https://doi.org/10.33698/NRF0229-Priyankprakash, Sandhya Ghai,Neenavir Singh, Ss Dhandapani
Abstract : Background: Ventriculo-peritoneal (VP) shunting is the leading neurosurgical treatment for hydrocephalus (HCP). Shunt malfunctioning have been reported even after the advancement in the technology and design of VP shunt systems. This further increases the morbidity and decreases the quality of life (QOL). Objectives:To assess the experienced health problems among patients who had undergone ventriculo-peritoneal shunt. To assess the QOL and factors influencing QOL of patients who had undergone ventriculo-peritoneal shunt. Material and methods: A total of 36 adult patients were selected through consecutive sampling technique. Subjects were interviewed by standard tool i.e. hydrocephalus outcome questionnaire (HOQ). Results: Findings showed that the mean age of adult patients was 35.89±14.39 years. Headache was the commonest problem experienced by adults (66.66%). Mean score of QOL was 122.50±55.99. Among all three domains, cognitive domain was mostly affected among patients with VP shunt. Factors influencing QOL of patients included longer duration of care requirement (p<0.001), left VP shunting (p=0.02) unemployment (p=0.02) and low per capita income (p=0.02). Conclusion:Patients who had undergone VP shunt face various health related problems in different domains and has low QOL, where cognitive domain of QOL was most affected. Various socio-economic factors are found to influence their QOL. Hence, appropriate nurse led interventions and holistic management is essential to improve the QOL of patients who had undergone VP shunt.
Keywords
Hydrocephalus; ventriculo-peritoneal shunt; QOL; domains.
Correspondence at
Mrs. Manju Dhandapani
Lecturer,
National Institute of Nursing Education, PGIMER, Chandigarh.
Introduction
The management of hydrocephalus (HCP) has evolved through the development of various shunting and bypass operations. Ventriculo-peritoneal (VP) shunt has become the mainstay of neurosurgical treatment in HCP1. Management with VP shunt is considered equally in both, children and adults2.Though shunt relieves various symptoms related to HCP, people with VP shunt live with certain problems which may affect their quality of life (QOL) and give rise to caregiver burden. VP shunt which is the gold standard of treatment has risen in many centers across the country.3 But with the advantages of shunt system, there are some pitfalls also which are faced by the individuals. Because of which there can be a need to lengthen or to replace the catheter. Complications can also occur related to shunt such as mechanical failure, infections and obstructions. Generally, shunt systems require regular monitoring and follow ups to assess its functioning. When complications occur, subsequent surgery is required to replace the failed part or the entire shunt system4.
Shunt infection is the common complication that accounts significant for morbidity and mortality5. It can happen after shunt placement, with highest incidence (80%) in the first year of insertion. Infection rate ranges from 4.1 to 20.5 % per patient and 2.5 to 12.3 % per procedure6. Shunt infection can be manifested with high temperature, neck stiffness, painful eyes, CSF leaking from the wound and the surgical wound may look swollen and/or broken. A part of the shunt may be visible from outside also.
In spite of significant developments in the technology and design of VP shunt systems, shunt failure remains a significant problem in neurological surgery. Malfunctioning of VP shunt and its complications has increased the morbidity. VP shunt malfunction places an individual at risk for potentially irreversible neurologic deficits and death, if not treated promptly. It needs hospitalization which itself is disruptive to the patient and family which results into impaired QOL. Early physical rehabilitation, stimulation of psychological development and continued monitoring by the health care personnel improve the independence of patients in their families and among their peers7 but, psychosocial factors are critical to recover completely.
Patients on VP shunt have reported to live with problems such as headache, epilepsy, cognitive impairment, gait disturbance and urinary incontinence. This affects their activities of daily living (ADL) and QOL. Appropriate and early identification of various problems faced by patients will help the health care worker to take appropriate measures to improve QOL of patients. Hence the present study was undertaken to assess the experienced health problems, QOL of patients with VP shunt and factors influencing their QOL.
