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Sasannejad C, Ely EW, Lahiri S. Long-term cognitive impairment after acute respiratory distress syndrome: a review of clinical impact and pathophysiological mechanisms. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:352. [PMID: 31718695 PMCID: PMC6852966 DOI: 10.1186/s13054-019-2626-z] [Citation(s) in RCA: 196] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/27/2019] [Indexed: 02/06/2023]
Abstract
Acute respiratory distress syndrome (ARDS) survivors experience a high prevalence of cognitive impairment with concomitantly impaired functional status and quality of life, often persisting months after hospital discharge. In this review, we explore the pathophysiological mechanisms underlying cognitive impairment following ARDS, the interrelations between mechanisms and risk factors, and interventions that may mitigate the risk of cognitive impairment. Risk factors for cognitive decline following ARDS include pre-existing cognitive impairment, neurological injury, delirium, mechanical ventilation, prolonged exposure to sedating medications, sepsis, systemic inflammation, and environmental factors in the intensive care unit, which can co-occur synergistically in various combinations. Detection and characterization of pre-existing cognitive impairment imparts challenges in clinical management and longitudinal outcome study enrollment. Patients with brain injury who experience ARDS constitute a distinct population with a particular combination of risk factors and pathophysiological mechanisms: considerations raised by brain injury include neurogenic pulmonary edema, differences in sympathetic activation and cholinergic transmission, effects of positive end-expiratory pressure on cerebral microcirculation and intracranial pressure, and sensitivity to vasopressor use and volume status. The blood-brain barrier represents a physiological interface at which multiple mechanisms of cognitive impairment interact, as acute blood-brain barrier weakening from mechanical ventilation and systemic inflammation can compound existing chronic blood-brain barrier dysfunction from Alzheimer’s-type pathophysiology, rendering the brain vulnerable to both amyloid-beta accumulation and cytokine-mediated hippocampal damage. Although some contributory elements, such as the presenting brain injury or pre-existing cognitive impairment, may be irreversible, interventions such as minimizing mechanical ventilation tidal volume, minimizing duration of exposure to sedating medications, maintaining hemodynamic stability, optimizing fluid balance, and implementing bundles to enhance patient care help dramatically to reduce duration of delirium and may help prevent acquisition of long-term cognitive impairment.
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Affiliation(s)
- Cina Sasannejad
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, Survivorship (CIBS) Center, Department of Pulmonary and Critical Care Medicine, Veteran's Affairs Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Shouri Lahiri
- Division of Neurocritical Care, Department of Neurology, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, AHSP Building, Suite A6600, A8103, Los Angeles, CA, 90048, USA. .,Division of Neurocritical Care, Department of Neurosurgery, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, AHSP Building, Suite A6600, A8103, Los Angeles, CA, 90048, USA. .,Division of Neurocritical Care, Department of Biomedical Sciences, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, AHSP Building, Suite A6600, A8103, Los Angeles, CA, 90048, USA.
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Murtaj V, Belloli S, Di Grigoli G, Pannese M, Ballarini E, Rodriguez-Menendez V, Marmiroli P, Cappelli A, Masiello V, Monterisi C, Bellelli G, Panina-Bordignon P, Moresco RM. Age and Sex Influence the Neuro-inflammatory Response to a Peripheral Acute LPS Challenge. Front Aging Neurosci 2019; 11:299. [PMID: 31749696 PMCID: PMC6848890 DOI: 10.3389/fnagi.2019.00299] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/17/2019] [Indexed: 12/21/2022] Open
Abstract
Aging is associated with an exaggerated response to peripheral inflammatory challenges together with behavioral and cognitive deficits. Studies considering both age and sex remain limited, despite sex dimorphism of astrocytes and microglial cells is largely recognized. To fill this knowledge gap, we investigated the effect of a single intraperitoneal lipopolysaccharide (LPS) administration in adult and aged mice. We assessed the expression of different inflammatory mediators, and the microglial response through binding of [18F]-VC701 tracer to translocator protein (TSPO) receptors in the male and female brain. Aged female brain showed a higher pro-inflammatory response to LPS compared to adult female and to aged male, as revealed by ex vivo binding to TSPO receptors and pro-inflammatory mediator transcript levels. The highest astroglial reaction was observed in the brain of aged females. Differently to the other groups of animals, in aged males LPS challenge did not affect transcription of triggering receptor expressed on myeloid cells 2 (TREM2). In conclusion, our study shows that in the mouse’s brain the neuro-inflammatory response to an acute peripheral insult is sex- and age-dependent. Moreover, our results might set the basis for further studies aimed at identifying sex-related targets involved in the modulation of the aberrant neuro-inflammatory response that characterizes aging. This knowledge could be relevant for the treatment of conditions such as delirium and dementia.
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Affiliation(s)
- Valentina Murtaj
- PhD Program in Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,PET and Nuclear Medicine Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Sara Belloli
- PET and Nuclear Medicine Unit, San Raffaele Scientific Institute, Milan, Italy.,Institute of Molecular Bioimaging and Physiology of National Reasearch Council, Segrate, Italy
| | - Giuseppe Di Grigoli
- PET and Nuclear Medicine Unit, San Raffaele Scientific Institute, Milan, Italy.,Institute of Molecular Bioimaging and Physiology of National Reasearch Council, Segrate, Italy
| | - Maria Pannese
- Neuroimmunology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisa Ballarini
- Milan Center for Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Medicine and Surgery, Tecnomed Foundation, University of Milano-Bicocca, Monza, Italy
| | - Virginia Rodriguez-Menendez
- Milan Center for Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Medicine and Surgery, Tecnomed Foundation, University of Milano-Bicocca, Monza, Italy
| | - Paola Marmiroli
- Milan Center for Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Medicine and Surgery, Tecnomed Foundation, University of Milano-Bicocca, Monza, Italy
| | - Andrea Cappelli
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
| | - Valeria Masiello
- PET and Nuclear Medicine Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Monterisi
- Department of Medicine and Surgery, Tecnomed Foundation, University of Milano-Bicocca, Monza, Italy
| | - Giuseppe Bellelli
- Acute Geriatric Unit, School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Paola Panina-Bordignon
- Neuroimmunology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine and Surgery, San Raffaele Vita-Salute University, Milan, Italy
| | - Rosa Maria Moresco
- PET and Nuclear Medicine Unit, San Raffaele Scientific Institute, Milan, Italy.,Department of Medicine and Surgery, Tecnomed Foundation, University of Milano-Bicocca, Monza, Italy
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53
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Slor CJ, Witlox J, Adamis D, Jansen RWMM, Houdijk APJ, van Gool WA, de Jonghe JFM, Eikelenboom P. The trajectory of C-reactive protein serum levels in older hip fracture patients with postoperative delirium. Int J Geriatr Psychiatry 2019; 34:1438-1446. [PMID: 31058343 DOI: 10.1002/gps.5139] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 04/29/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Important precipitating risk factors for delirium such as infections, vascular disorders, and surgery are accompanied by a systemic inflammatory response. Systemic inflammatory mediators can induce delirium in susceptible individuals. Little is known about the trajectory of systemic inflammatory markers and their role in the development and outcome of delirium. METHODS This is a prospective cohort study of older patients undergoing acute surgery for hip fracture. Baseline characteristics were assessed preoperatively. During hospital admission, presence of delirium was assessed daily according to the Confusion Assessment Method criteria. This study compared the trajectory of serum levels of the C-reactive protein (CRP) between people with and without postoperative delirium. Blood samples were taken at baseline and at postoperative day 1 through postoperative day 5. RESULTS Forty-one out of 121 patients developed postoperative delirium after hip fracture surgery. Longitudinal analysis of the trajectory of serum CRP levels using the Generalized Estimating Equations (GEE) method identified that higher CRP levels were associated with postoperative delirium. CRP levels were higher from postoperative day 2 through postoperative day 5. No significant differences in serum CRP levels were found when we compared patients with short (1-2 days) and more prolonged delirium (3 days or more). CONCLUSIONS Delirium is associated with an increased systemic inflammatory response, and our results suggest that CRP plays a role in the underlying (inflammatory-vascular) pathological pathway of postoperative delirium.
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Affiliation(s)
- Chantal J Slor
- Department of Geriatric Medicine, NoordWest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Joost Witlox
- Department of Geriatric Medicine, NoordWest Ziekenhuisgroep, Alkmaar, The Netherlands
- Psychogeriatric Observation Unit, Institution for Mental Health Care, Dijk en Duin (Parnassia Groep), Castricum, The Netherlands
| | - Dimitrios Adamis
- Department of Psychiatry, Sligo Mental Health Services, Sligo, Ireland
- Department of Psychiatry, Research and Academic Institute of Athens, Athens, Greece
| | - Rene W M M Jansen
- Department of Geriatric Medicine, NoordWest Ziekenhuisgroep, Alkmaar, The Netherlands
| | | | - Willem A van Gool
- Psychogeriatric Observation Unit, Institution for Mental Health Care, Dijk en Duin (Parnassia Groep), Castricum, The Netherlands
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jos F M de Jonghe
- Department of Geriatric Medicine, NoordWest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Piet Eikelenboom
- Department of Psychiatry, GGZinGeest and VuMC, Amsterdam, The Netherlands
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54
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Westhoff D, Engelen-Lee JY, Hoogland ICM, Aronica EMA, van Westerloo DJ, van de Beek D, van Gool WA. Systemic infection and microglia activation: a prospective postmortem study in sepsis patients. Immun Ageing 2019; 16:18. [PMID: 31384283 PMCID: PMC6664744 DOI: 10.1186/s12979-019-0158-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 07/17/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Systemic infection is associated with long-term cognitive deficits and functional decline. In this study we hypothesized that severe systemic inflammation leads to a neuroinflammatory response that is characterized by microglial activation, and that these effects might be more pronounced in patients using medication with anticholinergic side-effects. METHODS Based on the results of a pilot study in 8 patients, we assessed the number of MHC-II and CD-68 positive cells by immunohistochemistry and compared the number of microglia in specific brain regions of 16 well-characterized patients with septic shock and 15 controls. RESULTS In the pilot study, patients with sepsis tended to have higher density of MHC-II and CD-68 positive microglia in the basal ganglia (putamen, caudate nucleus and globus pallidus) and of MHC-II positive microglia in the hippocampus. In the validation study, patients with sepsis had a significantly higher number of CD-68 positive cells in hippocampus (1.5 fold; p = 0.012), putamen (2.2 fold; p = 0.008) and cerebellum (2.5 fold; p = 0.011) than control patients. The density of MHC-II positive microglia was similar between sepsis and control groups. There was no consistent correlation between microglia counts and anti-cholinergic activity drugs score. CONCLUSION In patients who die during septic shock, severe systemic inflammation is accompanied by localized and strong upregulation of CD-68 positive microglia, but not of MHC-II positive microglia. We identified regional differences in the brain with increased microglial activation in putamen, hippocampus and cerebellum.
