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Garcez FB, Apolinario D, Campora F, Curiati JAE, Jacob-Filho W, Avelino-Silva TJ. Delirium and post-discharge dementia: results from a cohort of older adults without baseline cognitive impairment. Age Ageing 2019; 48:845-851. [PMID: 31566669 DOI: 10.1093/ageing/afz107] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/04/2019] [Accepted: 07/05/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES to investigate the association between delirium occurrence in acutely ill older adults and incident dementia after hospital discharge. METHODS retrospective cohort study examining acutely ill older adults aged +60 years and consecutively admitted to the geriatric ward of a tertiary university hospital from 2010 to 2016. Inclusion criteria were absence of baseline cognitive decline on admission and documented clinical follow-up of +12 months after discharge. Admission data were collected from our local database, including results from a standardized comprehensive geriatric assessment completed for every patient. Pre-existing cognitive decline was identified based on clinical history, CDR and IQCODE-16. Delirium was diagnosed using short-CAM criteria, while post-discharge dementia after 12 months was identified based on medical records' review. We used competing-risk proportional-hazard models to explore the association between delirium and post-discharge dementia. RESULTS we included 309 patients. Mean age was 78 years, and 186 (60%) were women. Delirium was detected in 66 (21%) cases. After a median follow-up of 24 months, 21 (32%) patients who had experienced delirium progressed with dementia, while only 38 (16%) of those without delirium had the same outcome (P = 0.003). After adjusting for possible confounders, delirium was independently associated with post-discharge dementia with a sub-hazard ratio of 1.94 (95%CI = 1.10-3.44; P = 0.022). CONCLUSION one in three acutely ill older adults who experienced delirium in the hospital developed post-discharge dementia during follow-up. Further understanding of delirium as an independent and potentially preventable risk factor for cognitive decline emphasizes the importance of systematic initiatives to fight it.
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Affiliation(s)
| | - Daniel Apolinario
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Flavia Campora
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Wilson Jacob-Filho
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Thiago Junqueira Avelino-Silva
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil
- School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, Brazil
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Mietani K, Sumitani M, Ogata T, Shimojo N, Inoue R, Abe H, Kawamura G, Yamada Y. Dysfunction of the blood-brain barrier in postoperative delirium patients, referring to the axonal damage biomarker phosphorylated neurofilament heavy subunit. PLoS One 2019; 14:e0222721. [PMID: 31574089 PMCID: PMC6771997 DOI: 10.1371/journal.pone.0222721] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/05/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Delirium is the most common postoperative complication of the central nervous system (CNS) that can trigger long-term cognitive impairment. Its underlying mechanism is not fully understood, but the dysfunction of the blood-brain barrier (BBB) has been implicated. The serum levels of the axonal damage biomarker, phosphorylated neurofilament heavy subunit (pNF-H) increase in moderate to severe delirium patients, indicating that postoperative delirium can induce irreversible CNS damage. Here, we investigated the relationship among postoperative delirium, CNS damage and BBB dysfunction, using pNF-H as reference. METHODS Blood samples were collected from 117 patients within 3 postoperative days. These patients were clinically diagnosed with postoperative delirium using the Confusion Assessment Method for the Intensive Care Unit. We measured intercellular adhesion molecule-1, platelet and endothelial cell adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin, and P-selectin as biomarkers for BBB disruption, pro-inflammatory cytokines (tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6), and pNF-H. We conducted logistic regression analysis including all participants to identify independent biomarkers contributing to serum pNF-H detection. Next, by multiple regression analysis with a stepwise method we sought to determine which biomarkers influence serum pNF-H levels, in pNF-H positive patients. RESULTS Of the 117 subjects, 41 were clinically diagnosed with postoperative delirium, and 30 were positive for serum pNF-H. Sensitivity and specificity of serum pNF-H detection in the patients with postoperative delirium were 56% and 90%, respectively. P-selectin was the only independent variable to associate with pNF-H detection (P < 0.0001) in all 117 patients. In pNF-H positive patients, only PECAM-1 was associated with serum pNF-H levels (P = 0.02). CONCLUSIONS Serum pNF-H could be an objective delirium biomarker, superior to conventional tools in clinical settings. In reference to pNF-H, P-selectin may be involved in the development of delirium-related CNS damage and PECAM-1 may contribute to the progression of delirium- related CNS damage.
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Affiliation(s)
- Kazuhito Mietani
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
- * E-mail:
| | - Toru Ogata
- Department of Rehabilitation for the Movement Functions, Research Institute, National Rehabilitation Center for Persons with Disabilities, Saitama, Japan
| | - Nobutake Shimojo
- Department of Emergency and Critical Care Medicine, Tsukuba University Hospital, Ibaraki, Japan
| | - Reo Inoue
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroaki Abe
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Gaku Kawamura
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitsugu Yamada
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
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Risk Factors for Persistent Cognitive Impairment After Critical Illness, Nested Case-Control Study. Crit Care Med 2019; 46:1977-1984. [PMID: 30222636 DOI: 10.1097/ccm.0000000000003395] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Persistent cognitive impairment after critical illness is an important healthcare problem forecasted to worsen in the near future. However, the epidemiology is insufficiently explored. We aimed to determine potentially modifiable risk factors during ICU hospitalization that play a significant role in developing persistent cognitive impairment. DESIGN An observational case-control study. SETTINGS Mayo Clinic ICUs between July 1, 2004, and November 20, 2015. PATIENTS We conducted a study nested in a large cohort of 98,227 adult critically ill patients. Using previously validated computable phenotypes for dementia and cognitive impairment, we determined the onset of cognitive impairment relative to ICU hospitalization and associated risk factors. The primary endpoint of the study was new and persistent cognitive impairment documented between 3 and 24 months after ICU discharge. INTERVENTIONS Unadjusted and adjusted analyses were performed to identify potentially modifiable risk factors during ICU hospitalization. MEASUREMENTS AND MAIN RESULTS Among 21,923 unique patients identified as cognitively impaired (22% of the entire ICU cohort), 2,428 (2.5%) developed incident new and persistent cognitive dysfunction after the index ICU admission. Compared with age- and sex-matched ICU controls (2,401 pairs), cases had higher chronic illness burden (Charlson Comorbidity Index, 6.2 vs 5.1; p < 0.01), and were more likely to have multiple ICU stays (22% vs 14%; p < 0.01). After adjustment for baseline differences, new and persistent cognitive dysfunction was associated with higher frequency of acute brain failure in the ICU, a higher exposure to severe hypotension, hypoxemia, hyperthermia, fluctuations in serum glucose, and treatment with quinolones or vancomycin. Association with sepsis observed in univariate analysis did not persist after adjustment. CONCLUSIONS Cognitive dysfunction is highly prevalent in ICU patients. Incident new and persistent cognitive impairment is less common but important, potentially preventable problem after critical illness. Chronic comorbidities and number of ICU stays increase the risk of post-ICU cognitive dysfunction irrespective of age. Modifiable ICU exposures were identified as potential targets for future prevention trials.