Objectives
- To assess the experienced health problems among patients who had undergone ventriculo-peritoneal
- To assess the QOL of patients who had undergone ventriculo-peritoneal
- To assess the factors influencing QOL of patients who had undergone ventriculo- peritoneal
Materials and Methods
The current study was carried out to identify the problems experienced by the patients, their QOL and factors influencing them. Using consecutive sampling technique, a total of 36 adult patients were selected who met the inclusion criteria of age between 18 to 70 years, who consented to participate and accompanied by primary caregivers. Structured interview of the caregivers was done using standard tool i.e. Hydrocephalus Outcome Questionnaire (HOQ)7. The tool was checked for validity and It is the first and only reliable and valid outcome measure designed specifically for HCP with Cronbach’s alpha of 0.94. It is a 53-item questionnaire, divided into three domains namely physical (15 items), social- emotional (25 items) and cognitive domain (13 items) which have to be completed by the caregivers of patients who had undergone VP shunt. HOQ is measured in five point Likert Scale where four means not at all true and zero means very true. From total items, item no. 19, 20, 21 and 42 were scored in the reversed order as these were the positive aspects of health where zero means not at all true and four means very true. Maximum possible score of HOQ was 212 and minimum was zero. To find the QOL of the adult patients, converted score was calculated after dividing obtained score with the maximum score. Domain wise score was calculated by dividing the obtained score with the maximum score of each domain. Hence, higher is the HOQ score, better is the QOL. Data was collected after taking permission from Institutional ethics committee and written inform consent from the individual subjects. The primary caregivers were interviewed as tool. Analysis of data was done in accordance with the objectives laid down for the study using descriptive and inferential statistics in SPSS software version 20.0 using independent t-test and analysis of variance (ANOVA).
Results
As shown in table 1, mean age of the adult patients was 35.89±14.39 years with the range 20-74 years. Half of the patients were males (50%) and majority was married (63.9%). More than half of the patients had education upto secondary level. Most of the adults were unemployed (44.4%). Half of the patients had monthly per-capita income less than 2500/- and more than three fourth of the patients (83.3%) belonged to nuclear family.
Table 1: Socio-demographic profile of adult patients who had undergone VP shunt
N=36
| Socio-demographic variables of the patient | f (%) | |
| Age (years)* | Young adults (18-25) | 8(22.2) |
| Adulthood (25-40) | 15(41.7) | |
| Middle age (40-60) | 10(27.8) | |
| Old age (60+) | 3(8.3) | |
| Gender | Male | 18(50.0) |
| Female | 18(50.0) | |
| Marital status | Unmarried | 11(30.6) |
| Married | 23(63.9) | |
| Divorced/Separated/Widower | 02(5.6) | |
| Educational status | Primary and less | 06(16.7) |
| Secondary | 21(58.3) | |
| Graduate and above | 09(25.0) | |
| Occupational status | Student | 03(8.4) |
| Unemployed | 16(44.4) | |
| Employed | 08(22.2) | |
| Housewife | 09(25.0) | |
| Monthly per capita income (Rs.) | Less than 2500 | 18(50.0) |
| 2500-5000 | 08(22.2) | |
| More than 5000 | 10(27.8) | |
| Type of family | Nuclear | 30(83.3) |
| Joint | 06(16.7) | |
*Age (years)- Mean±SD (range) : 35.89±14.39 (20-74)
As shown in table 2, majority of the patients were diagnosed with infective HCP (27.8%), followed by traumatic HCP and low-grade tumor (16.7%). More than half of the patients underwent surgery for first time (72.2%). Right VP shunt was placed in more than three-fourth of the patients (80.6%). Post-surgery duration for majority of the patients was less than one year (52.8%) and there was no history of hospitalization after surgery for 83.3% patients.