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Affiliation(s)
- D. Westhoff
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - J. Y. Engelen-Lee
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - I. C. M. Hoogland
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - E. M. A. Aronica
- Department of Neuropathology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - D. J. van Westerloo
- Department of Intensive Care medicine, Leiden University Medical Center, Leiden, Netherlands
| | - D. van de Beek
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - W. A. van Gool
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
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Tsui A, Richards M, Davis D. Systemic inflammation and modifiable risk factors for cognitive impairment in older persons: Findings from a British birth cohort. Aging Med (Milton) 2019; 1:243-248. [PMID: 31328177 PMCID: PMC6640037 DOI: 10.1002/agm2.12044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Serum pro‐inflammatory markers may contribute to dementia pathophysiology and cognitive impairment. In a population‐representative birth cohort, serum C‐reactive protein (CRP), interleukin‐6 (IL‐6), and white cell count (WCC) were measured at age 60‐64 years and cognition was assessed using the Addenbrooke's Cognitive Examination (ACE‐III) at age 69 years. Higher baseline CRP and IL‐6 were associated with lower ACE‐III scores, but associations were attenuated on adjustment for educational attainment, sex, and other modifiable life course factors. No associations were found for CRP, IL‐6, and WCC with visual search speed or verbal memory. In conclusion, the relationship between increased baseline systemic inflammation and poorer cognition in later life may be explained by, or share pathways with, education and other modifiable life course factors.
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Affiliation(s)
- Alex Tsui
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
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56
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Rengel KF, Pandharipande PP, Hughes CG. Special Considerations for the Aging Brain and Perioperative Neurocognitive Dysfunction. Anesthesiol Clin 2019; 37:521-536. [PMID: 31337482 DOI: 10.1016/j.anclin.2019.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Postoperative delirium and postoperative cognitive dysfunction (POCD) occur commonly in older adults after surgery and are frequently underrecognized. Delirium has been associated with worse outcomes, and both delirium and cognitive dysfunction increase the risk of long-term cognitive decline. Although the pathophysiology of delirium and POCD have not been clearly defined, risk factors for both include increasing age, lower levels of education, and baseline cognitive impairment. In addition, developing delirium increases the risk of POCD. This article examines interventions that may reduce the risk of developing delirium and POCD and improve long-term recovery and outcomes in the vulnerable older population.
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Affiliation(s)
- Kimberly F Rengel
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA.
| | - Pratik P Pandharipande
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
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57
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Halaas NB, Blennow K, Idland AV, Wyller TB, Ræder J, Frihagen F, Staff AC, Zetterberg H, Watne LO. Neurofilament Light in Serum and Cerebrospinal Fluid of Hip Fracture Patients with Delirium. Dement Geriatr Cogn Disord 2019; 46:346-357. [PMID: 30522125 DOI: 10.1159/000494754] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/22/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Delirium is associated with new-onset dementia, suggesting that delirium pathophysiology involves neuronal injury. Neurofilament light (NFL) is a sensitive biomarker for neuroaxonal injury. METHODS NFL was measured in cerebrospinal fluid (CSF) (n = 130), preoperative serum (n = 192), and postoperative serum (n = 280) in hip fracture patients, and in CSF (n = 123) and preoperative serum (n = 134) in cognitively normal older adults undergoing elective surgery. Delirium was diagnosed with the Confusion Assessment Method. RESULTS Median serum NFL (pg/mL) was elevated in delirium in hip fracture patients (94 vs. 54 pre- and 135 vs. 92 postoperatively, both p < 0.001). Median CSF NFL tended to be higher in hip fracture patients with delirium (1,804 vs. 1,636, p = 0.074). Serum and CSF NFL were positively correlated (ρ = 0.56, p < 0.001). CONCLUSION Our findings support an association between neuroaxonal injury and delirium. The correlation between serum and CSF NFL supports the use of NFL as a blood biomarker in future delirium studies.
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Affiliation(s)
- Nathalie Bodd Halaas
- Oslo Delirium Research Group, Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway, .,Research Group for Lifespan Changes in Brain and Cognition, Department of Psychology, University of Oslo, Oslo, Norway,
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Ane-Victoria Idland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Johan Ræder
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Anne Cathrine Staff
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, United Kingdom.,UK Dementia Research Institute at UCL, London, United Kingdom
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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59
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Acute transient cognitive dysfunction and acute brain injury induced by systemic inflammation occur by dissociable IL-1-dependent mechanisms. Mol Psychiatry 2019; 24:1533-1548. [PMID: 29875474 PMCID: PMC6510649 DOI: 10.1038/s41380-018-0075-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 02/12/2018] [Accepted: 04/03/2018] [Indexed: 01/06/2023]
Abstract
Systemic inflammation can impair cognition with relevance to dementia, delirium and post-operative cognitive dysfunction. Episodes of delirium also contribute to rates of long-term cognitive decline, implying that these acute events induce injury. Whether systemic inflammation-induced acute dysfunction and acute brain injury occur by overlapping or discrete mechanisms remains unexplored. Here we show that systemic inflammation, induced by bacterial LPS, produces both working-memory deficits and acute brain injury in the degenerating brain and that these occur by dissociable IL-1-dependent processes. In normal C57BL/6 mice, LPS (100 µg/kg) did not affect working memory but impaired long-term memory consolidation. However prior hippocampal synaptic loss left mice selectively vulnerable to LPS-induced working memory deficits. Systemically administered IL-1 receptor antagonist (IL-1RA) was protective against, and systemic IL-1β replicated, these working memory deficits. Dexamethasone abolished systemic cytokine synthesis and was protective against working memory deficits, without blocking brain IL-1β synthesis. Direct application of IL-1β to ex vivo hippocampal slices induced non-synaptic depolarisation and irreversible loss of membrane potential in CA1 neurons from diseased animals and systemic LPS increased apoptosis in the degenerating brain, in an IL-1RI-dependent fashion. The data suggest that LPS induces working memory dysfunction via circulating IL-1β but direct hippocampal action of IL-1β causes neuronal dysfunction and may drive neuronal death. The data suggest that acute systemic inflammation produces both reversible cognitive deficits, resembling delirium, and acute brain injury contributing to long-term cognitive impairment but that these events are mechanistically dissociable. These data have significant implications for management of cognitive dysfunction during acute illness.
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Morris G, Berk M, Maes M, Puri BK. Could Alzheimer's Disease Originate in the Periphery and If So How So? Mol Neurobiol 2019; 56:406-434. [PMID: 29705945 PMCID: PMC6372984 DOI: 10.1007/s12035-018-1092-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 04/17/2018] [Indexed: 12/11/2022]
Abstract
The classical amyloid cascade model for Alzheimer's disease (AD) has been challenged by several findings. Here, an alternative molecular neurobiological model is proposed. It is shown that the presence of the APOE ε4 allele, altered miRNA expression and epigenetic dysregulation in the promoter region and exon 1 of TREM2, as well as ANK1 hypermethylation and altered levels of histone post-translational methylation leading to increased transcription of TNFA, could variously explain increased levels of peripheral and central inflammation found in AD. In particular, as a result of increased activity of triggering receptor expressed on myeloid cells 2 (TREM-2), the presence of the apolipoprotein E4 (ApoE4) isoform, and changes in ANK1 expression, with subsequent changes in miR-486 leading to altered levels of protein kinase B (Akt), mechanistic (previously mammalian) target of rapamycin (mTOR) and signal transducer and activator of transcription 3 (STAT3), all of which play major roles in microglial activation, proliferation and survival, there is activation of microglia, leading to the subsequent (further) production of cytokines, chemokines, nitric oxide, prostaglandins, reactive oxygen species, inducible nitric oxide synthase and cyclooxygenase-2, and other mediators of inflammation and neurotoxicity. These changes are associated with the development of amyloid and tau pathology, mitochondrial dysfunction (including impaired activity of the electron transport chain, depleted basal mitochondrial potential and oxidative damage to key tricarboxylic acid enzymes), synaptic dysfunction, altered glycogen synthase kinase-3 (GSK-3) activity, mTOR activation, impairment of autophagy, compromised ubiquitin-proteasome system, iron dyshomeostasis, changes in APP translation, amyloid plaque formation, tau hyperphosphorylation and neurofibrillary tangle formation.
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Affiliation(s)
- Gerwyn Morris
- IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, P.O. Box 291, Geelong, Victoria, Australia
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, P.O. Box 291, Geelong, Victoria, Australia
- Department of Psychiatry, Level 1 North, Main Block, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute for Neuroscience and Mental Health, Kenneth Myer Building, University of Melbourne, 30 Royal Parade, Parkville, Victoria, Australia
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Victoria, Australia
| | - Michael Maes
- IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, P.O. Box 291, Geelong, Victoria, Australia
- Department of Psychiatry, Chulalongkorn University, Bangkok, Thailand
| | - Basant K Puri
- Department of Medicine, Hammersmith Hospital, Imperial College London, London, UK.
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61
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Bennett JM, Reeves G, Billman GE, Sturmberg JP. Inflammation-Nature's Way to Efficiently Respond to All Types of Challenges: Implications for Understanding and Managing "the Epidemic" of Chronic Diseases. Front Med (Lausanne) 2018; 5:316. [PMID: 30538987 PMCID: PMC6277637 DOI: 10.3389/fmed.2018.00316] [Citation(s) in RCA: 211] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/23/2018] [Indexed: 01/06/2023] Open
Abstract
Siloed or singular system approach to disease management is common practice, developing out of traditional medical school education. Textbooks of medicine describe a huge number of discrete diseases, usually in a systematic fashion following headings like etiology, pathology, investigations, differential diagnoses, and management. This approach suggests that the body has a multitude of ways to respond to harmful incidences. However, physiology and systems biology provide evidence that there is a simple mechanism behind this phenotypical variability. Regardless if an injury or change was caused by trauma, infection, non-communicable disease, autoimmune disorders, or stress, the typical physiological response is: an increase in blood supply to the area, an increase in white cells into the affected tissue, an increase in phagocytic activity to remove the offending agent, followed by a down-regulation of these mechanisms resulting in healing. The cascade of inflammation is the body's unique mechanism to maintain its integrity in response to macroscopic as well as microscopic injuries. We hypothesize that chronic disease development and progression are linked to uncontrolled or dysfunctional inflammation to injuries regardless of their nature, physical, environmental, or psychological. Thus, we aim to reframe the prevailing approach of management of individual diseases into a more integrated systemic approach of treating the "person as a whole," enhancing the patient experience, ability to a make necessary changes, and maximize overall health and well-being. The first part of the paper reviews the local immune cascades of pro- and anti-inflammatory regulation and the interconnected feedback loops with neural and psychological pathways. The second part emphasizes one of nature's principles at work-system design and efficiency. Continually overwhelming this finely tuned system will result in systemic inflammation allowing chronic diseases to emerge; the pathways of several common conditions are described in detail. The final part of the paper considers the implications of these understandings for clinical care and explore how this lens could shape the physician-patient encounter and health system redesign. We conclude that healthcare professionals must advocate for an anti-inflammatory lifestyle at the patient level as well as at the local and national levels to enhance population health and well-being.