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Abstract
Developments in the management of critically ill patients suffering organ dysfunctions have demonstrated that brain is the prominent organ to be effected during critical illness. Acute brain dysfunction due to pathologic neuroinflammatory processes associated with sepsis is commonly seen and related to morbidity and mortality in the ICU treatment. Studies reported that survivors of sepsis may suffer long-term cognitive dysfunction that affects quality of life. However, there are no specific approaches to diagnose acute brain dysfunction in the early phase to target protective measures. In recent years, imaging methods and biomarkers are the most important issues of studies. This review will address the current diagnostic approaches to acute brain dysfunction related to sepsis.
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Abstract
Delirium is a serious complication of acute illness. Little is known, however, regarding the neurobiology of delirium, largely due to challenges in studying the complex inpatient population. Neuroimaging is one noninvasive method that can be used to study structural and functional brain abnormalities associated with delirium. The purpose of this integrative literature review was to examine the content and quality of current structural neuroimaging evidence in delirium. After meeting inclusion criteria, 11 articles were included in the review. Commonly noted structural abnormalities were impaired white matter integrity, brain atrophy, ischemic lesions, edema, and inflammation. Findings demonstrated widespread alterations in several brain structures. Limitations of the studies in this review included small sample sizes, inappropriate or questionable delirium measurements, and failure to consider confounding variables. This review provides insight into possible structural changes responsible for the signs and symptoms seen in patients with delirium, but more high-quality studies are needed.
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Affiliation(s)
| | - Todd B Monroe
- 1 The Ohio State University College of Nursing, Columbus, OH, USA
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Nwafor DC, Brichacek AL, Mohammad AS, Griffith J, Lucke-Wold BP, Benkovic SA, Geldenhuys WJ, Lockman PR, Brown CM. Targeting the Blood-Brain Barrier to Prevent Sepsis-Associated Cognitive Impairment. J Cent Nerv Syst Dis 2019; 11:1179573519840652. [PMID: 31007531 PMCID: PMC6456845 DOI: 10.1177/1179573519840652] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 01/21/2019] [Indexed: 12/17/2022] Open
Abstract
Sepsis is a systemic inflammatory disease resulting from an infection. This disorder affects 750 000 people annually in the United States and has a 62% rehospitalization rate. Septic symptoms range from typical flu-like symptoms (eg, headache, fever) to a multifactorial syndrome known as sepsis-associated encephalopathy (SAE). Patients with SAE exhibit an acute altered mental status and often have higher mortality and morbidity. In addition, many sepsis survivors are also burdened with long-term cognitive impairment. The mechanisms through which sepsis initiates SAE and promotes long-term cognitive impairment in septic survivors are poorly understood. Due to its unique role as an interface between the brain and the periphery, numerous studies support a regulatory role for the blood-brain barrier (BBB) in the progression of acute and chronic brain dysfunction. In this review, we discuss the current body of literature which supports the BBB as a nexus which integrates signals from the brain and the periphery in sepsis. We highlight key insights on the mechanisms that contribute to the BBB's role in sepsis which include neuroinflammation, increased barrier permeability, immune cell infiltration, mitochondrial dysfunction, and a potential barrier role for tissue non-specific alkaline phosphatase (TNAP). Finally, we address current drug treatments (eg, antimicrobials and intravenous immunoglobulins) for sepsis and their potential outcomes on brain function. A comprehensive understanding of these mechanisms may enable clinicians to target specific aspects of BBB function as a therapeutic tool to limit long-term cognitive impairment in sepsis survivors.
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Affiliation(s)
- Divine C Nwafor
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Allison L Brichacek
- Immunology and Microbial Pathogenesis, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Microbiology, Immunology, and Cell Biology, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Afroz S Mohammad
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Jessica Griffith
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Brandon P Lucke-Wold
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Stanley A Benkovic
- Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Werner J Geldenhuys
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Paul R Lockman
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Candice M Brown
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Immunology and Microbial Pathogenesis, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Microbiology, Immunology, and Cell Biology, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Center for Basic and Translational Stroke Research, Rockefeller Neuroscience Institute, Health Sciences Center, West Virginia University, Morgantown, WV, USA
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Rengel KF, Hayhurst CJ, Pandharipande PP, Hughes CG. Long-term Cognitive and Functional Impairments After Critical Illness. Anesth Analg 2019; 128:772-780. [DOI: 10.1213/ane.0000000000004066] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Kalvas LB. The Life Course Health Development Model: A theoretical research framework for paediatric delirium. J Clin Nurs 2019; 28:2351-2360. [PMID: 30653772 DOI: 10.1111/jocn.14776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 12/05/2018] [Accepted: 01/07/2019] [Indexed: 12/31/2022]
Abstract
AIMS AND OBJECTIVES To create a framework for future research through application and critique of the Life Course Health Development Model to the phenomenon of paediatric delirium. BACKGROUND Delirium in the paediatric intensive care unit is associated with increased duration of mechanical ventilation, length of stay and mortality. Nurses are uniquely positioned at the bedside to identify, prevent and treat delirium. An understanding of the potential long-term consequences of paediatric delirium is necessary to provide impetus for nursing research and practice change. The Life Course Health Development Model is a valuable tool when considering the multiple mechanisms and processes through which the experience of delirium could affect a child's life trajectory. DESIGN Critical review of the literature through application and critique of the Life Course Health Development Model in the context of paediatric delirium. Gaps in the current understanding of paediatric delirium, as well as future directions for research and practice, are discussed. METHODS The seven core principles of the model are considered in the context of paediatric delirium. Each of the principles has the potential to further understanding of paediatric delirium and identify areas for future inquiry. This discussion leads to a critique of the ability of the model to lead future research and practice change. CONCLUSIONS The Life Course Health Development Model depicts a process in which the acute and severe stress of critical illness leads to maladaptive neurologic changes that contribute to the development of delirium and impair a child's life trajectory. RELEVANCE TO CLINICAL PRACTICE By emphasising the potential lifelong consequences for critically ill children who experience delirium, this application of the Life Course Health Development Model will stimulate discussion, research and practice change among paediatric clinicians and researchers.