Table 2: Clinical variables of adult patients who had undergone VP shunt
N=36
| Clinical variables of the patients | f (%) | |
| Diagnosis | Infective hydrocephalus (HCP) | 10(27.8) |
| Traumatic HCP | 06(16.7) | |
| Low grade tumor | 06(16.7) | |
| Idiopathic HCP | 05(13.9) | |
| Arnold Chiari malformation/Syrinx | 05(13.9) | |
| Normal pressure hydrocephalus (NPH) | 04(11.1) | |
| Type of surgery | Right VP shunt | 29(80.6) |
| Left VP shunt | 06(16.7) | |
| Endoscopic third ventriculostomy (ETV) and VP shunt | 01(2.8) | |
| Surgeries | First surgery | 26(72.2) |
| Multiple surgeries | 10(27.8) | |
| Duration since surgery | Less than 1 year | 19(52.8) |
| 1-6 years | 14(38.9) | |
| 6-12 years | 03(8.4) | |
| History of hospitalization | No | 30(83.3) |
| post-surgery | Yes | 06(16.7) |
As shown in table 3, headache was the most common problem experienced by the patients who had undergone VP shunt (66.66%). Other common problems experienced were weakness in all four limbs (58.33%), generalized pain (52.77%), dizziness (33.33%), blurred/decreased vision (30.55%), vomiting (19.44%), decreased memory (13.88%), seizure and numbness (11.11%). Very few (2.77%) experienced diplopia, squinting, vision loss, infection at shunt site, speech difficulty and decreased appetite. Few of them (8.33%) experienced difficulty in walking and nausea.
Table 3: Problems experienced by adult patients who had undergone VP shunt
|
N=36
QOL of patients who had undergone VP shunt using HOQ
Table 4 shows that majority of patients were requiring help in dressing (69.4%), going to washroom (72.2%), has poor vision (52.8%), poor physical balance (58.3%) and has difficulty in
Table 4: Patient’s QOL in physical domain
N=36
| S.
No. |
My spouse/parent/sibling | Not at all true | A little true | Somewhat True | Quite a bit true | Very True |
| 1 | Needs help dressing | 8(22.2) | 1(2.8) | 2(5.6) | 0 | 25(69.4) |
| 2 | Needs help going to washroom | 9(25) | 0 | 1(2.8) | 0 | 26(72.2) |
| 3 | Has poor vision | 6(16.7) | 3(8.3) | 3(8.3) | 5(13.9) | 19(52.8) |
| 4 | Has difficulty walking | 9(25) | 4(11.1) | 6(16.7) | 4(11.1) | 13(36.1) |
| 5 | Needs a wheelchair | 6(16.7) | 0 | 2(5.6) | 0 | 28(77.8) |
| 6 | Has difficulty participating in sports | 17(47.2) | 0 | 5(13.9) | 0 | 14(38.9) |
| 7 | Has difficulty with hand writing | 11(30.6) | 0 | 5(13.9) | 1(2.8) | 19(52.8) |
| 8 | Has poor physical balance | 11(30.6) | 1(2.8) | 2(5.6) | 1(2.8) | 21(58.3) |
| 9 | Has difficulty tying shoe laces | 10(27.8) | 2(5.6) | 2(5.6) | 1(2.8) | 21(58.3) |
| 10 | Gets tired easily | 23(63.9) | 1(2.8) | 5(13.9) | 4(11.1) | 3(8.3) |
| 11 | Has difficulty speaking | 4(11.1) | 3(8.3) | 1(2.8) | 1(2.8) | 27(75) |
| 12 | Suffers from headaches | 14(38.9) | 2(5.6) | 6(16.7) | 3(8.3) | 11(30.6) |
| 13 | Has many seizures | 1(2.8) | 0 | 4(11.1) | 0 | 31(86.1) |
| 14 | Needs help bathing | 10(27.8) | 0 | 2(5.6) | 0 | 24(66.7) |
| 15 | Needs help eating food | 6(16.7) | 0 | 2(5.6) | 0 | 28(77.8) |
tying shoe laces (58.3%), speaking (75%). Majority have reported that they had seizures (86.1%). Most of the patients has reported that they did not find it difficult to participate in sports (47.2%) and didn’t get tired easily (63.9%).
Table 5 shows that majority of the patients felt that they are being stared at in public (72.2%), solitary (52.8%), becomes anxious in social situations (52.8%) and shy in public (58.3%). More than three-fourth of the patients felt it difficult in expressing their feelings verbally (77.8%). Most of the patients have reported that they have not missed their job because of their illness (55.6%) and didn’t find it difficult in working with peers (47.2%). Half of the patients reported that they are not irritable (52.8%), neither stressed (50%) nor frustrated (52.8%).