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Affiliation(s)
- Jeanette M. Bennett
- Department of Psychological Science, StressWAVES Biobehavioral Research Lab, The University of North Carolina at Charlotte, Charlotte, NC, United States
| | - Glenn Reeves
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - George E. Billman
- Department of Physiology and Cell Biology, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, United States
| | - Joachim P. Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
- Foundation President, International Society for Systems and Complexity Sciences for Health, Delaware, United States
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Meagher D, Agar MR, Teodorczuk A. Debate article: Antipsychotic medications are clinically useful for the treatment of delirium. Int J Geriatr Psychiatry 2018; 33:1420-1427. [PMID: 28758323 DOI: 10.1002/gps.4759] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/01/2017] [Indexed: 11/05/2022]
Abstract
Prescribing of antipsychotic medications for patients with delirium remains controversial. Concerns exist that these vulnerable and frail patients may be prescribed antipsychotics inappropriately as a substitute for non-pharmacological approaches when identifiable causes are not found or they challenge ward processes. Moreover, recent evidence suggests that antipsychotics may cause more harm than good in the palliative care patient group with delirium. On the other hand, guidelines in the United Kingdom and the Netherlands support prescribing of antipsychotics in certain circumstances, and a large European survey has revealed that antipsychotics tend to be prescribed first line for hyperactive delirium. Never before, therefore, is there a greater need to examine whether indeed these medications are clinically useful for the treatment of delirium. With this in mind, evidence-based arguments for and against prescribing antipsychotics for the treatment of delirium are presented in this debate article. The paper concludes with a moderation piece to help guide clinical practice.
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Affiliation(s)
- David Meagher
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Ireland
| | - Meera R Agar
- Faculty of Health, University of Technology Sydney, New South Wales, Australia.,South West Sydney Clinical School, University of New South Wales, New South Wales, Australia.,Ingham Institute of Applied Medical Research, New South Wales, Australia.,Discipline, Palliative and Supportive Services, Flinders University, South Australia, Australia
| | - Andrew Teodorczuk
- School of Medicine, Griffith University, Gold Coast, Australia.,Health Institute for the Development of Education and Scholarship (Health IDEAS), Griffith University, Queensland, Australia
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Hall RJ, Watne LO, Cunningham E, Zetterberg H, Shenkin SD, Wyller TB, MacLullich AMJ. CSF biomarkers in delirium: a systematic review. Int J Geriatr Psychiatry 2018; 33:1479-1500. [PMID: 28585290 DOI: 10.1002/gps.4720] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/16/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In recent years, there has been a blossoming of studies examining cerebrospinal fluid (CSF) as a method of studying the pathophysiology of delirium. We systematically reviewed the literature for CSF studies in delirium and provide here a summary of the implications for our understanding of delirium pathophysiology. We also summarise the methods used for CSF analysis and discuss challenges and implications for future studies. METHODS In this systematic review, we screened MEDLINE, EMBASE, PsycINFO, Web of Science, PubMed and the Cochrane Library for articles on CSF biomarkers in delirium, published on 3 September 2016. Studies were required to use Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria for delirium or a validated tool. We excluded case reports. There were no other restrictions on study type. RESULTS We identified 3280 articles from our initial search, and 22 articles were included in this review. All studies were prospective, including over 400 patients with delirium and 700 controls. More than 70 different biomarkers were studied. Studies could not be compared with each other for meta-analysis because of their heterogeneity and varied widely in their risk of bias and quality assessments. CONCLUSIONS The 22 studies identified in this review reveal a small but growing literature, in which many of the important hypotheses in delirium pathogenesis have been examined, but from which few firm conclusions can currently be drawn. Nevertheless, the overall interpretation of the literature supports the vulnerable brain concept, that is, that biomarker evidence of, for example, Alzheimer's disease pathology and/or neuroinflammation, is associated with delirium.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Emma Cunningham
- Centre for Public Health, Queen's University of Belfast, Belfast, Ireland
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Susan D Shenkin
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
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Bellelli G, Zambon A, Volpato S, Abete P, Bianchi L, Bo M, Cherubini A, Corica F, Di Bari M, Maggio M, Manca GM, Rizzo MR, Rossi A, Landi F, Brombo G, Ortolani B, Savino E, Maietti E, Fisichella A, Buttò V, Zamboni M, Caliari C, Ferrari E, Orso F, Sacco F, Di Meo ML, Pittella F, Motta M, Massariello F, Fusco S, Schepisi R, Ferro C, Marchese L, Agosta L, Basile C, Coppola C, Dalise AM, Fava I, Catte O, Orru M, Salaris P, Martone AM, Ortolani E, Salini S, dell'Aquila G, Carrieri B. The association between delirium and sarcopenia in older adult patients admitted to acute geriatrics units: Results from the GLISTEN multicenter observational study. Clin Nutr 2018; 37:1498-1504. [DOI: 10.1016/j.clnu.2017.08.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 07/24/2017] [Accepted: 08/30/2017] [Indexed: 12/25/2022]
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Clark IA, Vissel B. The Inflammatory Nature of Post-surgical Delirium Predicts Benefit of Agents With Anti-TNF Effects, Such as Dexmedetomidine. Front Neurosci 2018; 12:257. [PMID: 29725287 PMCID: PMC5917006 DOI: 10.3389/fnins.2018.00257] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 04/03/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Ian A Clark
- Biomedical Sciences and Biochemistry, Research School of Biology, Australian National University, Canberra, ACT, Australia
| | - Bryce Vissel
- Centre for Neuroscience and Regenerative Medicine, Faculty of Science, University of Technology, Sydney, NSW, Australia.,St. Vincent's Centre for Applied Medical Research (AMR), Sydney, NSW, Australia
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Reduced ex vivo release of pro-inflammatory cytokines and elevated plasma interleukin-6 are inflammatory signatures of post-stroke delirium. J Neuroinflammation 2018; 15:111. [PMID: 29669581 PMCID: PMC5907192 DOI: 10.1186/s12974-018-1156-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/09/2018] [Indexed: 11/10/2022] Open
Abstract
Background Experimental studies suggest that systemic inflammation contributes to the pathophysiology of delirium. The aim of our study was to determine blood-derived inflammatory signatures of post-stroke delirium. Methods We included 144 ischemic stroke patients. We assessed delirium on a daily basis during the first 7 days of hospitalization. Venous blood was collected at day 3 after the onset of stroke and stimulated ex vivo with lipopolysaccharide (LPS). We measured LPS-induced cytokine concentration (TNFα, IP-10, IL-1β, IL-6, IL-8, IL-10, and IL-12p70) as well as plasma levels of IL-6 and TNFα. Results Delirium was diagnosed in 21.5% of patients. After correction for monocyte count, patients with delirium had reduced LPS-induced TNFα, IP-10, IL-1β, IL-6, and IL-12 release. The plasma IL-6 level was higher in delirious patients compared to patients without delirium. After adjusting for stroke severity and infections, higher ex vivo TNFα (OR 0.29, 95%CI 0.11–0.72, P = 0.01), IP-10 (OR 0.25, 95%CI 0.08–0.73, P = 0.01), IL-1β (OR 0.42, 95%CI 0.20–0.89, P = 0.02), and IL-12 (OR 0.07, 95%CI 0.01–0.70, P = 0.02) release was associated with the reduced risk of delirium. In multivariate analysis, the higher plasma IL-6 was associated with the increased risk of delirium (OR 1.61, 95%CI 1.00–2.58, P = 0.04). Conclusions Reduced ex vivo release of pro-inflammatory cytokines after LPS stimulation and the elevated plasma IL-6 are signatures of post-stroke delirium.
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Abstract
The blood-brain interface (BBI) is the subject of a new named series at Brain, Behavior, and Immunity. It is timely to reflect on a number of advances in the field within the last ten years, which may lead to an increased understanding of human behaviour and a wide range of psychiatric and neurological conditions. We cover discoveries made in solute and cell trafficking, endothelial cell and pericyte biology, extracellular matrix and emerging tools, especially those which will enable study of the human BBI. We now recognize the central role of the BBI in a number of immunopsychiatric syndromes, including sickness behaviour, delirium, septic encephalopathy, cognitive side effects of cytokine-based therapies and the frank psychosis observed in neuronal surface antibody syndromes. In addition, we find ourselves interrogating and modulating the brain across the BBI, during diagnostic investigation and treatment of brain disease. The past ten years of BBI research have been exciting but there is more to come.
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69
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The association between plasma endotoxin, endotoxin pathway proteins and outcome after ischemic stroke. Atherosclerosis 2018; 269:138-143. [DOI: 10.1016/j.atherosclerosis.2017.12.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 12/14/2017] [Accepted: 12/22/2017] [Indexed: 11/21/2022]
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Rolandi E, Cavedo E, Pievani M, Galluzzi S, Ribaldi F, Buckley C, Cunningham C, Guerra UP, Musarra M, Morzenti S, Magnaldi S, Patassini M, Terragnoli F, Matascioli L, Franzoni S, Annoni G, Carnevali L, Bellelli G, Frisoni GB. Association of postoperative delirium with markers of neurodegeneration and brain amyloidosis: a pilot study. Neurobiol Aging 2018; 61:93-101. [DOI: 10.1016/j.neurobiolaging.2017.09.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 09/17/2017] [Accepted: 09/19/2017] [Indexed: 02/09/2023]
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Clark IA, Vissel B. The meteorology of cytokine storms, and the clinical usefulness of this knowledge. Semin Immunopathol 2017; 39:505-516. [PMID: 28451786 PMCID: PMC5495849 DOI: 10.1007/s00281-017-0628-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/10/2017] [Indexed: 01/07/2023]
Abstract
The term cytokine storm has become a popular descriptor of the dramatic harmful consequences of the rapid release of polypeptide mediators, or cytokines, that generate inflammatory responses. This occurs throughout the body in both non-infectious and infectious disease states, including the central nervous system. In infectious disease it has become a useful concept through which to appreciate that most infectious disease is not caused directly by a pathogen, but by an overexuberant innate immune response by the host to its presence. It is less widely known that in addition to these roles in disease pathogenesis these same cytokines are also the basis of innate immunity, and in lower concentrations have many essential physiological roles. Here we update this field, including what can be learned through the history of how these interlinking three aspects of biology and disease came to be appreciated. We argue that understanding cytokine storms in their various degrees of acuteness, severity and persistence is essential in order to grasp the pathophysiology of many diseases, and thus the basis of newer therapeutic approaches to treating them. This particularly applies to the neurodegenerative diseases.
