Is it normal to feel delirious after surgery?

I recently suffered delirium and subsequent loss of memory after an operation. I needed 24-hour observation as I was so disturbed during my stay in hospital. Is this a common complication after major surgery?

Mrs P. Funnell, Eastbourne.

This must have been an alarming experience, for you and your loved ones.

The important thing now is that you have some understanding of what happened and why, so you can try to avoid a repeat experience.

Delirium, essentially where a patient suddenly becomes confused, is one of several possible complications after an operation. The chances of these complications occurring are determined by several factors, including the nature of the surgery, the type and technique of anaesthetic used and any other medical conditions you have.

Delirium, essentially where a patient suddenly becomes confused, is one of several possible complications after an operation

It’s to prevent such complications — or to at least to enable quick action — that patients are taken to the recovery unit following an operation.

Here, the anaesthetist who looked after you during surgery will brief the nurses — explaining, for example, the dose of drugs given, any problems that occurred during the procedure and the details of medications prescribed for pain relief. It is the nurses’ role to keep an eye on your vital signs (such as pulse, blood pressure and breathing) and ensure you recover fully from the anaesthetic.

The most common problem immediately after an operation is nausea and vomiting, which affects about 10 per cent of patients post-surgery. There may also be complications involving the airway — for example, unexpected reflux of stomach acid which, because the coughing reflex has been suppressed by the effect of the anaesthetic, the patient could potentially breathe into their lungs.

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Around 6 per cent of patients have low blood pressure after an operation, and some have an abnormal heart rhythm.

Neurological complications are far less common. These may include a delay in waking up from the anaesthetic, or delirium, as you experienced.

The signs of delirium can vary. As well as being confused, the patient may appear restless and agitated or sluggish and drowsy.

Delirium may also be linked to pain — treating it should ease the delirium, though care must be taken with morphine or similar drugs as these can potentially make delirium worse.

Urinary retention (an inability to empty the bladder) can also be a cause, as can abnormal oxygen, carbon dioxide and blood sugar levels. Hospital staff will consider all these and whether the specific anaesthetic drugs that were used might be responsible.

While most cases of delirium resolve within the first hour after surgery, sometimes it lasts hours or even days. In these cases, the patient usually has a pre-existing cognitive impairment, such as early dementia, or a history of heavy drinking. Prolonged delirium after an operation is also more common in older patients.

The important point for you — if you have a general anaesthetic again — is to remember to brief the anaesthetist before the operation. Explain this has happened to you before, describe the medication you are on and give details of your alcohol intake so they can minimise the risk of it occurring again.

Most people with heart conditions are aware of the importance of diet and the benefits of the Mediterranean diet. However, many have to take warfarin, which limits vegetable intake. Unfortunately there seems to be very little professional advice given on diet for people taking this drug. Can you advise?

Rod Williams, Great Holland, Essex.

Patients on warfarin should always consult their doctor when taking any new medication

Let me start by explaining how warfarin works, as this is key to the dietary advice.

Warfarin is an anticoagulant. Some people refer to these drugs as blood thinners, but they don’t actually make the blood thinner — they help prevent blood clots.

They are typically prescribed to patients with atrial fibrillation (an irregular and often abnormally fast heartbeat) or those who have suffered a stroke or heart attack.

Treatment with warfarin is something of a balancing act. The aim is to reduce the tendency of the blood to clot, but not prevent clotting altogether (otherwise there is a risk of fatal bleeds).

This means patients are monitored regularly to ensure the dose is correct. This is done in the form of blood tests every few weeks or months to measure how long it takes for the blood to clot — known as the prothrombin time.

This figure is then used to calculate the international normalised ratio (INR) — the higher this is, the longer the blood takes to clot. It is the INR which helps determine the dose of warfarin that a patient needs.

Doctors typically want patients’ INR to be between 2 and 3. The daily dose of warfarin can be raised or lowered as necessary to keep it in the target range.

If it shoots too high, patients run the risk of bleeding excessively, even if they have not suffered an injury. If it’s too low, then there will be little or no anticoagulation, and potentially dangerous clots may occur.

Some foods, supplements and herbal medicines can interfere with the action of warfarin and upset the INR. One of the key things to be aware of is vitamin K.

Found in green leafy vegetables including broccoli, spinach, kale, lettuce, Brussels sprouts, and cabbage, this nutrient plays a key role in the blood clotting process. Eating lots of vitamin K-rich foods makes the warfarin less effective and the INR drop, therefore increasing the risk of clotting.

This doesn’t mean you have to avoid these foods. Instead, the advice is to have the same amount of vitamin K each week — it doesn’t matter how much you have as long as it’s roughly the same week in, week out.

A final point is that patients on warfarin should always consult their doctor when taking any new medication, whether it’s over-the-counter tablets, a herbal preparation, vitamins or supplements because medication can also affect blood clotting.

By the way… There’s no such thing as male menopause

There’s been a lot of talk in recent years of a ‘male’ menopause — the idea that men experience symptoms such as mood swings, lack of energy and muscle mass due to a drop in testosterone in middle age.

But as someone who keeps a close eye on the latest research, I have come to the conclusion that the thinking about this is muddled. Though testosterone levels do decline with age, this is gradual, unlike the sharper drop in oestrogen seen in the female menopause proper.

And there is little or no evidence a real syndrome exists that can be treated with hormone supplements in the same way women’s menopause symptoms can be resolved by oestrogen. Despite this, men often ask me whether they should have their levels tested, often a prelude to requesting supplements of testosterone. However, the evidence for the benefits of testosterone treatment in men generally is thin.

Though testosterone levels do decline with age, this is gradual, unlike the sharper drop in oestrogen seen in the female menopause proper

What we know for sure is that testosterone supplements do increase haemoglobin levels in those with unexplained anaemia (haemoglobin carries oxygen in the blood, but levels decline for no detectable reason in some men as they age) and bone density.

There are also modest increases in muscle strength and this has been found in studies of older men who have become weakened through lack of exercise. This is also why anabolic steroids — essentially testosterone — are used and abused by body builders.

However, a recent study of 800 men with an average age of 72 looking for evidence of improvement in cognitive function failed to show any improvement.

What the study did find, however, was a significant increase in the formation of plaque (fatty deposits of cholesterol) in the coronary arteries. This is a good reason to avoid testosterone supplements if possible.

Why push up the chances of coronary heart disease for so little real gain?