Table 5: Patient’s QOL in social-emotional domain
N=36
| S.
No. |
My spouse/parent/sibling | Not at all true | A little true | Somewhat True | Quite a bit true | Very True |
| 1 | Has difficulty participating in social activities | 14(38.9) | 1(2.8) | 8(22.2) | 2(5.6) | 11(30.6) |
| 2 | Feels like he/she is being stared at in public | 6(16.7) | 0 | 3(8.3) | 1(2.8) | 26(72.2) |
| 3 | Has difficulty separating from spouse/parent | 13(36.1) | 1(2.8) | 4(11.1) | 1(2.8) | 17(47.2) |
| 4 | Has many friends | 7(19.4) | 7(19.4) | 5(13.9) | 1(2.8) | 16(44.4) |
| 5 | Is treated as an equal by his/her peers | 7(19.4) | 5(13.9) | 5(13.9) | 1(2.8) | 18(50) |
| 6 | Is able to visit his/her friends | 13(36.1) | 5(13.9) | 2(5.6) | 0 | 16(44.4) |
| 7 | Is solitary and keeps to him/herself | 9(25) | 0 | 6(16.7) | 2(5.6) | 19(52.8) |
| 8 | Has difficulty recognizing the consequences of his/her actions | 13(36.1) | 1(2.8) | 4(11.1) | 1(2.8) | 17(47.2) |
| 9 | Misses a lot of job due to illness | 20(55.6) | 0 | 4(11.1) | 1(2.8) | 11(30.6) |
| 10 | Gets anxious in social situations | 7(19.4) | 0 | 6(16.7) | 4(11.1) | 19(52.8) |
| 11 | Has difficulty getting along with his/her peers | 12(33.3) | 0 | 6(16.7) | 3(8.3) | 15(41.7) |
| 12 | Is shy in public | 7(19.4) | 1(2.8) | 4(11.1) | 3(8.3) | 21(58.3) |
| 13 | Has difficulty working with his/her peers | 17(47.2) | 0 | 7(19.4) | 2(5.6) | 10(27.8) |
| 14 | Is easily frustrated | 19(52.8) | 2(5.6) | 4(11.1) | 2(5.6) | 9(25) |
| 15 | Copes well with his/her disabilities | 8(22.2) | 0 | 11(30.6) | 4(11.1) | 13(36.1) |
| 16 | Has difficulty verbally expressing his/her feelings | 4(11.1) | 1(2.8) | 2(5.6) | 1(2.8) | 28(77.8) |
| 17 | Feels confident about him/herself | 14(38.9) | 1(2.8) | 7(19.4) | 1(2.8) | 13(36.1) |
| 18 | Often feels stressed | 18(50) | 2(5.6) | 3(8.3) | 4(11.1) | 9(25) |
| 19 | Is often irritable | 19(52.8) | 1(2.8) | 5(13.9) | 2(5.6) | 9(25) |
| 20 | Is unmotivated | 10(27.8) | 1(2.8) | 7(19.4) | 1(2.8) | 17(47.2) |
| 21 | Is concerned about his/her physical appearance | 12(33.3) | 0 | 6(16.7) | 2(5.6) | 16(44.4) |
| 22 | Often feels sad | 13(36.1) | 2(5.6) | 10(27.8) | 0 | 11(30.6) |
| 23 | Worries about the future | 17(47.2) | 3(8.3) | 6(16.7) | 1(2.8) | 9(25) |
| 24 | Is often restless | 16(44.4) | 4(11.1) | 5(13.9) | 1(2.8) | 10(27.8) |
| 25 | Lacks self confidence | 9(25) | 0 | 4(11.1) | 5(13.9) | 18(50) |
Table 6 shows that majority of the patients over reacted to other people’s illnesses (88.9%), had poor concept of time (69.4%), had difficulty in reading (66.7%) and was forgetting their daily routines (55.6%). Most of the patients had poor abstract thinking (44.4%), difficulty in performing several tasks in a row (47.2%).
Table 6: Patient’s QOL in cognitive domain
N=36
| S.