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Neuroimaging Findings in Sepsis-Induced Brain Dysfunction: Association with Clinical and Laboratory Findings. Neurocrit Care 2019; 30:106-117. [PMID: 30027347 DOI: 10.1007/s12028-018-0581-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Incidence and patterns of brain lesions of sepsis-induced brain dysfunction (SIBD) have been well defined. Our objective was to investigate the associations between neuroimaging features of SIBD patients and well-known neuroinflammation and neurodegeneration factors. METHODS In this prospective observational study, 93 SIBD patients (45 men, 48 women; 50.6 ± 12.7 years old) were enrolled. Patients underwent a neurological examination and brain magnetic resonance imaging (MRI). Severity-of-disease scoring systems (APACHE II, SOFA, and SAPS II) and neurological outcome scoring system (GOSE) were used. Also, serum levels of a panel of mediators [IL-1β, IL-6, IL-8, IL-10, IL-12, IL-17, IFN-γ, TNF-α, complement factor Bb, C4d, C5a, iC3b, amyloid-β peptides, total tau, phosphorylated tau (p-tau), S100b, neuron-specific enolase] were measured by ELISA. Voxel-based morphometry (VBM) was employed to available patients for assessment of neuronal loss pattern in SIBD. RESULTS MRI of SIBD patients were normal (n = 27, 29%) or showed brain lesions (n = 51, 54.9%) or brain atrophy (n = 15, 16.1%). VBM analysis showed neuronal loss in the insula, cingulate cortex, frontal lobe, precuneus, and thalamus. Patients with abnormal MRI findings had worse APACHE II, SOFA, GOSE scores, increased prevalence of delirium and mortality. Presence of MRI lesions was associated with reduced C5a and iC3b levels and brain atrophy was associated with increased p-tau levels. Regression analysis identified an association between C5a levels and presence of lesion on MRI and p-tau levels and the presence of atrophy on MRI. CONCLUSIONS Neuronal loss predominantly occurs in limbic and visceral pain perception regions of SIBD patients. Complement breakdown products and p-tau stand out as adverse neuroimaging outcome markers for SIBD.
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110
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Nitchingham A, Kumar V, Shenkin S, Ferguson KJ, Caplan GA. A systematic review of neuroimaging in delirium: predictors, correlates and consequences. Int J Geriatr Psychiatry 2018; 33:1458-1478. [PMID: 28574155 DOI: 10.1002/gps.4724] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/23/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Neuroimaging advances our understanding of delirium pathophysiology and its consequences. A previous systematic review identified 12 studies (total participants N = 764, delirium cases N = 194; years 1989-2007) and found associations with white matter hyperintensities (WMH) and cerebral atrophy. Our objectives were to perform an updated systematic review of neuroimaging studies in delirium published since January 2006 and summarise the available literature on predictors, correlates or outcomes. METHODS Studies were identified by keyword and MeSH-based electronic searches of EMBASE, MEDLINE and PsycINFO combining terms for neuroimaging, brain structure and delirium. We included neuroimaging studies of delirium in adults using validated delirium assessment methods. RESULTS Thirty-two studies (total N = 3187, delirium N = 1086) met the inclusion criteria. Imaging included magnetic resonance imaging (MRI; N = 9), computed tomography (N = 4), diffusion tensor imaging (N = 3), transcranial Doppler (N = 5), near infrared spectroscopy (N = 5), functional-MRI (N = 2), single photon emission computed tomography (N = 1), proton MRI spectroscopy (N = 1), arterial spin-labelling MRI (N = 1) and 2-13 fluoro-2-deoxyglucose positron emission tomography (N = 1). Despite heterogeneity in study design, delirium was associated with WMH, lower brain volume, atrophy, dysconnectivity, impaired cerebral autoregulation, reduced blood flow and cerebral oxygenation and glucose hypometabolism. There was evidence of long-term brain changes following intensive care unit delirium. CONCLUSIONS Neuroimaging is now used more widely in delirium research due to advances in technology. However, imaging delirious patients presents challenges leading to methodological limitations and restricted generalisability. The findings that atrophy and WMH burden predict delirium replicates findings from the original review, while advanced techniques have identified other substrates and mechanisms that warrant further investigation.
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Affiliation(s)
- Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Varun Kumar
- Department of Psychiatry, Blacktown Hospital, Sydney, Australia
| | - Susan Shenkin
- Department of Geriatric Medicine, The University of Edinburgh, Edinburgh, UK
| | - Karen J Ferguson
- Department of Geriatric Medicine, The University of Edinburgh, Edinburgh, UK
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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Patel MB, Bednarik J, Lee P, Shehabi Y, Salluh JI, Slooter AJ, Klein KE, Skrobik Y, Morandi A, Spronk PE, Naidech AM, Pun BT, Bozza FA, Marra A, John S, Pandharipande PP, Ely EW. Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review. Crit Care Med 2018; 46:1832-1841. [PMID: 30142098 PMCID: PMC6185789 DOI: 10.1097/ccm.0000000000003349] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population. DATA SOURCES We systematically reviewed Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed. STUDY SELECTION AND DATA EXTRACTION Inclusion criteria allowed any study design investigating delirium monitoring in neurocritically ill patients (e.g., neurotrauma, ischemic, and/or hemorrhagic stroke) of any age. We extracted data relevant to delirium tool sensitivity, specificity, negative predictive value, positive predictive value, interrater reliability, and associated clinical outcomes. DATA SYNTHESIS Among seven prospective cohort studies and a total of 1,173 patients, delirium was assessed in neurocritically patients using validated delirium tools after considering primary neurologic diagnoses and associated complications, finding a pooled prevalence rate of 12-43%. When able to compare against a common reference standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the test characteristics showed a sensitivity of 62-76%, specificity of 74-98%, positive predictive value of 63-91%, negative predictive value of 70-94%, and reliability kappa of 0.64-0.94. Among four studies reporting multivariable analyses, delirium in neurocritically patients was associated with increased hospital length of stay (n = 3) and ICU length of stay (n = 1), as well as worse functional independence (n = 1) and cognition (n = 2), but not survival. CONCLUSIONS These data from studies of neurocritically ill patients demonstrate that patients with primary neurologic diagnoses can meet diagnostic criteria for delirium and that delirious features may predict relevant untoward clinical outcomes. There is a need for ongoing investigations regarding delirium in these complicated neurocritically ill patients.
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Affiliation(s)
- Mayur B. Patel
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
- Section of Surgical Sciences, Departments of Surgery, Neurosurgery, Hearing & Speech Sciences, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN; Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Josef Bednarik
- Department of Neurology, University Hospital Brno, Czech Republic
- Applied Neuroscience Research Group, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Patricia Lee
- Center for Knowledge Management, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yahya Shehabi
- University New South Wales, Clinical School of Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Jorge I. Salluh
- D’Or Institute for Research and Education, Rio De Janeiro, Brazil
| | - Arjen J. Slooter
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Kate E. Klein
- Novant Health Presbyterian Medical Center, Charlotte, NC, USA
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, Canada
| | - Alessandro Morandi
- Department of Rehabilitation and Aged Care of the Fondazione Camplani, Ancelle Hospital, Cremona, Italy. Geriatric Research Group, Brescia, Italy
| | - Peter E. Spronk
- Department of Intensive Care, Gelre Ziekenhuizen (Lukas), the Netherlands
| | - Andrew M. Naidech
- Departments of Neurology (Stroke and Neurocritical Care), Neurological Surgery, Anesthesiology, Medical Social Sciences, and Preventive Medicine (Health and Biomedical Informatics), Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Brenda T. Pun
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fernando A. Bozza
- Intensive Care Lab, Instituto Nacioinal de Infectologia Evandro, Chagas (INI), Fundacao Oswaldo Cruz, (FIOCRUZ), Rio De Janeiro, Brazil
| | - Annachiara Marra
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurosciences and Department of Public Health, University of Naples, Italy
| | - Sayona John
- Section of Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Pratik P. Pandharipande
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN; Anesthesiology Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E. Wesley Ely
- ICU Delirium and Cognitive Impairment Study Group, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Abstract
PURPOSE OF THE REVIEW To discuss the diagnostic approach to patients with septic encephalopathy as well as the need for specific neuro-monitoring and the perspectives on future therapeutic approaches in this setting. RECENT FINDINGS Most of data-concern experimental studies evaluating the pathophysiology of septic encephalopathy. A combination of neurodegenerative pathways with neurovascular injury is the cornerstone for the development of such complication and the long-term neurological sequelae among survivors. Septic encephalopathy is a common complication in septic patients. Clinical presentation may range from mild confusion and disorientation to convulsions and deep coma. The diagnosis of septic encephalopathy is made difficult by the lack of any specific clinical and non-clinical feature, in particular among sedated patients in whom neurological examination is unreliable. In spite of the high mortality rate associated with this condition, there is no prophylactic or targeted therapy to reduce or minimize brain damage in septic patients and clinical management is limited to the treatment of the underlying infection.
