting with indications for stoma formation is increasing.

• This patient group’s increased risk of both psychological and physical health complications must be considered when determining suitability for stoma formation.

• More work is needed to examine and address the postoperative implications of stoma formation for those with dementia.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s)