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Affiliation(s)
- Ian A Clark
- Research School of Biology, Australian National University, Canberra, Australia.
| | - Bryce Vissel
- School of Life Sciences, Faculty of Science, University of Technology, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
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Schreuder L, Eggen BJ, Biber K, Schoemaker RG, Laman JD, de Rooij SE. Pathophysiological and behavioral effects of systemic inflammation in aged and diseased rodents with relevance to delirium: A systematic review. Brain Behav Immun 2017; 62:362-381. [PMID: 28088641 DOI: 10.1016/j.bbi.2017.01.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 12/26/2016] [Accepted: 01/10/2017] [Indexed: 01/20/2023] Open
Abstract
Delirium is a frequent outcome for aged and demented patients that suffer a systemic inflammatory insult. Animal models that reconstruct these etiological processes have potential to provide a better understanding of the pathophysiology of delirium. Therefore, we systematically reviewed animal studies in which systemic inflammation was superimposed on aged or diseased animal models. In total, 77 studies were identified. Aged animals were challenged with a bacterial endotoxin in 29 studies, 25 studies superimposed surgery on aged animals, and in 6 studies a bacterial infection, Escherichia coli (E. coli), was used. Diseased animals were challenged with a bacterial endotoxin in 15 studies, two studies examined effects of the cytokine IL-1β, and one study used polyinosinic:polycytidilic acid (poly I:C). This systematic review analyzed the impact of systemic inflammation on the production of inflammatory and neurotoxic mediators in peripheral blood, cerebrospinal fluid (CSF), and on the central nervous system (CNS). Moreover, concomitant behavioral and cognitive symptoms were also evaluated. Finally, outcomes of behavioral and cognitive tests from animal studies were compared to features and symptoms present in delirious patients.
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Affiliation(s)
- Leroy Schreuder
- University of Groningen, University Medical Center Groningen, University Center for Geriatric Medicine, Groningen, The Netherlands.
| | - B J Eggen
- Department of Neuroscience, Section Medical Physiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Knut Biber
- Department of Neuroscience, Section Medical Physiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Psychiatry and Psychotherapy, Section of Molecular Psychiatry, University of Freiburg, Freiburg, Germany.
| | - Regien G Schoemaker
- Department of Neurobiology, GELIFES, University of Groningen, Groningen, The Netherlands.
| | - Jon D Laman
- Department of Neuroscience, Section Medical Physiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Sophia E de Rooij
- University of Groningen, University Medical Center Groningen, University Center for Geriatric Medicine, Groningen, The Netherlands.
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Chang A, Fox SH. Psychosis in Parkinson's Disease: Epidemiology, Pathophysiology, and Management. Drugs 2017; 76:1093-118. [PMID: 27312429 DOI: 10.1007/s40265-016-0600-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Psychotic symptoms are common in Parkinson's disease (PD) and are associated with poorer quality of life and increased caregiver burden. PD psychosis is correlated with several factors, such as more advanced disease, cognitive impairment, depression, and sleep disorders. The underlying causes of psychosis in PD thus involve a complex interplay between exogenous (e.g., drugs, intercurrent illnesses) and endogenous (e.g., PD disease pathology) factors. Current theories of the pathophysiology of PD psychosis have come from several neuropathological and neuroimaging studies that implicate pathways involving visual processing and executive function, including temporo-limbic structures and neocortical gray matter with altered neurotransmitter functioning (e.g., dopamine, serotonin, and acetylcholine). Treatment of PD psychosis requires a step-wise process, including initial careful investigation of treatable triggering conditions and a comprehensive evaluation with adjustment of PD medications and/or initiation of specific antipsychotic therapies. Clozapine remains the only recommended drug for the treatment of PD psychosis; however, because of regular blood monitoring, quetiapine is usually first-line therapy, although less efficacious. Emerging studies have focused on agents involving other neurotransmitters, including the serotonin 5-HT2A receptor inverse agonist pimavanserin, cholinesterase inhibitors, and antidepressants and anxiolytics.
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Affiliation(s)
- Anna Chang
- Morton and Gloria Shulman Movement Disorder Clinic, University of Toronto, Toronto Western Hospital, 7th Floor, McLaughlin Pavilion, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.,Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Susan H Fox
- Morton and Gloria Shulman Movement Disorder Clinic, University of Toronto, Toronto Western Hospital, 7th Floor, McLaughlin Pavilion, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.
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Davis DHJ, Muniz-Terrera G, Keage HAD, Stephan BCM, Fleming J, Ince PG, Matthews FE, Cunningham C, Ely EW, MacLullich AMJ, Brayne C. Association of Delirium With Cognitive Decline in Late Life: A Neuropathologic Study of 3 Population-Based Cohort Studies. JAMA Psychiatry 2017; 74:244-251. [PMID: 28114436 PMCID: PMC6037291 DOI: 10.1001/jamapsychiatry.2016.3423] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Delirium is associated with accelerated cognitive decline. The pathologic substrates of this association are not yet known, that is, whether they are the same as those associated with dementia, are independent, or are interrelated. OBJECTIVE To examine whether the accelerated cognitive decline observed after delirium is independent of the pathologic processes of classic dementia. DESIGN, SETTING, AND PARTICIPANTS Harmonized data from 987 individual brain donors from 3 observational cohort studies with population-based sampling (Vantaa 85+, Cambridge City Over-75s Cohort, Cognitive Function and Ageing Study) performed from January 1, 1985, through December 31, 2011, with a median follow-up of 5.2 years until death, were used in this study. Neuropathologic assessments were performed with investigators masked to clinical data. Data analysis was performed from January 1, 2012, through December 31, 2013. Clinical characteristics of brain donors were not different from the rest of the cohort. Outcome ascertainment was complete given that the participants were brain donors. EXPOSURES Delirium (never vs ever) and pathologic burden of neurofibrillary tangles, amyloid plaques, vascular lesions, and Lewy bodies. Effects modeled using random-effects linear regression and interactions between delirium and pathologic burden were assessed. OUTCOMES Change in Mini-Mental State Examination (MMSE) scores during the 6 years before death. RESULTS There were 987 participants (290 from Vantaa 85+, 241 from the Cambridge City Over-75s Cohort, and 456 from the Cognitive Function and Ageing Study) with neuropathologic data; mean (SD) age at death was 90 (6.4) years, including 682 women (69%). The mean MMSE score 6 years before death was 24.7 points. The 279 individuals with delirium (75% women) had worse initial scores (-2.8 points; 95% CI, -4.5 to -1.0; P < .001). Cognitive decline attributable to delirium was -0.37 MMSE points per year (95% CI, -0.60 to -0.13; P < .001). Decline attributable to the pathologic processes of dementia was -0.39 MMSE points per year (95% CI, -0.57 to -0.22; P < .001). However, the combination of delirium and the pathologic processes of dementia resulted in the greatest decline, in which the interaction contributed an additional -0.16 MMSE points per year (95% CI, -0.29 to -0.03; P = .01). The multiplicative nature of these variables resulted in individuals with delirium and the pathologic processes of dementia declining 0.72 MMSE points per year faster than age-, sex-, and educational level-matched controls. CONCLUSIONS AND RELEVANCE Delirium in the presence of the pathologic processes of dementia is associated with accelerated cognitive decline beyond that expected for delirium or the pathologic process itself. These findings suggest that additional unmeasured pathologic processes specifically relate to delirium. Age-related cognitive decline has many contributors, and these findings at the population level support a role for delirium acting independently and multiplicatively to the pathologic processes of classic dementia.
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Affiliation(s)
- Daniel H J Davis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, England2Medical Research Council Unit for Lifelong Health and Ageing at University College London, London, England
| | | | - Hannah A D Keage
- School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia
| | | | - Jane Fleming
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, England
| | - Paul G Ince
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, England
| | - Fiona E Matthews
- Institute of Health and Society, Newcastle University, Newcastle, England
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity College, Dublin, Ireland
| | - E Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee9Tennessee Valley Veterans Affairs Geriatric Research Education Clinical Center, Nashville
| | | | - Carol Brayne
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, England
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Brain Barrier Breakdown as a Cause and Consequence of Neuroinflammation in Sepsis. Mol Neurobiol 2017; 55:1045-1053. [DOI: 10.1007/s12035-016-0356-7] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/22/2016] [Indexed: 12/31/2022]
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Hennessy E, Gormley S, Lopez-Rodriguez AB, Murray C, Murray C, Cunningham C. Systemic TNF-α produces acute cognitive dysfunction and exaggerated sickness behavior when superimposed upon progressive neurodegeneration. Brain Behav Immun 2017; 59:233-244. [PMID: 27633985 PMCID: PMC5176008 DOI: 10.1016/j.bbi.2016.09.011] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 09/01/2016] [Accepted: 09/12/2016] [Indexed: 12/13/2022] Open
Abstract
Inflammation influences chronic neurodegeneration but its precise roles are not yet clear. Systemic inflammation caused by infection, trauma or co-morbidity can alter the brain's inflammatory status, produce acute cognitive impairments, such as delirium, and drive new pathology and accelerated decline. Consistent with this, elevated systemic TNF-α is associated with more rapid cognitive decline over 6months in Alzheimer's disease patients. In the current study we challenged normal animals and those with existing progressive neurodegeneration (ME7 prion disease) with TNF-α (i.p.) to test the hypothesis that this cytokine has differential effects on cognitive function, sickness behavior and features of underlying pathology contingent on the animals' baseline condition. TNF-α (50μg/kg) had no impact on performance of normal animals (normal brain homogenate; NBH) on working memory (T-maze) but produced acute impairments in ME7 animals similarly challenged. Plasma TNF-α and CCL2 levels were equivalent in NBH and ME7 TNF-challenged animals but hippocampal and hypothalamic transcription of IL-1β, TNF-α and CCL2 and translation of IL-1β were higher in ME7+TNF-α than NBH+TNF-α animals. TNF-α produced an exaggerated sickness behavior response (hypothermia, weight loss, inactivity) in ME7 animals compared to that in NBH animals. However a single challenge with this dose was not sufficient to produce de novo neuronal death, synaptic loss or tau hyperphosphorylation that was distinguishable from that arising from ME7 alone. The data indicate that acutely elevated TNF-α has robust acute effects on brain function, selectively in the degenerating brain, but more sustained levels may be required to significantly impact on underlying neurodegeneration.
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Affiliation(s)
- Edel Hennessy
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Shane Gormley
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Ana Belen Lopez-Rodriguez
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Caoimhe Murray
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Carol Murray
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland.