No. |
My spouse/parent/sibling | Not at all true | A little true | Somewhat True | Quite a bit true | Very True |
| 1 | Over reacts to other people’s illnesses | 1(2.8) | 0 | 2(5.6) | 1(2.8) | 32(88.9) |
| 2 | Has a poor concept of time | 10(27.8) | 0 | 1(2.8) | 0 | 25(69.4) |
| 3 | Has difficulty with calculation/abstract thinking | 16(44.4) | 4(11.1) | 2(5.6) | 0 | 14(38.9) |
| 4 | Is well organized | 12(33.3) | 3(8.3) | 6(16.7) | 1(2.8) | 14(38.9) |
| 5 | Has difficulty concentrating | 14(38.9) | 4(11.1) | 3(8.3) | 1(2.8) | 14(38.9) |
| 6 | Is forgetful | 15(41.7) | 2(5.6) | 4(11.1) | 0 | 15(41.7) |
| 7 | Has difficulty performing several tasks in a row | 17(47.2) | 1(2.8) | 7(19.4) | 1(2.8) | 10(27.8) |
| 8 | Has difficulty reading | 7(19.4) | 1(2.8) | 3(8.3) | 1(2.8) | 24(66.7) |
| 9 | Is a slow worker | 16(44.4) | 2(5.6) | 7(19.4) | 3(8.3) | 8(22.2) |
| 10 | Needs instructions repeated | 13(36.1) | 1(2.8) | 8(22.2) | 2(5.6) | 12(33.3) |
| 11 | Forgets his/her daily routines | 8(22.2) | 1(2.8) | 6(16.7) | 1(2.8) | 20(55.6) |
| 12 | Has difficulty in doing fine motor work | 15(41.7) | 2(5.6) | 6(16.7) | 2(5.6) | 11(30.6) |
| 13 | Has a short attention span | 12(33.3) | 1(2.8) | 4(11.1) | 2(5.6) | 17(47.2) |
Table 7 shows the QOL and mean converted score (to equalize the domains) of QOL based on HOQ of adult patients who had undergone VP shunt. The total QOL score was 0.57+ 0.26 out of one. Based on domain wise HOQ score, the score was highest in physical domain (0.65±0.29) followed by social-emotional domain (0.59±0.32) and cognitive domain (0.47±0.23).
Table 7: QOL among adult patients who had undergone VP shunt
N=36
|
QOL score |
HOQ | ||
| Converted score* Mean±SD | Actual Score Mean±SD | Maximum Possible Score (Range) | |
| Total QOL score | 0.57±0.26 | 122.50±55.99 | 0-212 |
| Physical | 0.65±0.29 | 39.25±17.80 | 0-60 |
| Social emotional | 0.59±0.32 | 59.33±32.16 | 0-100 |
| Cognitive | 0.47±0.23 | 24.36±12.04 | 0-52 |
*scoring is from 0-1
Association of QOL of adult patients who had undergone VP shunt with their demographic variables
The association of QOL of adults who had undergone VP shunt with their demographic variables is shown in table 8. Independent t-test and ANOVA was applied to find the association.