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Kyeong S, Shin JE, Yang KH, Lee WS, Chung TS, Kim JJ. Neural predisposing factors of postoperative delirium in elderly patients with femoral neck fracture. Sci Rep 2018; 8:7602. [PMID: 29765105 PMCID: PMC5954080 DOI: 10.1038/s41598-018-26030-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/30/2018] [Indexed: 01/18/2023] Open
Abstract
Elderly adults are more likely to develop delirium after major surgery, but there is limited knowledge of the vulnerability for postoperative delirium. In this study, we aimed to identify neural predisposing factors for postoperative delirium and develop a prediction model for estimating an individual’s probability of postoperative delirium. Among 57 elderly participants with femoral neck fracture, 25 patients developed postoperative delirium and 32 patients did not. We preoperatively obtained data for clinical assessments, anatomical MRI, and resting-state functional MRI. Then we evaluated gray matter (GM) density, fractional anisotropy, and the amplitude of low-frequency fluctuation (ALFF), and conducted a group-level inference. The prediction models were developed to estimate an individual’s probability using logistic regression. The group-level analysis revealed that neuroticism score, ALFF in the dorsolateral prefrontal cortex, and GM density in the caudate/suprachiasmatic nucleus were predisposing factors. The prediction model with these factors showed a correct classification rate of 86% using a leave-one-out cross-validation. The predicted probability computed from the logistic model was significantly correlated with delirium severity. These results suggest that the three components are the most important predisposing factors for postoperative delirium, and our prediction model may reflect the core pathophysiology in estimating the probability of postoperative delirium.
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Affiliation(s)
- Sunghyon Kyeong
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Eun Shin
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Hyun Yang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Suk Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Sub Chung
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Jin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Perioperative Research into Memory (PRiMe): Cognitive impairment following a severe burn injury and critical care admission, part 1. Burns 2018; 44:1167-1178. [PMID: 29752016 DOI: 10.1016/j.burns.2018.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 03/20/2018] [Accepted: 04/10/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION An investigation into long-term cognitive impairment and Quality of Life (QoL) after severe burns. METHODS A proof of principle, cohort design, prospective, observational clinical study. Patients with severe burns (>15% TBSA) admitted to Burns ICU for invasive ventilation were recruited for psychocognitive assessment with a convenience sample of age and sex-matched controls. Participants completed psychological and QoL questionnaires, the Cogstate® electronic battery, Hopkins Verbal Learning, Verbal Fluency and Trail making tasks. RESULTS 15 patients (11M, 4F; 41±14 years; TBSA 38.4%±18.5) and comparators (11M, 4F; 40±13 years) were recruited. Burns patients reported worse QoL (Neuro-QoL Short Form v2, patient 30.1±8.2, control 38.7±3.2, p=0.0004) and cognitive function (patient composite z-score 0.01, IQR -0.11 to 0.33, control 0.13, IQR 0.47-0.73, p=0.02). Compared to estimated premorbid FSIQ, patients dropped an equivalent of 8 IQ points (p=0.002). Cognitive function negatively correlated with burn severity (rBaux score, p=0.04). QoL strongly correlated with depressive symptoms (Rho=-0.67, p=0.009) but not cognitive function. CONCLUSIONS Severe burns injuries are associated with a significant, global, cognitive deficit. Patients also report worse QoL, depression and post-traumatic stress. Perceived QoL from cognitive impairment was more closely associated with depression than cognitive impairment.
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Gotur DB. Delirium in the Critically Ill. JOURNAL OF MEDICAL SCIENCES AND HEALTH 2018. [DOI: 10.46347/jmsh.2018.v04i01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Huang C, Mårtensson J, Gögenur I, Asghar MS. Exploring Postoperative Cognitive Dysfunction and Delirium in Noncardiac Surgery Using MRI: A Systematic Review. Neural Plast 2018; 2018:1281657. [PMID: 29743884 PMCID: PMC5878869 DOI: 10.1155/2018/1281657] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/09/2018] [Indexed: 12/25/2022] Open
Abstract
Surgical patients are at high risk of developing postoperative cognitive dysfunction (POCD) and postoperative delirium (POD). POCD and POD are associated with increased morbidity and mortality and worsening functional outcomes leading to severe socioeconomic consequences for the patient and the society in general. Magnetic resonance imaging (MRI) offers a unique opportunity to study the anatomy and function of the brain. MRI thus plays an important role in elucidating the neuronal component of POCD and POD. Our aim has been to systematically gather MRI findings that are related to POCD and POD. Systematic searches were conducted in PubMed, EMBASE, and PsycINFO: MRI studies investigating patients with POCD as identified by perioperative cognitive testing or patients with delirium identified postoperatively by the Confusion Assessment Method. A total of ten eligible papers were included with a total of 269 surgical patients, 36 patient controls, and 55 healthy controls who all underwent MRI examination. These studies suggested that reduction of thalamic and hippocampal volumes and reduction of cerebral blood flow may be associated with POCD, while presurgery/preexisting and postoperative white matter pathology may be associated with POD. However, the evidence from these studies is rather weak. Future MRI studies are warranted to verify the current findings.