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Nadkarni NK, Boudreau RM, Studenski SA, Lopez OL, Liu G, Kritchevsky S, Yaffe K, Newman AB, Rosano C. Slow gait, white matter characteristics, and prior 10-year interleukin-6 levels in older adults. Neurology 2016; 87:1993-1999. [PMID: 27733566 DOI: 10.1212/wnl.0000000000003304] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 07/22/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the relationship between gait speed and prior 10 years interleukin-6 (IL-6) burden in older adults. We then assessed whether white matter characteristics influence this relationship. METHODS In 179 community-dwelling older adults, gait speed was assessed on an automated walkway and serum IL-6 was assayed on ELISA. Concurrently, white matter characteristics were assessed on MRI by quantifying volume of white matter hyperintensities (WMH), a marker of small vessel disease, and normal-appearing white matter on fractional anisotropy (NAWM-FA), a marker of axonal integrity. IL-6 was assayed at regular intervals at gait assessment and over the prior 10 years and estimates of sustained 10-year IL-6 exposure and the rate of change in IL-6 over 10 years were obtained. Multivariate linear regressions were used to examine the relationships among sustained IL-6 exposure, rate of change in IL-6, gait speed, and white matter characteristics. RESULTS In this sample (age 83 years, 58% female, 41% black, gait speed 0.9 m/s), higher sustained IL-6 levels, but not the rate of change in IL-6 or IL-6 at gait assessment, was significantly related to slower gait (β = -0.27, p < 0.001) and to higher WMH (β = 0.23, p = 0.002), but not NAWM-FA, withstanding covariate adjustments. WMH accounted for 30% attenuation in the relationship between higher sustained IL-6 levels and slower gait speed (p = 0.043) in the mediation analyses. CONCLUSIONS Sustained exposure to high IL-6 over 10 years rather than the rate of change in IL-6 or an isolated high IL-6 level may adversely affect gait speed by influencing cerebral WMH.
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Affiliation(s)
- Neelesh K Nadkarni
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine (N.K.N.), Department of Neurology (O.L.L.) and the Pittsburgh Alzheimer's Disease Research Center (O.L.L., N.K.N.), University of Pittsburgh School of Medicine, and Department of Epidemiology, Graduate School of Public Health (R.M.B., G.L., A.B.N., C.R.), University of Pittsburgh, PA; Sticht Center on Aging (S.K.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Psychiatry (K.Y.), University of California at San Francisco; and the Longitudinal Studies Section (S.A.S.), Translational Gerontology Branch, National Institute on Aging, Baltimore, MD.
| | - Robert M Boudreau
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine (N.K.N.), Department of Neurology (O.L.L.) and the Pittsburgh Alzheimer's Disease Research Center (O.L.L., N.K.N.), University of Pittsburgh School of Medicine, and Department of Epidemiology, Graduate School of Public Health (R.M.B., G.L., A.B.N., C.R.), University of Pittsburgh, PA; Sticht Center on Aging (S.K.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Psychiatry (K.Y.), University of California at San Francisco; and the Longitudinal Studies Section (S.A.S.), Translational Gerontology Branch, National Institute on Aging, Baltimore, MD
| | - Stephanie A Studenski
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine (N.K.N.), Department of Neurology (O.L.L.) and the Pittsburgh Alzheimer's Disease Research Center (O.L.L., N.K.N.), University of Pittsburgh School of Medicine, and Department of Epidemiology, Graduate School of Public Health (R.M.B., G.L., A.B.N., C.R.), University of Pittsburgh, PA; Sticht Center on Aging (S.K.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Psychiatry (K.Y.), University of California at San Francisco; and the Longitudinal Studies Section (S.A.S.), Translational Gerontology Branch, National Institute on Aging, Baltimore, MD
| | - Oscar L Lopez
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine (N.K.N.), Department of Neurology (O.L.L.) and the Pittsburgh Alzheimer's Disease Research Center (O.L.L., N.K.N.), University of Pittsburgh School of Medicine, and Department of Epidemiology, Graduate School of Public Health (R.M.B., G.L., A.B.N., C.R.), University of Pittsburgh, PA; Sticht Center on Aging (S.K.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Psychiatry (K.Y.), University of California at San Francisco; and the Longitudinal Studies Section (S.A.S.), Translational Gerontology Branch, National Institute on Aging, Baltimore, MD
| | - Ge Liu
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine (N.K.N.), Department of Neurology (O.L.L.) and the Pittsburgh Alzheimer's Disease Research Center (O.L.L., N.K.N.), University of Pittsburgh School of Medicine, and Department of Epidemiology, Graduate School of Public Health (R.M.B., G.L., A.B.N., C.R.), University of Pittsburgh, PA; Sticht Center on Aging (S.K.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Psychiatry (K.Y.), University of California at San Francisco; and the Longitudinal Studies Section (S.A.S.), Translational Gerontology Branch, National Institute on Aging, Baltimore, MD
| | - Stephen Kritchevsky
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine (N.K.N.), Department of Neurology (O.L.L.) and the Pittsburgh Alzheimer's Disease Research Center (O.L.L., N.K.N.), University of Pittsburgh School of Medicine, and Department of Epidemiology, Graduate School of Public Health (R.M.B., G.L., A.B.N., C.R.), University of Pittsburgh, PA; Sticht Center on Aging (S.K.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Psychiatry (K.Y.), University of California at San Francisco; and the Longitudinal Studies Section (S.A.S.), Translational Gerontology Branch, National Institute on Aging, Baltimore, MD
| | - Kristine Yaffe
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine (N.K.N.), Department of Neurology (O.L.L.) and the Pittsburgh Alzheimer's Disease Research Center (O.L.L., N.K.N.), University of Pittsburgh School of Medicine, and Department of Epidemiology, Graduate School of Public Health (R.M.B., G.L., A.B.N., C.R.), University of Pittsburgh, PA; Sticht Center on Aging (S.K.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Psychiatry (K.Y.), University of California at San Francisco; and the Longitudinal Studies Section (S.A.S.), Translational Gerontology Branch, National Institute on Aging, Baltimore, MD
| | - Anne B Newman
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine (N.K.N.), Department of Neurology (O.L.L.) and the Pittsburgh Alzheimer's Disease Research Center (O.L.L., N.K.N.), University of Pittsburgh School of Medicine, and Department of Epidemiology, Graduate School of Public Health (R.M.B., G.L., A.B.N., C.R.), University of Pittsburgh, PA; Sticht Center on Aging (S.K.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Psychiatry (K.Y.), University of California at San Francisco; and the Longitudinal Studies Section (S.A.S.), Translational Gerontology Branch, National Institute on Aging, Baltimore, MD
| | - Caterina Rosano
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine (N.K.N.), Department of Neurology (O.L.L.) and the Pittsburgh Alzheimer's Disease Research Center (O.L.L., N.K.N.), University of Pittsburgh School of Medicine, and Department of Epidemiology, Graduate School of Public Health (R.M.B., G.L., A.B.N., C.R.), University of Pittsburgh, PA; Sticht Center on Aging (S.K.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Psychiatry (K.Y.), University of California at San Francisco; and the Longitudinal Studies Section (S.A.S.), Translational Gerontology Branch, National Institute on Aging, Baltimore, MD
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Hall RJ, Watne LO, Idland AV, Raeder J, Frihagen F, MacLullich AMJ, Staff AC, Wyller TB, Fekkes D. Cerebrospinal fluid levels of neopterin are elevated in delirium after hip fracture. J Neuroinflammation 2016; 13:170. [PMID: 27357281 PMCID: PMC4928278 DOI: 10.1186/s12974-016-0636-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 06/21/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The inflammatory cell product neopterin is elevated in serum before and during delirium. This suggests a role for disordered cell-mediated immunity or oxidative stress. Cerebrospinal fluid (CSF) neopterin levels reflect brain neopterin levels more closely than serum levels. Here we hypothesized that CSF neopterin levels would be higher in delirium. METHODS In this prospective cohort study, 139 elderly patients with acute hip fracture were recruited in Oslo and Edinburgh. Delirium was diagnosed with the confusion assessment method performed daily pre-operatively and on the first 5 days post-operatively. Paired CSF and blood samples were collected at the onset of spinal anaesthesia. Neopterin levels were measured using high-performance liquid chromatography. RESULTS Sixty-four (46 %) of 139 hip fracture patients developed delirium perioperatively. CSF neopterin levels were higher in delirium compared to controls (median 29.6 vs 24.7 nmol/mL, p = 0.003), with highest levels in patients who developed delirium post-operatively. Serum neopterin levels were also higher in delirium (median 37.0 vs 27.1 nmol/mL, p = 0.003). CSF neopterin remained significantly associated with delirium after controlling for relevant risk factors. Higher neopterin levels were associated with poorer outcomes (death or new institutionalization) 1 year after surgery (p = 0.02 for CSF and p = 0.03 for serum). CONCLUSIONS This study is the first to examine neopterin in CSF from patients with delirium. Our findings suggest potential roles for activation of cell-mediated immune responses or oxidative stress in the delirium process. High levels of serum or CSF neopterin in hip fracture patients may also be useful in predicting poor outcomes.
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Affiliation(s)
- Roanna J. Hall
- />Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
- />Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Ane-Victoria Idland
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Johan Raeder
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- />Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- />Department of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Alasdair M. J. MacLullich
- />Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
- />Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Anne Cathrine Staff
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- />Department of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Torgeir Bruun Wyller
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Durk Fekkes
- />Department of Anaesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Neerland BE, Hall RJ, Seljeflot I, Frihagen F, MacLullich AMJ, Raeder J, Wyller TB, Watne LO. Associations Between Delirium and Preoperative Cerebrospinal Fluid C-Reactive Protein, Interleukin-6, and Interleukin-6 Receptor in Individuals with Acute Hip Fracture. J Am Geriatr Soc 2016; 64:1456-63. [DOI: 10.1111/jgs.14238] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Bjørn Erik Neerland
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Roanna J. Hall
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Ingebjørg Seljeflot
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Center for Clinical Heart Research; Department of Cardiology; Oslo University Hospital; Oslo Norway
| | - Frede Frihagen
- Department of Orthopedic Surgery; Oslo University Hospital; Oslo Norway
| | - Alasdair M. J. MacLullich
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Johan Raeder
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Anesthesiology; Oslo University Hospital; Oslo Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Basic Medical Sciences; University of Oslo; Oslo Norway
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Rummel C, Bredehöft J, Damm J, Schweighöfer H, Peek V, Harden LM. Obesity Impacts Fever and Sickness Behavior During Acute Systemic Inflammation. Physiology (Bethesda) 2016; 31:117-30. [DOI: 10.1152/physiol.00049.2015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Obesity is reaching dramatic proportions in humans and is associated with a higher risk for cardiovascular disease, diabetes, and cognitive alterations, and a higher mortality during infection and inflammation. The focus of the present review is on the influence of obesity on the presentation of fever, sickness behavior, and inflammatory responses during acute systemic inflammation.