Table 8: Association of QOL of adult patients who had undergone VP shunt with their demographic variables
N=36
| Variable of patients who had undergone VP shunt | QOL score | ||
| Mean±SD | t/F value# (p value) | ||
| Age (years) | Young adults (18-25) | 106.62±60.15 | 0.69 (0.56) |
| Adulthood (25-40) | 123.06±55.45 | ||
| Middle age(40-60) | 124.0±59.56 | ||
| Old age(>60) | 162.33±48.80 | ||
| Gender | Male | 117.55±62.91 | – 0.56 (0.57) |
| Female | 128.33±50.61 | ||
| Educational status | Primary | 92.66±60.48 | 1.14 (0.33) |
| Secondary | 125.95±62.44 | ||
| Graduate & above | 136.11±32.29 | ||
| Marital status | Married | 117.60±58.35 | 0.81 (0.45) |
| Unmarried | 125.45±56.26 | ||
| Divorced/Widower | 170.50±6.36 | ||
| Occupational status | Employed | 161.50±35.24 | 4.18 (0.02*) |
| Unemployed | 100.78±51.22 | ||
| Housewife | 135.44±64.54 | ||
| Type of family | Nuclear | 115±51.60 | -1.96 (0.05) |
| Joint | 162.67±29.30 | ||
| Diagnosis | Low grade tumor HCP | 95.83±80.14 | 1.53 (0.21) |
| Traumatic HCP | 87.50±53.12 | ||
| Infective HCP | 129.60±38.86 | ||
| ACM/syrinx | 141.0±58.38 | ||
| Congenital HCP | 165.20±30.34 | ||
| Idiopathic HCP | 128.0±62.03 | ||
| No. of surgery | 1st surgery | 125.08±60.83 | 0.36(0.72) |
| Multiple surgery | 117.40±45.86 | ||
| Surgical intervention | Right VP shunt | 134.75±53.05 | 4.26(0.02*) |
| Left VP shunt | 66.83±44.90 | ||
| VP shunt & ETV | 117 | ||
| Duration after surgery | Less than 1year | 119.63±62.71 | 0.07 (0.9) |
| 1-6 year | 127.71±47.49 | ||
| 6-12 year | 121.66±74.92 | ||
| History of hospitalization | No | 124.56±86.90 | 0.38 (0.71) |
| Yes | 114.83±59.13 | ||
| Per capita income (Rs.) | Less than 2500/- | 99.38±48.90 | 4.07(0.02*) |
| 2500-5000/- | 158.75±33.25 | ||
| More than 5000/- | 136.70±67.77 | ||
| Duration of care required | Less than 4 | 169.55±29.89 | 34.74 |
| (hours/day) | 4-8 | 185.42±29.06 | (<0.001*) |
| More than 8 | 69.00±37.39 | ||
#Independent t test/ANOVA *significant at p-value <0.05
The mean QOL score was significantly higher among the employed patients and lowest among unemployed (p= 0.02). Adult patients who had undergone right VP shunt had the significantly higher mean QOL scoreas compared to patients undergone left VP shunt and VP shunt with endoscopic third ventriculostomy (ETV). QOL score was significantly lower in patients who required care more than eight hours per day (p<0.001). The mean QOL score was significantly lower among the patients whose caregiver had monthly income less than Rs.2500/- (p=0.02).
Discussion
VP shunt can be an effective palliative measure in HCP, but VP shunt malfunction places an individual at risk for potentially irreversible neurologic deficits and death, if not treated promptly. I t needs hospitalization which itself is disruptive to the patient and family which results into impaired QOL. Therefore, a cross sectional study was undertaken in which 36 adult patients who underwent VP shunt for hydrocephalus were enrolled to assess their common problems, QOL and factors influencing their QOL.
Mean age of the subjects in the present study was 35.89±14.39 years which was similar to the study8 conducted at neurosurgery clinics, whereas it was slightly higher upto 46.5 years in other studies and most of them were males9-11 . This contradictory finding could be due to increased rate of road side accidents (RSAs) occur in young age, that result in traumatic HCP or infective HCP13. Right VP shunt in the present study was performed in most of the patients. The commonest cases of hydrocephalus in adults include intracranial tumor, trauma and infection9,12. In present study, the main reasons for placing VP shunt were infective HCP, traumatic HCP and intracranial tumors.
The common problems experienced by 50 to 67% adults on VP shunt in our study were headache, generalized pain and weakness. The prevalence of post VP shunt headache is well reported and varies from 54 to 80%14. Though these symptoms are ignored by the parents and other caregivers, there are evidences to prove their effect on impaired functional status and disability10. Other problems experienced by 30 to 33% of adults included blurred vision, dizziness and only 03 to 11% of adults experienced seizure, fever, diplopia and speech difficulty. Previous reports of early shunt related symptoms included fever in 91.4% and seizures in 17 to 20% of the patients11. But in our study, fever was reported by only 06% of the patients and seizures by only 11% of the patients, as approximately 47% of the patients were of more than one year post shunt duration. The symptoms present in the patients after VP shunt could be due to existing underlying pathology, shunt malfunction, infection or most of the time remains unknown. The intensity, duration and frequency of these symptoms may also affect abstract thinking of the adults and fine motor activities. Headache associated with shunt results in poor QOL and it’s management increases the cost of treatment (Rekate et al 2009)15. Hydrocephalus outcome questionnaire used in present study is a simple, valid and reliable measure of quality of life in adults with hydrocephalus. Mean score of QOL of adults was 0.57±0.26 which While the physical symptoms are addressed during their follow up visits, these aspects remain overlooked due to inadequate reporting by the caregivers and lack of monitoring by health professionals. But was in line with previous reports16,17.HOQ Kutscher et al (2015)23 reported that the score reported in our study was same as that of patients who underwent ETV as first treatment and was lower than 0.72 in patients who underwent shunt as first treatment14,18.