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Affiliation(s)
- Chenxi Huang
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Copenhagen University Hospital, Køge, Denmark
| | | | - Ismail Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Copenhagen University Hospital, Køge, Denmark
| | - Mohammad Sohail Asghar
- Department of Neuroanaesthesia and Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Aranake-Chrisinger A, Cheng JZ, Muench MR, Tang R, Mickle A, Maybrier H, Lin N, Wildes T, Lenze E, Avidan MS. Ability of postoperative delirium to predict intermediate-term postoperative cognitive function in patients undergoing elective surgery at an academic medical centre: protocol for a prospective cohort study. BMJ Open 2018; 8:e017079. [PMID: 29550773 PMCID: PMC5875681 DOI: 10.1136/bmjopen-2017-017079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common complication in elderly patients, characterised by a fluctuating course of altered consciousness, disordered thinking and inattention. Preliminary research has linked POD with persistent cognitive impairment and decreased quality of life. However, these findings maybe confounded by patient comorbidities, postoperative complications and frailty. Our objective is to determine whether POD is an independent risk factor for persistent impairments in attention and executive function after elective surgery. Our central hypothesis is that patients with POD are more likely to have declines in cognition and quality of life 1 year after surgery compared with patients without POD. We aim to clarify whether these associations are independent of potentially confounding factors. We will also explore the association between POD and incident dementia. METHODS AND ANALYSIS This study will recruit 200 patients from the ongoing Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) study. Patients who live ≤45 miles from the study centre or have a planned visit to the centre 10-16 months postoperatively will be eligible. Patients with POD, measured by the Confusion Assessment Method, will be compared with patients without delirium. The primary outcome of cognitive function and secondary outcomes of quality of life and incident dementia will be compared between cohorts. Cognition will be measured by Trails A and B and Stroop Color and Word Test, quality of life with Veteran's RAND 12-item Health Survey and incident dementia with the Short Blessed Test. Multivariable regression analyses and a Cox proportional hazards analysis will be performed. All results will be reported with 95% CIs and α=0.05. ETHICS AND DISSEMINATION The study has been approved by the Washington University in St. Louis Institutional Review Board (IRB no 201601099). Plans for dissemination include scientific publications and presentations at scientific conferences. TRIAL REGISTRATION NUMBER NCT02241655.
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Affiliation(s)
- Amrita Aranake-Chrisinger
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Jenny Zhao Cheng
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Maxwell R Muench
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
- Kirksville College of Osteopathic Medicine, Kirksville, Missouri, USA
| | - Rose Tang
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Hannah Maybrier
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Nan Lin
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
- Division of Biostatistics, Department of Mathematics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Troy Wildes
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Eric Lenze
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Michael Simon Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
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Wang S, Allen D, Kheir YN, Campbell N, Khan B. Aging and Post-Intensive Care Syndrome: A Critical Need for Geriatric Psychiatry. Am J Geriatr Psychiatry 2018; 26:212-221. [PMID: 28716375 PMCID: PMC5711627 DOI: 10.1016/j.jagp.2017.05.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 01/31/2023]
Abstract
Because of the aging of the intensive care unit (ICU) population and an improvement in survival rates after ICU hospitalization, an increasing number of older adults are suffering from long-term impairments because of critical illness, known as post-intensive care syndrome (PICS). This article focuses on PICS-related cognitive, psychological, and physical impairments and the impact of ICU hospitalization on families and caregivers. The authors also describe innovative models of care for PICS and what roles geriatric psychiatrists could play in the future of this rapidly growing population.
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Affiliation(s)
- Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN; Center of Health Innovation and Implementation Science, Center for Translational Science and Innovation, Indianapolis, IN; Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Hospital, Indianapolis, IN.
| | - Duane Allen
- Department of Internal Medicine, and Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - You Na Kheir
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Noll Campbell
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Hospital, Indianapolis, IN; Department of Pharmacy Practice, Purdue University School of Pharmacy, West Lafayette, IN; IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
| | - Babar Khan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN; Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Hospital, Indianapolis, IN; IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
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Sakusic A, O'Horo JC, Dziadzko M, Volha D, Ali R, Singh TD, Kashyap R, Farrell AM, Fryer JD, Petersen R, Gajic O, Rabinstein AA. Potentially Modifiable Risk Factors for Long-Term Cognitive Impairment After Critical Illness: A Systematic Review. Mayo Clin Proc 2018; 93:68-82. [PMID: 29304923 DOI: 10.1016/j.mayocp.2017.11.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/03/2017] [Accepted: 11/13/2017] [Indexed: 01/08/2023]
Abstract
Long-term cognitive impairment is common in survivors of critical illness. Little is known about the etiology of this serious complication. We sought to summarize current scientific knowledge about potentially modifiable risk factors during intensive care unit (ICU) treatment that may play a substantial role in the development of long-term cognitive impairment. All searches were run on October 1, 2017. The search strategy included Ovid MEDLINE, Ovid Embase, Ovid CDR, Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effect, Scopus, and Web of Science, and included MeSH headings and keywords related to intensive care, critical care, and cognitive disorders. Searches were restricted to adult subjects. Inclusion required follow-up cognitive evaluation at least 2 months after ICU discharge. Studies assessing patients with cardiac arrest, traumatic brain injury, and cardiac surgery history were excluded. The search strategy resulted in 3180 studies. Of these, 28 studies (.88%) met our inclusion criteria and were analyzed. Delirium and duration of delirium were associated with long-term cognitive impairment after ICU admission in 6 of 9 studies in which this factor was analyzed. Weaker and more inconsistent associations have been reported with hypoglycemia, hyperglycemia, fluctuations in serum glucose levels, and in-hospital acute stress symptoms. Instead, most of the studies did not find significant associations between long-term cognitive impairment and mechanical ventilation; use of sedatives, vasopressors, or analgesic medications; enteral feeding; hypoxia; extracorporeal membrane oxygenation; systolic blood pressure; pulse rate; or length of ICU stay. Prolonged delirium may be a risk factor for long-term cognitive impairment after critical illness, though this association has not been entirely consistent across studies. Other potentially preventable factors have not been shown to have strong or consistent associations with long-term cognitive dysfunction in survivors of critical illness.
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Affiliation(s)
- Amra Sakusic
- Department of Physiology, Faculty of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina; University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina; Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - John C O'Horo
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Mikhail Dziadzko
- Department of Anesthesiology, Mayo Clinic, Rochester, MN; Department of Anesthesiology, CHU Croix Rousse, Lyon, France
| | - Dziadzko Volha
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Rashid Ali
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Tarun D Singh
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | | | - John D Fryer
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL
| | | | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN.
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Boukrina O, Barrett AM. Disruption of the ascending arousal system and cortical attention networks in post-stroke delirium and spatial neglect. Neurosci Biobehav Rev 2017; 83:1-10. [PMID: 28963037 DOI: 10.1016/j.neubiorev.2017.09.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 08/11/2017] [Accepted: 09/22/2017] [Indexed: 11/22/2022]
Abstract
Delirium is an acute attention and cognitive dysfunction, adversely affecting functional outcomes and mortality. As many as half of hospitalized right brain stroke survivors may develop delirium. Further, about 50% of right stroke patients experience spatial neglect, impairing safety and recovery. In this review we explore the brain mechanisms, which may explain the high incidence of delirium and spatial neglect after right-brain stroke. We suggest that brain networks for spatial attention and arousal, composed of ascending projections from the midbrain nuclei and integrating dorsal and ventral cortical and limbic components, may underlie impairments in delirium and spatial neglect. We propose that lateralized deficits in spatial neglect may arise because cortical and limbic components of these functional networks are disproportionally impaired by right-brain strokes, and that spatial neglect may lower the threshold for developing delirium. An improved understanding of the brain basis of delirium and spatial neglect could provide a critical biomarker for initiating preventive care in stroke patients at high risk of hospital morbidity and loss of independence.