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Affiliation(s)
- Christoph Rummel
- Department of Veterinary-Physiology and Biochemistry, Justus-Liebig-University Giessen, Giessen, Germany; and
| | - Janne Bredehöft
- Department of Veterinary-Physiology and Biochemistry, Justus-Liebig-University Giessen, Giessen, Germany; and
| | - Jelena Damm
- Department of Veterinary-Physiology and Biochemistry, Justus-Liebig-University Giessen, Giessen, Germany; and
| | - Hanna Schweighöfer
- Department of Veterinary-Physiology and Biochemistry, Justus-Liebig-University Giessen, Giessen, Germany; and
| | - Verena Peek
- Department of Veterinary-Physiology and Biochemistry, Justus-Liebig-University Giessen, Giessen, Germany; and
| | - Lois M Harden
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Biomarkers of Delirium in a Low-Risk Community-Acquired Pneumonia-Induced Sepsis. Mol Neurobiol 2016; 54:722-726. [DOI: 10.1007/s12035-016-9708-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 01/07/2016] [Indexed: 11/26/2022]
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Poon DCH, Ho YS, You R, Tse HL, Chiu K, Chang RCC. PKR deficiency alters E. coli-induced sickness behaviors but does not exacerbate neuroimmune responses or bacterial load. J Neuroinflammation 2015; 12:212. [PMID: 26585788 PMCID: PMC4653925 DOI: 10.1186/s12974-015-0433-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 11/14/2015] [Indexed: 11/15/2022] Open
Abstract
Background Systemic inflammation induces neuroimmune activation, ultimately leading to sickness (e.g., fever, anorexia, motor impairments, exploratory deficits, and social withdrawal). In this study, we evaluated the role of protein kinase R (PKR), a serine-threonine kinase that can control systemic inflammation, on neuroimmune responses and sickness. Methods Wild-type (WT) PKR+/+ mice and PKR−/− mice were subcutaneously injected with live Escherichia coli (E. coli) or vehicle. Food consumption, rotarod test performance, burrowing, open field activity, object investigation, and social interaction were monitored. Plasma TNF-α and corticosterone were measured by ELISA. The percentage of neutrophils in blood was deduced from blood smears. Inflammatory gene expression (IL-1β, TNF-α, IL-6, cyclooxygenase (COX)-2, iNOS) in the liver and the brain (hypothalamus and hippocampus) were quantified by real-time PCR. Blood and lavage fluid (injection site) were collected for microbiological plate count and for real-time PCR of bacterial 16S ribosomal DNA (rDNA). Corticotrophin-releasing hormone (CRH) expression in the hypothalamus was also determined by real-time PCR. Results Deficiency of PKR diminished peripheral inflammatory responses following E. coli challenge. However, while the core components of sickness (anorexia and motor impairments) were similar between both strains of mice, the behavioral components of sickness (reduced burrowing, exploratory activity deficits, and social withdrawal) were only observable in PKR−/− mice but not in WT mice. Such alteration of behavioral components was unlikely to be caused by exaggerated neuroimmune activation, by an impaired host defense to the infection, or due to a dysregulated corticosterone response, because both strains of mice displayed similar neuroimmune responses, bacterial titers, and plasma corticosterone profiles throughout the course of infection. Nevertheless, the induction of hypothalamic corticotrophin-releasing hormone (CRH) by E. coli was delayed in PKR−/− mice relative to WT mice, suggesting that PKR deficiency may postpone the CRH response during systemic inflammation. Conclusions Taken together, our findings show that (1) loss of PKR could alter E. coli-induced sickness behaviors and (2) this was unlikely to be due to exacerbated neuroimmune activation, (3) elevated bacterial load, or (4) dysregulation in the corticosterone response. Further studies can address the role of PKR in the CRH response together with its consequence on sickness.
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Affiliation(s)
- David Chun-Hei Poon
- Laboratory of Neurodegenerative Diseases, School of Biomedical Sciences, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Yuen-Shan Ho
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China.
| | - Ran You
- Laboratory of Neurodegenerative Diseases, School of Biomedical Sciences, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Hei-Long Tse
- Laboratory of Neurodegenerative Diseases, School of Biomedical Sciences, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Kin Chiu
- Department of Ophthalmology, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Raymond Chuen-Chung Chang
- Laboratory of Neurodegenerative Diseases, School of Biomedical Sciences, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China. .,Research Centre of Heart, Brain, Hormone and Healthy Aging, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China. .,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China. .,Rm. L1-49, Laboratory Block, Faculty of Medicine Building, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China.
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Westhoff D, Witlox J, van Aalst C, Scholtens RM, de Rooij SE, van Munster BC, de Jonghe JFM, Houdijk APJ, Eikelenboom P, van Westerloo DJ, van de Beek D, van Gool WA, Koenderman L. Preoperative protein profiles in cerebrospinal fluid in elderly hip fracture patients at risk for delirium: A proteomics and validation study. BBA CLINICAL 2015; 4:115-22. [PMID: 26675981 PMCID: PMC4661734 DOI: 10.1016/j.bbacli.2015.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 10/12/2015] [Accepted: 10/26/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND A neuroinflammatory response is suggested to play an important role in delirium, a common complication in older hospitalized patients. We examined whether hip fracture patients who develop postoperative delirium have a different proteome in cerebrospinal fluid (CSF) prior to surgery. METHODS Patients (≥ 75 years) were admitted for hip fracture surgery. CSF was collected during spinal anaesthesia; proteins were separated using gel electrophoresis and identified with mass spectrometry. We compared the proteome of patients with and without postoperative delirium. Findings were validated in an independent, comparable cohort using immuno-assays. RESULTS In the derivation cohort 53 patients were included, 35.8% developed postoperative delirium. We identified differences in levels of eight CSF proteins between patients with and without subsequent delirium: complement factor C3, contactin-1, fibulin-1 and I-beta-1,3-N-acetylglucosaminyltransferase were significantly lower in patients with postoperative delirium, while neural cell adhesion molecule-2, fibrinogen, zinc-α-2-glycoprotein and haptoglobin levels were significantly higher. In the validation cohort 21.2% of 52 patients developed postoperative delirium. Immuno-assays confirmed contactin-1 results although not statistically significant. Complement factor C3 was significantly higher in patients with postoperative delirium. CONCLUSION Our results show the complexity of pathophysiological mechanisms involved in delirium and emphasizes the need of independent validation of findings. GENERAL SIGNIFICANCE This study highlights the challenges and inconsistent findings in studies of delirium, a serious complication in older patients. We analysed proteins in CSF, the most proximal fluid to the brain. All patients were free from delirium at the time of sampling.
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Affiliation(s)
- Dunja Westhoff
- Department of Neurology, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Joost Witlox
- Department of Geriatrics, Medical Center Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands
| | - Corneli van Aalst
- Department of Respiratory Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Rikie M Scholtens
- Department of Geriatrics, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Sophia E de Rooij
- Department of Geriatrics, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands ; Department of Geriatrics, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatrics, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands ; Department of Geriatrics, Gelre hospitals, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, The Netherlands
| | - Jos F M de Jonghe
- Department of Geriatrics, Medical Center Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands
| | - Alexander P J Houdijk
- Department of Surgery, Medical Center Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands ; Trial Center Holland Health, Alkmaar, The Netherlands
| | | | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Willem A van Gool
- Department of Neurology, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Leo Koenderman
- Department of Respiratory Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Wang HL, Ma RH, Fang H, Xue ZG, Liao QW. Impaired Spatial Learning Memory after Isoflurane Anesthesia or Appendectomy in Aged Mice is Associated with Microglia Activation. J Cell Death 2015; 8:9-19. [PMID: 26380557 PMCID: PMC4560456 DOI: 10.4137/jcd.s30596] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/03/2015] [Accepted: 08/06/2015] [Indexed: 12/18/2022] Open
Abstract
Postoperative cognitive dysfunction (POCD) has been one of the most common problems in elderly patients following surgery. But the specific mechanism of POCD is still not clear. To further understand the reason of these postoperative behavioral deficits, we evaluated the spatial learning memory of both adult (3 months) and aged (18 months) male mice, 3 or 28 days after isoflurane (Iso) exposure for two hours or appendectomy (App). Hippocampal microglia activation and IL-1β, TNF-α, and IFN-γ expression were also evaluated at day 3, day 14 and day 28 after Iso exposure or appendectomy. Results showed that spatial learning memory of aged, but not adult, mice was impaired after Iso exposure or appendectomy, accompanied with more hippocampal microglia activation and IL-1β, TNF-α, and IFN-γ overexpression. These findings suggest that the cognitive deficits of elderly patients who have undergone surgeries are quite possibly caused by hippocampal microglia overactivation and the subsequent inflammation.
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Affiliation(s)
- Hui-Lin Wang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Rui-Hua Ma
- Department of Anesthesiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Hao Fang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China. ; Department of Anesthesiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Zhang-Gang Xue
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qing-Wu Liao
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
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Anticholinergic Medication Use and Transition to Delirium in Critically Ill Patients. Crit Care Med 2015; 43:1846-52. [DOI: 10.1097/ccm.0000000000001094] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Sickness: From the focus on cytokines, prostaglandins, and complement factors to the perspectives of neurons. Neurosci Biobehav Rev 2015; 57:30-45. [PMID: 26363665 DOI: 10.1016/j.neubiorev.2015.07.015] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/06/2015] [Accepted: 07/31/2015] [Indexed: 12/29/2022]
Abstract
Systemic inflammation leads to a variety of physiological (e.g. fever) and behavioral (e.g. anorexia, immobility, social withdrawal, depressed mood, disturbed sleep) responses that are collectively known as sickness. While these phenomena have been studied for the past few decades, the neurobiological mechanisms by which sickness occurs remain unclear. In this review, we first revisit how the body senses and responds to infections and injuries by eliciting systemic inflammation. Next, we focus on how peripheral inflammatory molecules such as cytokines, prostaglandins, and activated complement factors communicate with the brain to trigger neuroinflammation and sickness. Since depression also involves inflammation, we further elaborate on the interrelationship between sickness and depression. Finally, we discuss how immune activation can modulate neurons in the brain, and suggest future perspectives to help unravel how changes in neuronal functions relate to sickness responses.