Though VP shunt improves the health status of the patients post-operatively, the QOL remains affected due to various problems faced by the patients as shown in our study and related other literature14. There is also impairment in physical, socio- emotional and cognitive status of the patients as the QOL of patients in these domains is affected. Similar to previous reports19,20, cognitive domain was most affected in adults enrolled in our study that was followed by socio-emotional domain and physical domain. Therefore these areas need to be addressed and managed like physical manifestations, during post- surgical management of these patients. Considerable attention must be given to improve the cognitive and socio-emotional aspects as that can improve the performance in career of the adult, social functioning and their mental health. Compared to physical deficit, neuropsychological symptoms (Dhandapani et al 2016 and Sherwood et al)21 and cognitive deficits (Dhandapani et al)22 affect the burden and QOL of caregivers of patients suffering from intracranial tumors and other neurological illnesses. health-related quality of life of adult survivors of congenital HCP with regard to mental health and social functioning was similar to healthy controls, but physical impairment was the major factor that led to compromised QOL. Hence it is imperative to consider cognitive, socio-emotional and physical domain of patients undergone VP shunt. Impairment in cognitive dysfunction and behavioral changes are reported by patients with different neurological and neurosurgical diseases and are affected more than other domains (Dhandapani et al 2016,2017)24,25. These findings emphasize the need of team approach towards the holistic care of the patients undergone shunt.
Similar to previous reports26,27, QOL of adult was comparatively diminished in adults who are unemployed, underwent left VP shunt and required longer duration of care. The adults who underwent left VP shunt either due to shunt malfunctioning, complications or affected dominant area must have required longer and repeated hospital stay and longer duration of care by the caregivers. Similarly, due to multifactorial reasons, poor QOL is not only reported by patients undergone shunt, but the same is reported in many other neurological disorders28,29 . Hence, appropriate measures must be taken to improve the quality of life of children undergoing multiple surgeries for the treatment of hydrocephalus.
Present study has excluded the adults underwent shunt for hydrocephalus due to head trauma, stroke, hemorrhage and malignant tumor so as to eliminate the influence of these co-morbidities on QOL. Our findings suggest the monitoring of QOL of adults underwent VP shunt during their follow up in terms of cognitive, socio- emotional and physical aspects. Adults and their caregivers must be trained and instructed to identify and report various problems in different domains to the health care team so that appropriate interventions can be initiated. A protocol can be prepared regarding care and rehabilitation for adults who had undergone VP shunt and health care team can be made more sensitive towards the assessment of the domains of QOL and providing care accordingly. Special attention must be emphasized to these adults by the parents and professional collegues/authorities to reduce the difficulties at job/workplace by helping them to overcome their cognitive deficits. Findings of the present study also suggest the importance of long term follow up of adults in terms of their professional performance, abstract thinking, motor skills etc.
A protocol can be prepared regarding care and rehabilitation for adults who had undergone VP shunt and health care team can be made more sensitive towards the assessment of the domains of QOL and providing care accordingly. Findings of the present study also suggest the importance of long term follow up of adults in terms of their practical performance, QOL etc.
The study concluded that patients who had undergone VP shunt face various health related problems in different domains and low QOL, where cognitive domain of QOL was most affected. Hence appropriate nurse led interventions and holistic management is essential to improve the QOL of patients who had undergone VP shunt. The study can be useful by instructing patients to report various problems in different domains to the health care team so that appropriate interventions can be taken. Also, by educating the caregivers to identify problems and how they can manage those problems.
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