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Affiliation(s)
- Olga Boukrina
- Stroke Rehabilitation Research, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ, 07052, USA.
| | - A M Barrett
- Stroke Rehabilitation Research, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ, 07052, USA; Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, 185 S Orange Avenue, Newark, NJ, 07103, USA; Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ, USA.
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Maldonado JR. Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium. Crit Care Clin 2017; 33:461-519. [PMID: 28601132 DOI: 10.1016/j.ccc.2017.03.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.
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Affiliation(s)
- José R Maldonado
- Psychosomatic Medicine Service, Emergency Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stanford, CA 94305-5718, USA.
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Marra A, Pandharipande PP, Patel MB. Intensive Care Unit Delirium and Intensive Care Unit-Related Posttraumatic Stress Disorder. Surg Clin North Am 2017; 97:1215-1235. [PMID: 29132506 PMCID: PMC5747308 DOI: 10.1016/j.suc.2017.07.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Delirium is one of the most common behavioral manifestations of acute brain dysfunction in the intensive care unit (ICU) and is a strong predictor of worse outcome. Routine monitoring for delirium is recommended for all ICU patients using validated tools. In delirious patients, a search for all reversible precipitants is the first line of action and pharmacologic treatment should be considered when all causes have been ruled out, and it is not contraindicated. Long-term morbidity has significant consequences for survivors of critical illness and for their caregivers. ICU patients may develop posttraumatic stress disorder related to their critical illness experience.
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Affiliation(s)
- Annachiara Marra
- Doctoral Candidate, University of Naples Federico II, Visiting Research Fellow, Center for Health Services Research, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, 1215 21st Avenue South, Medical Center East, Suite 6100, Nashville, TN 37232-8300
| | - Pratik P. Pandharipande
- Professor of Anesthesiology and Surgery, Chief, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Center for Health Services Research, Vanderbilt University Medical Center, 1211 21st Avenue South, Medical Arts Building, Suite 526, Nashville, TN 37212
| | - Mayur B. Patel
- Assistant Professor of Surgery, Neurosurgery, Hearing & Speech Sciences, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Section of Surgical Sciences, Center for Health Services Research, Vanderbilt Brain Institute, Vanderbilt University Medical Center, 1211 21st Avenue South, Medical Arts Building, Suite 404, Nashville, TN 37212
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Ehler J, Barrett LK, Taylor V, Groves M, Scaravilli F, Wittstock M, Kolbaske S, Grossmann A, Henschel J, Gloger M, Sharshar T, Chretien F, Gray F, Nöldge-Schomburg G, Singer M, Sauer M, Petzold A. Translational evidence for two distinct patterns of neuroaxonal injury in sepsis: a longitudinal, prospective translational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:262. [PMID: 29058589 PMCID: PMC5653470 DOI: 10.1186/s13054-017-1850-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/28/2017] [Indexed: 12/14/2022]
Abstract
Background Brain homeostasis deteriorates in sepsis, giving rise to a mostly reversible sepsis-associated encephalopathy (SAE). Some survivors experience chronic cognitive dysfunction thought to be caused by permanent brain injury. In this study, we investigated neuroaxonal pathology in sepsis. Methods We conducted a longitudinal, prospective translational study involving (1) experimental sepsis in an animal model; (2) postmortem studies of brain from patients with sepsis; and (3) a prospective, longitudinal human sepsis cohort study at university laboratory and intensive care units (ICUs). Thirteen ICU patients with septic shock, five ICU patients who died as a result of sepsis, fourteen fluid-resuscitated Wistar rats with fecal peritonitis, eleven sham-operated rats, and three human and four rat control subjects were included. Immunohistologic and protein biomarker analysis were performed on rat brain tissue at baseline and 24, 48, and 72 h after sepsis induction and in sham-treated rats. Immunohistochemistry was performed on human brain tissue from sepsis nonsurvivors and in control patients without sepsis. The clinical diagnostics of SAE comprised longitudinal clinical data collection and magnetic resonance imaging (MRI) and electroencephalographic assessments. Statistical analyses were performed using SAS software (version 9.4; SAS Institute, Inc., Cary, NC, USA). Because of non-Gaussian distribution, the nonparametric Wilcoxon test general linear models and the Spearman correlation coefficient were used. Results In postmortem rat and human brain samples, neurofilament phosphoform, β-amyloid precursor protein, β-tubulin, and H&E stains distinguished scattered ischemic lesions from diffuse neuroaxonal injury in septic animals, which were absent in controls. These two patterns of neuroaxonal damage were consistently found in septic but not control human postmortem brains. In experimental sepsis, the time from sepsis onset correlated with tissue neurofilament levels (R = 0.53, p = 0.045) but not glial fibrillary acidic protein. Of 13 patients with sepsis who had clinical features of SAE, MRI detected diffuse axonal injury in 9 and ischemia in 3 patients. Conclusions Ischemic and diffuse neuroaxonal injury to the brain in experimental sepsis, human postmortem brains, and in vivo MRI suggest these two distinct lesion types to be relevant. Future studies should be focused on body fluid biomarkers to detect and monitor brain injury in sepsis. The relationship of neurofilament levels with time from sepsis onset may be of prognostic value. Trial registration ClinicalTrials.gov, NCT02442986. Registered on May 13, 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1850-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johannes Ehler
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - Lucinda K Barrett
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Valerie Taylor
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Michael Groves
- Department of Pathology, UCL Institute of Neurology, University College London, London, UK
| | - Francesco Scaravilli
- Department of Pathology, UCL Institute of Neurology, University College London, London, UK
| | - Matthias Wittstock
- Department of Neurology, University Medical Center Rostock, Rostock, Germany
| | - Stephan Kolbaske
- Department of Neurology, University Medical Center Rostock, Rostock, Germany
| | - Annette Grossmann
- Institute for Diagnostic and Interventional Radiology, University Medical Center Rostock, Rostock, Germany
| | - Jörg Henschel
- Department of Internal Medicine, Intensive Care Unit, University Medical Center Rostock, Rostock, Germany
| | - Martin Gloger
- Department of Internal Medicine, Intensive Care Unit, University Medical Center Rostock, Rostock, Germany
| | - Tarek Sharshar
- General Intensive Care Medicine, Assistance Publique - Hôpitaux de Paris, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Paris, France
| | - Fabrice Chretien
- General Intensive Care Medicine, Assistance Publique - Hôpitaux de Paris, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Paris, France
| | - Francoise Gray
- General Intensive Care Medicine, Assistance Publique - Hôpitaux de Paris, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Paris, France
| | - Gabriele Nöldge-Schomburg
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Martin Sauer
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - Axel Petzold
- Department of Neuroimmunology, UCL Institute of Neurology, University College London, Queen Square, London, WC1N 3BG, UK.