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Clark IA, Vissel B. Amyloid β: one of three danger-associated molecules that are secondary inducers of the proinflammatory cytokines that mediate Alzheimer's disease. Br J Pharmacol 2015; 172:3714-27. [PMID: 25939581 PMCID: PMC4523330 DOI: 10.1111/bph.13181] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 03/31/2015] [Accepted: 04/14/2015] [Indexed: 12/11/2022] Open
Abstract
This review concerns how the primary inflammation preceding the generation of certain key damage-associated molecular patterns (DAMPs) arises in Alzheimer's disease (AD). In doing so, it places soluble amyloid β (Aβ), a protein hitherto considered as a primary initiator of AD, in a novel perspective. We note here that increased soluble Aβ is one of the proinflammatory cytokine-induced DAMPs recognized by at least one of the toll-like receptors on and in various cell types. Moreover, Aβ is best regarded as belonging to a class of DAMPs, as do the S100 proteins and HMBG1, that further exacerbate production of these same proinflammatory cytokines, which are already enhanced, and induces them further. Moreover, variation in levels of other DAMPs of this same class in AD may explain why normal elderly patients can exhibit high Aβ plaque levels, and why removing Aβ or its plaque does not retard disease progression. It may also explain why mouse transgenic models, having been designed to generate high Aβ, can be treated successfully by this approach.
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Affiliation(s)
- I A Clark
- Biomedical Sciences and Biochemistry, Research School of Biology, Australian National UniversityCanberra, ACT, Australia
| | - B Vissel
- Neurodegeneration Research Group, Garvan InstituteSydney, NSW, Australia
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Vasunilashorn SM, Ngo L, Inouye SK, Libermann TA, Jones RN, Alsop DC, Guess J, Jastrzebski S, McElhaney JE, Kuchel GA, Marcantonio ER. Cytokines and Postoperative Delirium in Older Patients Undergoing Major Elective Surgery. J Gerontol A Biol Sci Med Sci 2015. [PMID: 26215633 DOI: 10.1093/gerona/glv083] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A proinflammatory state has been associated with several age-associated conditions; however, the inflammatory mechanisms of delirium remain poorly characterized. METHODS Using the Successful Aging after Elective Surgery Study of adults age ≥70 undergoing major noncardiac surgery, 12 cytokines were measured at four timepoints: preoperative, postanesthesia care unit, postoperative day 2 (POD2) and 30 days later (POD1M). We conducted a nested, longitudinal matched (on age, sex, surgery type, baseline cognition, vascular comorbidity, and Apolipoprotein E genotype) case-control study: delirium cases and no-delirium controls were selected from the overall cohort (N = 566; 24% delirium). Analyses were independently conducted in discovery, replication, and pooled cohorts (39, 36, 75 matched pairs, respectively). Nonparametric signed-rank tests evaluating differences in cytokine levels between matched pairs were used to identify delirium-associated cytokines. RESULTS In the discovery and replication cohorts, matching variables were similar in cases and controls. Compared to controls, cases had (*p < .05, **p < .01) significantly higher interleukin-6 on POD2 in the discovery, replication, and pooled cohorts (median difference [pg/mL] 50.44**, 20.17*, 39.35**, respectively). In the pooled cohort, cases were higher than controls for interleukin-2 (0.99*, 0.77*, 1.07**, 0.73* at preoperative, postanesthesia care unit, POD2, POD1M, respectively), vascular endothelial growth factor (4.10* at POD2), and tumor necrosis factor-alpha (3.10* at POD1M), while cases had lower interleukin-12 at POD1M (-4.24*). CONCLUSIONS In this large, well-characterized cohort assessed at multiple timepoints, we observed an inflammatory signature of delirium involving elevated interleukin-6 at POD2, which may be an important disease marker for delirium. We also observed preliminary evidence for involvement of other cytokines.
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Affiliation(s)
- Sarinnapha M Vasunilashorn
- Harvard Medical School, Boston, Massachusetts. Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts. Department of Medicine, and
| | - Long Ngo
- Harvard Medical School, Boston, Massachusetts. Department of Medicine, and
| | - Sharon K Inouye
- Harvard Medical School, Boston, Massachusetts. Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts. Department of Medicine, and
| | - Towia A Libermann
- Harvard Medical School, Boston, Massachusetts. Department of Medicine, and
| | - Richard N Jones
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts. Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - David C Alsop
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts. Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Sandra Jastrzebski
- UConn Center on Aging, University of Connecticut Health Center, Farmington
| | - Janet E McElhaney
- Advanced Medical Research Institute of Canada, Sudbury, Ontario, Canada
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut Health Center, Farmington
| | - Edward R Marcantonio
- Harvard Medical School, Boston, Massachusetts. Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts. Department of Medicine, and
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Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol 2015; 14:823-832. [PMID: 26139023 DOI: 10.1016/s1474-4422(15)00101-5] [Citation(s) in RCA: 338] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/27/2015] [Accepted: 05/18/2015] [Indexed: 02/02/2023]
Abstract
Delirium and dementia are two of the most common causes of cognitive impairment in older populations, yet their interrelation remains poorly understood. Previous studies have shown that dementia is the leading risk factor for delirium and that delirium is an independent risk factor for subsequent development of dementia. However, a major area of controversy is whether delirium is simply a marker of vulnerability to dementia, whether the effect of delirium is solely related to its precipitating factors, or whether delirium itself can cause permanent neuronal damage and lead to dementia. Ultimately, all of these hypotheses are likely to be true. Emerging evidence from epidemiological, clinicopathological, neuroimaging, biomarker, and experimental studies lends support to a strong relation between delirium and dementia, and to both shared and distinct pathological mechanisms. New preventive and therapeutic approaches that target delirium might offer a sought-after opportunity for early intervention, preservation of cognitive reserve, and prevention of irreversible cognitive decline in ageing.
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Affiliation(s)
- Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, UCL, London, UK
| | - Matthew E Growdon
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
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92
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Zhang QH, Li AM, He SL, Yao XD, Zhu J, Zhang ZW, Sheng ZY, Yao YM. Serum Total Cholinesterase Activity on Admission Is Associated with Disease Severity and Outcome in Patients with Traumatic Brain Injury. PLoS One 2015; 10:e0129082. [PMID: 26107885 PMCID: PMC4479571 DOI: 10.1371/journal.pone.0129082] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 05/06/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is one of the leading causes of neurological disability. In this retrospective study, serum total cholinesterase (ChE) activities were analyzed in 188 patients for diagnostic as well as predictive values for mortality. METHODS AND FINDINGS Within 72 hours after injury, serum ChE activities including both acetylcholinesterase and butyrylcholinesterase were measured. Disease severity was evaluated with Acute Physiology and Chronic Health Evaluation (APACHE) II score, Glasgow Coma Score, length of coma, post-traumatic amnesia and injury feature. Neurocognitive and functional scores were assessed using clinical records. Of 188 patients, 146 (77.7%) survived and 42 (22.3%) died within 90 days. Lower ChE activities were noted in the non-survivors vs. survivors (5.94±2.19 vs. 7.04±2.16 kU/L, p=0.023), in septic vs. non-infected patients (5.93±1.89 vs. 7.31±2.45 kU/L, p=0.0005) and in patients with extremely severe injury vs. mild injury (6.3±1.98 vs. 7.57±2.48 kU/L, p=0.049). The trajectories of serum ChE levels were also different between non-survivors and survivors, septic and non-infected patients, mild and severely injured patients, respectively. Admission ChE activities were closely correlated with blood cell counts, neurocognitive and functional scores both on admission and at discharge. Receiver operating characteristic analysis showed that the area under the curve for ChE was inferior to that for either APACHE II or white blood cell (WBC) count. However, at the optimal cutoff value of 5 kU/L, the sensitivity of ChE for correct prediction of 90-day mortality was 65.5% and the specificity was 86.4%. Kaplan-Meier analysis showed that lower ChE activity (<5 kU/L) was more closely correlated with poor survival than higher ChE activity (>5 kU/L) (p=0.04). After adjusting for other variables, ChE was identified as a borderline independent predictor for mortality as analyzed by Binary logistic regression (P=0.078). CONCLUSIONS Lowered ChE activity measured on admission appears to be associated with disease severity and outcome for TBI patients.
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Affiliation(s)
- Qing-Hong Zhang
- Key Research Laboratory of Tissue Repair and Regeneration of PLA, and Beijing Key Research Laboratory of Skin Injury, Repair and Regeneration; First Hospital Affiliated to the Chinese PLA General Hospital, Beijing, 100048, P. R. China
- * E-mail: (QHZ); (YMY)
| | - An-Min Li
- Department of Neurosurgery, Hainan Branch of the Chinese PLA General Hospital, Sanya, Hainan, 572013, P. R. China
| | - Sai-Lin He
- Department of Neurosurgery, First Hospital Affiliated to the Chinese PLA General Hospital, Beijing, 100048, P. R. China
| | - Xu-Dong Yao
- Department of Emergency, First Hospital Affiliated to Wenzhou Medical University, Wenzhou, 325000, P. R. China
| | - Jing Zhu
- Department of Laboratory Medicine, First Hospital Affiliated to the Chinese PLA General Hospital, Beijing, 100048, P. R. China
| | - Zhi-Wen Zhang
- Department of Neurosurgery, First Hospital Affiliated to the Chinese PLA General Hospital, Beijing, 100048, P. R. China
| | - Zhi-Yong Sheng
- Key Research Laboratory of Tissue Repair and Regeneration of PLA, and Beijing Key Research Laboratory of Skin Injury, Repair and Regeneration; First Hospital Affiliated to the Chinese PLA General Hospital, Beijing, 100048, P. R. China
| | - Yong-Ming Yao
- Key Research Laboratory of Tissue Repair and Regeneration of PLA, and Beijing Key Research Laboratory of Skin Injury, Repair and Regeneration; First Hospital Affiliated to the Chinese PLA General Hospital, Beijing, 100048, P. R. China
- * E-mail: (QHZ); (YMY)
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93
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Kim Y, Hong SJ. Intensive Care Unit Delirium. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.2.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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94
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Vardy ERLC, Teodorczuk A, Yarnall AJ. Review of delirium in patients with Parkinson's disease. J Neurol 2015; 262:2401-10. [PMID: 25957635 DOI: 10.1007/s00415-015-7760-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 04/17/2015] [Accepted: 04/20/2015] [Indexed: 01/09/2023]
Abstract
Parkinson's disease (PD) is common and has a number of associated neuropsychiatric disturbances. Of these, delirium has historically been under-recognised. Delirium is an acute disturbance of attention and awareness that fluctuates, and is accompanied by an additional disturbance of cognition. As delirium is known to carry a particularly poor prognosis in terms of morbidity and mortality, and the relationship between delirium and dementia is becoming better defined, we completed a literature review of delirium in the context of PD. A literature search was completed using the databases PubMed, Embase and Ovid Medline. PubMed (1945-2014) was searched in September 2014; Embase (1974-2014); and Ovid Medline (1946-2014) in October 2014. The search terms 'delirium' and 'Parkinsons' in combination were used. Large studies using a robust definition of delirium were lacking in PD. There is the suggestion that PD is a risk factor for delirium and that delirium negatively impacts upon the motor symptom trajectory. Deficits in the neurotransmitters dopamine and acetylcholine are implicated in the pathophysiology of delirium in PD. Systemic inflammation also appears to have a role. Treatment of delirium in PD should include medication review and cautious use of atypical antipsychotics where pharmacological treatment is indicated. Of the atypical antipsychotics studied, quetiapine has the least extrapyramidal side effects. Evidence suggests a specific link between delirium and PD but well-designed clinical studies to evaluate the prevalence, impact and treatment of delirium in PD are required. Given the potential to improve outcomes through delirium prevention we conclude that delirium in PD is an area worthy of further study.
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Affiliation(s)
- Emma R L C Vardy
- Department of Older Peoples Medicine, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Rd, Newcastle upon Tyne, Tyne and Wear, NE7 7DN, UK.
- Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK.
| | - Andrew Teodorczuk
- School of Medical Education, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
- Northumberland Tyne and Wear NHS Foundation Trust, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Alison J Yarnall
- Department of Older Peoples Medicine, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Rd, Newcastle upon Tyne, Tyne and Wear, NE7 7DN, UK
- Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
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95
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Rathbone ATL, Tharmaradinam S, Jiang S, Rathbone MP, Kumbhare DA. A review of the neuro- and systemic inflammatory responses in post concussion symptoms: Introduction of the "post-inflammatory brain syndrome" PIBS. Brain Behav Immun 2015; 46:1-16. [PMID: 25736063 DOI: 10.1016/j.bbi.2015.02.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 02/08/2015] [Accepted: 02/09/2015] [Indexed: 12/22/2022] Open
Abstract
Post-concussion syndrome is an aggregate of symptoms that commonly present together after head injury. These symptoms, depending on definition, include headaches, dizziness, neuropsychiatric symptoms, and cognitive impairment. However, these symptoms are common, occurring frequently in non-head injured controls, leading some to question the existence of post-concussion syndrome as a unique syndrome. Therefore, some have attempted to explain post-concussion symptoms as post-traumatic stress disorder, as they share many similar symptoms and post-traumatic stress disorder does not require head injury. This explanation falls short as patients with post-concussion syndrome do not necessarily experience many key symptoms of post-traumatic stress disorder. Therefore, other explanations must be sought to explain the prevalence of post-concussion like symptoms in non-head injury patients. Many of the situations in which post-concussion syndrome like symptoms may be experienced such as infection and post-surgery are associated with systemic inflammatory responses, and even neuroinflammation. Post-concussion syndrome itself has a significant neuroinflammatory component. In this review we examine the evidence of neuroinflammation in post-concussion syndrome and the potential role systemic inflammation plays in post-concussion syndrome like symptoms. We conclude that given the overlap between these conditions and the role of inflammation in their etiologies, a new term, post-inflammatory brain syndromes (PIBS), is necessary to describe the common outcomes of many different inflammatory insults. The concept of post-concussion syndrome is in its evolution therefore, the new term post-inflammatory brain syndromes provides a better understanding of etiology of its wide-array of symptoms and the wide array of conditions they can be seen in.
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Affiliation(s)
| | - Surejini Tharmaradinam
- Division of Pediatric Neurology, Department of Pediatrics, McMaster Children's Hospital, Pediatric Neurology, MUMC 3A, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Shucui Jiang
- Division of Neurosurgery, Department of Surgery, and Hamilton Neurorestorative Group, McMaster University, HSC 4E15, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
| | - Michel P Rathbone
- Department of Medicine, Division of Neurology, McMaster University - Juravinski Hospital, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
| | - Dinesh A Kumbhare
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, University Health Network - Toronto Rehab - University Centre, 550 University Ave, Toronto, Ontario M5G 2A2, Canada
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96
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The American Geriatrics Society/National Institute on Aging Bedside-to-Bench Conference: Research Agenda on Delirium in Older Adults. J Am Geriatr Soc 2015; 63:843-52. [PMID: 25834932 PMCID: PMC5407494 DOI: 10.1111/jgs.13406] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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97
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Cunningham C, Hennessy E. Co-morbidity and systemic inflammation as drivers of cognitive decline: new experimental models adopting a broader paradigm in dementia research. ALZHEIMERS RESEARCH & THERAPY 2015; 7:33. [PMID: 25802557 PMCID: PMC4369837 DOI: 10.1186/s13195-015-0117-2] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Dementia prevalence increases with age and Alzheimer’s disease (AD) accounts for up to 75% of cases. However, significant variability and overlap exists in the extent of amyloid-β and Tau pathology in AD and non-demented populations and it is clear that other factors must influence progression of cognitive decline, perhaps independent of effects on amyloid pathology. Coupled with the failure of amyloid-clearing strategies to provide benefits for AD patients, it seems necessary to broaden the paradigm in dementia research beyond amyloid deposition and clearance. Evidence has emerged from alternative animal model approaches as well as clinical and population epidemiological studies that co-morbidities contribute significantly to neurodegeneration/cognitive decline and systemic inflammation has been a strong common theme in these approaches. We hypothesise, and discuss in this review, that a disproportionate inflammatory response to infection, injury or chronic peripheral disease is a key determinant of cognitive decline. We propose that detailed study of alternative models, which encompass acute and chronic systemic inflammatory co-morbidities, is an important priority for the field and we examine the cognitive consequences of several of these alternative experimental approaches. Experimental models of severe sepsis in normal animals or moderate acute systemic inflammation in animals with existing neurodegenerative pathology have uncovered roles for inflammatory mediators interleukin-1β, tumour necrosis factor-α, inducible nitric oxide synthase, complement, prostaglandins and NADPH oxidase in inflammation-induced cognitive dysfunction and neuronal death. Moreover, microglia are primed by existing neurodegenerative pathology to produce exaggerated responses to subsequent stimulation with bacterial lipopolysaccharide or other inflammatory stimuli and these insults drive acute dysfunction and negatively affect disease trajectory. Chronic co-morbidities, such as arthritis, atherosclerosis, obesity and diabetes, are risk factors for subsequent dementia and those with high inflammatory status are particularly at risk. Models of chronic co-morbidities, and indeed low grade systemic inflammation in the absence of specific pathology, indicate that interleukin-1β, tumour necrosis factor-α and other inflammatory mediators drive insulin resistance, hypothalamic dysfunction, impaired neurogenesis and cognitive function and impact on functional decline. Detailed study of these pathways will uncover important mechanisms of peripheral inflammation-driven cognitive decline and are already driving clinical initiatives to mitigate AD progression through minimising systemic inflammation.
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Affiliation(s)
- Colm Cunningham
- Trinity College Institute of Neuroscience and School of Biochemistry and Immunology, Trinity College Dublin, Dublin 2, Republic of Ireland
| | - Edel Hennessy
- Trinity College Institute of Neuroscience and School of Biochemistry and Immunology, Trinity College Dublin, Dublin 2, Republic of Ireland
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98
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González-López A, Albaiceta GM, Talbot K. Newly identified precipitating factors in mechanical ventilation-induced brain damage: implications for treating ICU delirium. Expert Rev Neurother 2015; 14:583-8. [PMID: 24852225 DOI: 10.1586/14737175.2014.915743] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Delirium is 1.5 to 4.1 times as likely in intensive care unit patients when they are mechanically ventilated. While progress in treatment has occurred, delirium is still a major problem in mechanically ventilated patients. Based on studies of a murine mechanical ventilation model, we summarize evidence here for a novel mechanism by which such ventilation can quickly initiate brain damage likely to cause cognitive deficits expressed as delirium. That mechanism consists of aberrant vagal sensory input driving sustained dopamine D2 receptor (D2R) signaling in the hippocampal formation, which induces apoptosis in that brain area within 90 min without causing hypoxia, oxidative stress, or inflammatory responses. This argues for minimizing the duration and tidal volumes of mechanical ventilation and for more effectively reducing sustained D2R signaling than achieved with haloperidol alone. The latter might be accomplished by reducing D2R cell surface expression and D2R-mediated Akt inhibition by elevating protein expression of dysbindin-1C.
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Affiliation(s)
- Adrián González-López
- Charité - Universitätsmedizin Berlin - Anesthesiology and Intensive Care Medicine, Berlin, Germany
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99
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Poljak A, Hill M, Hall RJ, MacLullich AM, Raftery MJ, Tai J, Yan S, Caplan GA. Quantitative proteomics of delirium cerebrospinal fluid. Transl Psychiatry 2014; 4:e477. [PMID: 25369144 PMCID: PMC4259987 DOI: 10.1038/tp.2014.114] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 09/05/2014] [Accepted: 09/11/2014] [Indexed: 12/12/2022] Open
Abstract
Delirium is a common cause and complication of hospitalization in older people, being associated with higher risk of future dementia and progression of existing dementia. However relatively little data are available on which biochemical pathways are dysregulated in the brain during delirium episodes, whether there are protein expression changes common among delirium subjects and whether there are any changes which correlate with the severity of delirium. We now present the first proteomic analysis of delirium cerebrospinal fluid (CSF), and one of few studies exploring protein expression changes in delirium. More than 270 proteins were identified in two delirium cohorts, 16 of which were dysregulated in at least 8 of 17 delirium subjects compared with a mild Alzheimer's disease neurological control group, and 31 proteins were significantly correlated with cognitive scores (mini-mental state exam and acute physiology and chronic health evaluation III). Bioinformatics analyses revealed expression changes in several protein family groups, including apolipoproteins, secretogranins/chromogranins, clotting/fibrinolysis factors, serine protease inhibitors and acute-phase response elements. These data not only provide confirmatory evidence that the inflammatory response is a component of delirium, but also reveal dysregulation of protein expression in a number of novel and unexpected clusters of proteins, in particular the granins. Another surprising outcome of this work is the level of similarity of CSF protein profiles in delirium patients, given the diversity of causes of this syndrome. These data provide additional elements for consideration in the pathophysiology of delirium as well as potential biomarker candidates for delirium diagnosis.
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Affiliation(s)
- A Poljak
- Bioanalytical Mass Spectrometry Facility, University of New South Wales, Sydney, NSW, Australia,School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia,Center for Healthy Brain Ageing, University of New South Wales, Sydney, NSW, Australia,Bioanalytical Mass Spectrometry Facility, University of New South Wales, Anzac Pde, Kensington, Sydney, NSW 2052, Australia. E-mail:
| | - M Hill
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - R J Hall
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, UK
| | - A M MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, UK
| | - M J Raftery
- Bioanalytical Mass Spectrometry Facility, University of New South Wales, Sydney, NSW, Australia
| | - J Tai
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - S Yan
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - G A Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia,Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
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100
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Lavigne B, Villate A, Moreau S, Clément JP. Dépression, anxiété et confusion en soins palliatifs. MÉDECINE PALLIATIVE : SOINS DE SUPPORT - ACCOMPAGNEMENT - ÉTHIQUE 2014. [DOI: 10.1016/j.medpal.2014.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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