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Jackson JC, Warrington HJ, Kessler R, Kiehl AL, Ely WE. Florbetapir-PET β-amyloid imaging and associated neuropsychological trajectories in survivors of critical illness: A case series. J Crit Care 2017; 44:331-336. [PMID: 29274595 DOI: 10.1016/j.jcrc.2017.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 10/02/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Cognitive impairment resembling Alzheimer's disease is common in survivors of critical illness. We hypothesized that Intensive Care Unit (ICU) survivors with cognitive impairment would have significant amyloid and designed a pilot study to explore this relationship. MATERIALS AND METHODS A pilot, case series of a convenience sample of 14 adult medical and surgical ICU survivors, in a clinical neuroradiology clinic. Patients underwent cognitive testing at 3months, 1year, 4years, and 6years after hospital discharge with the Repeatable Battery for the Assessment of Neuropsychological Status. They received a single PET scan using amyloid PET imaging (florbetapir F18) 2 to 4years after their ICU stay. RESULTS Amyloid (defined as a Standard Uptake Value ratio or SUVr >1.10) was present in 2 of 14 (14%) individuals, both of whom demonstrated significant cognitive impairment yet no consistent decline over time. Of the 6 impaired patients (RBANS<78), 4 (66.7%) were amyloid negative. CONCLUSIONS It is feasible to assess ICU survivors with amyloid imaging. In this small sample, most patients with cognitive impairment were negative on amyloid PET imaging, which raises the possibility that ICU survivors may experience a unique form of dementia not driven by an amyloid related mechanism.
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Affiliation(s)
- James C Jackson
- Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, United States; VA Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States.
| | - Hillary J Warrington
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, United States
| | - Robert Kessler
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Amy L Kiehl
- Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Wesley E Ely
- Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, United States; VA Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
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Latronico N, Minelli C, Eikermann M. Prediction of long-term outcome subtypes in ARDS: first steps towards personalised medicine in critical care. Thorax 2017; 72:1067-1068. [PMID: 28988218 DOI: 10.1136/thoraxjnl-2017-210775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Department of Anesthesia, Critical Care and Emergency, Brescia University Hospital, Brescia, Italy
| | - Cosetta Minelli
- Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College London, London, UK
| | - Matthias Eikermann
- Department of Anesthesia, Critical and Pain Medicine, Beth Israel Deconness Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Paterson RS, Kenardy JA, De Young AC, Dow BL, Long DA. Delirium in the Critically Ill Child: Assessment and Sequelae. Dev Neuropsychol 2017; 42:387-403. [PMID: 28949771 DOI: 10.1080/87565641.2017.1374961] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Delirium is a common and serious neuropsychiatric complication in critically ill patients of all ages. In the context of critical illness, delirium may emerge as a result of a cascade of underlying pathophysiologic mechanisms and signals organ failure of the brain. Awareness of the clinical importance of delirium in adults is growing as emerging research demonstrates that delirium represents a serious medical problem with significant sequelae. However, our understanding of delirium in children lags significantly behind the adult literature. In particular, our knowledge of how to assess delirium is complicated by challenges in recognizing symptoms of delirium in pediatric patients especially in critical and intensive care settings, and our understanding of its impact on acute and long-term functioning remains in its infancy. This paper focuses on (a) the challenges associated with assessing delirium in critically ill children, (b) the current literature on the outcomes of delirium including morbidity following discharge from PICU, and care-giver well-being, and (c) the importance of assessment in determining impact of delirium on outcome. Current evidence suggests that delirium is a diagnostic challenge for clinicians and may play a detrimental role in a child's recovery after discharge from the pediatric intensive care unit (PICU). Recommendations are proposed for how our knowledge and assessment of delirium in children could be improved.
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Affiliation(s)
- Rebecca S Paterson
- a School of Psychology , The University of Queensland , Brisbane , Australia.,c Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland , Brisbane , QLD , Australia
| | - Justin A Kenardy
- a School of Psychology , The University of Queensland , Brisbane , Australia.,b RECOVER Injury Research Centre , The University of Queensland , Brisbane , Australia
| | - Alexandra C De Young
- d Centre for Children's Burn and Trauma Research, The University of Queensland , Brisbane , Australia
| | - Belinda L Dow
- b RECOVER Injury Research Centre , The University of Queensland , Brisbane , Australia
| | - Debbie A Long
- c Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland , Brisbane , QLD , Australia.,e Paediatric Intensive Care Unit, Lady Cilento Children's Hospital , Brisbane , Australia
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Cavallari M, Dai W, Guttmann CRG, Meier DS, Ngo LH, Hshieh TT, Fong TG, Schmitt E, Press DZ, Travison TG, Marcantonio ER, Jones RN, Inouye SK, Alsop DC. Longitudinal diffusion changes following postoperative delirium in older people without dementia. Neurology 2017; 89:1020-1027. [PMID: 28779010 DOI: 10.1212/wnl.0000000000004329] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 06/13/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the effect of postoperative delirium on longitudinal brain microstructural changes, as measured by diffusion tensor imaging. METHODS We studied a subset of the larger Successful Aging after Elective Surgery (SAGES) study cohort of older adults (≥70 years) without dementia undergoing elective surgery: 113 participants who had diffusion tensor imaging before and 1 year after surgery. Postoperative delirium severity and occurrence were assessed during the hospital stay using the Confusion Assessment Method and a validated chart review method. We investigated the association of delirium severity and occurrence with longitudinal diffusion changes across 1 year, adjusting for age, sex, vascular comorbidity, and baseline cognitive performance. We also assessed the association between changes in diffusion and cognitive performance across the 1-year follow-up period, adjusting for age, sex, education, and baseline cognitive performance. RESULTS Postoperative delirium occurred in 25 participants (22%). Delirium severity and occurrence were associated with longitudinal diffusion changes in the periventricular, frontal, and temporal white matter. Diffusion changes were also associated with changes in cognitive performance across 1 year, although the cognitive changes did not show significant association with delirium severity or occurrence. CONCLUSIONS Our study raises the possibility that delirium has an effect on the development of brain microstructural abnormalities, which may reflect brain changes underlying cognitive trajectories. Future studies are warranted to clarify whether delirium is the driving factor of the observed changes or rather a correlate of a vulnerable brain that is at high risk for neurodegenerative processes.
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Affiliation(s)
- Michele Cavallari
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Weiying Dai
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Charles R G Guttmann
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Dominik S Meier
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Long H Ngo
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Tammy T Hshieh
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Tamara G Fong
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Eva Schmitt
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Daniel Z Press
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Thomas G Travison
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Edward R Marcantonio
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Richard N Jones
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Sharon K Inouye
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
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Alzheimer's-related cortical atrophy is associated with postoperative delirium severity in persons without dementia. Neurobiol Aging 2017; 59:55-63. [PMID: 28846882 DOI: 10.1016/j.neurobiolaging.2017.07.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 01/31/2023]
Abstract
Patients with dementia due to Alzheimer's disease (AD) have increased risk of developing delirium. This study investigated the relationship between a magnetic resonance imaging (MRI)-derived biomarker associated with preclinical AD and postoperative delirium. Participants were older adults (≥70 years) without dementia who underwent preoperative MRI and elective surgery. Delirium incidence and severity were evaluated daily during hospitalization. Cortical thickness was averaged across a published set of a priori brain regions to derive a measure known as the "AD signature." Logistic and linear regression was used, respectively, to test whether the AD signature was associated with delirium incidence in the entire sample (N = 145) or with the severity of delirium among those who developed delirium (N = 32). Thinner cortex in the AD signature did not predict incidence of delirium (odds ratio = 1.15, p = 0.38) but was associated with greater delirium severity among those who developed delirium (b = -1.2, p = 0.014). These results suggest that thinner cortices, perhaps reflecting underlying neurodegeneration due to preclinical AD, may serve as a vulnerability factor that increases severity once delirium occurs.
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131
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Dong R, Sun L, Lu Y, Yang X, Peng M, Zhang Z. NeurimmiRs and Postoperative Delirium in Elderly Patients Undergoing Total Hip/Knee Replacement: A Pilot Study. Front Aging Neurosci 2017; 9:200. [PMID: 28690539 PMCID: PMC5481321 DOI: 10.3389/fnagi.2017.00200] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 06/06/2017] [Indexed: 12/20/2022] Open
Abstract
Objective: Postoperative delirium (POD) is a frequent complication after surgery and its occurrence is associated with poor outcomes. The pathophysiology of this complication is not clear, but identification of risk factors is important for positive postoperative outcomes. The purpose of this study was to investigate the associations between the preoperative expression levels of microRNA (miR)-146a, miR-125b, and miR-181c in cerebrospinal fluid (CSF) and serum and the development and severity of POD. Methods: Forty elderly patients aged 65 years old and older admitted for elective total hip/knee replacement under spinal anesthesia. Preoperatively, baseline cognitive function was assessed using the Mini-Mental State Examination. Each patient was interviewed daily on the first and second postoperative days. Delirium was diagnosed using the Confusion Assessment Method, and delirium severity was measured using the Memorial Delirium Assessment Scale (MDAS). Preoperative serum and CSF miR levels were determined by quantitative real-time PCR (qRT-PCR). Results: POD was detected in 27.5% (11/40) of patients. Up-regulation of miR-146a and miR-181c in CSF and down-regulation of miR-146a in serum were observed preoperatively in patients who developed POD, while patients with and without POD did not differ in serum or CSF levels of miR-125b. Delirious patients had higher CSF/serum ratios of miR-146a and miR-181c levels than non-delirious patients. The lower CSF miR-146a and CSF/serum miR-146a ratios were significantly associated with milder POD severity, represented by a lower MDAS score. Conclusion: The dysregulation of preoperative miR-146a and miR-181c in CSF and serum was associated with the development and severity of POD. These NeurimmiRs might participate in the neuropathogenesis of POD, pending further investigations. Clinical trial registration: this study was registered at ClinicalTrials.gov (NCT02817386).
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Affiliation(s)
- Rui Dong
- Department of Anesthesiology, Zhongnan Hospital of Wuhan UniversityWuhan, China
| | - Lingling Sun
- Department of Anesthesiology, Zhongnan Hospital of Wuhan UniversityWuhan, China
| | - Yayuan Lu
- Department of Anesthesiology, Zhongnan Hospital of Wuhan UniversityWuhan, China
| | - Xi Yang
- Department of Anesthesiology, Zhongnan Hospital of Wuhan UniversityWuhan, China
| | - Mian Peng
- Department of Anesthesiology, Zhongnan Hospital of Wuhan UniversityWuhan, China
| | - Zongze Zhang
- Department of Anesthesiology, Zhongnan Hospital of Wuhan UniversityWuhan, China
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Munro CL, Cairns P, Ji M, Calero K, Anderson WM, Liang Z. Delirium prevention in critically ill adults through an automated reorientation intervention - A pilot randomized controlled trial. Heart Lung 2017; 46:234-238. [PMID: 28606450 DOI: 10.1016/j.hrtlng.2017.05.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 05/04/2017] [Accepted: 05/05/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Explore the effect of an automated reorientation intervention on ICU delirium in a prospective randomized controlled trial. BACKGROUND Delirium is common in ICU patients, and negatively affects outcomes. Few prevention strategies have been tested. METHODS Thirty ICU patients were randomized to 3 groups. Ten received hourly recorded messages in a family member's voice during waking hours over 3 ICU days, 10 received the same messages in a non-family voice, and 10 (control) did not receive any automated reorientation messages. The primary outcome was delirium free days during the intervention period (evaluated by CAM-ICU). Groups were compared by Fisher's Exact Test. RESULTS The family voice group had more delirium free days than the non-family voice group, and significantly more delirium free days (p = 0.0437) than the control group. CONCLUSIONS Reorientation through automated, scripted messages reduced incidence of delirium. Using identical scripted messages, family voice was more effective than non-family voice.
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Affiliation(s)
- Cindy L Munro
- University of South Florida College of Nursing, 12901 Bruce B. Downs Blvd, MDC 22, Tampa, FL 33612-4766, USA.
| | - Paula Cairns
- University of South Florida College of Nursing, 12901 Bruce B. Downs Blvd, MDC 22, Tampa, FL 33612-4766, USA
| | - Ming Ji
- University of South Florida College of Nursing, 12901 Bruce B. Downs Blvd, MDC 22, Tampa, FL 33612-4766, USA
| | - Karel Calero
- University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd, MDC 19, Tampa, FL 33612-4766, USA
| | - W McDowell Anderson
- University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd, MDC 19, Tampa, FL 33612-4766, USA
| | - Zhan Liang
- University of South Florida College of Nursing, 12901 Bruce B. Downs Blvd, MDC 22, Tampa, FL 33612-4766, USA
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Detweiler MB, Sherigar RM, Bader G, Sullivan K, Kenneth A, Kalafat N, Reddy P, Lutgens B. Association of White Matter Lesions, Cerebral Atrophy, Intracranial Extravascular Calcifications, and Ventricular-Communicating Hydrocephalus with Delirium Among Veterans. South Med J 2017; 110:432-439. [DOI: 10.14423/smj.0000000000000663] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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134
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Luther R, McLeod A. The effect of chronotherapy on delirium in critical care - a systematic review. Nurs Crit Care 2017; 23:283-290. [PMID: 28508438 DOI: 10.1111/nicc.12300] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Delirium is highly prevalent within critical care and is linked to adverse clinical outcomes, increased mortality and impaired quality of life. Development of delirium is thought to be caused by multiple risk factors, including disruption of the circadian rhythm. Chronotherapeutic interventions, such as light therapy, music and use of eye shades, have been suggested as an option to improve circadian rhythm within intensive care units. AIM This review aims to answer the question: Can chronotherapy reduce the prevalence of delirium in adult patients in critical care? DESIGN This study is a systematic review of quantitative studies. RESEARCH METHOD Six major electronic databases were searched, and a hand search was undertaken using selected key search terms. Research quality was assessed using the critical appraisal skills programme tools. The studies were critically appraised by both authors independently, and data were extracted. Four themes addressing the research question were identified and critically evaluated. FINDINGS Six primary research articles that investigated different methods of chronotherapy were identified, and the results suggest that multi-component non-pharmacological interventions are the most effective for reducing the prevalence of delirium in critical care. The melatonergic agonist Ramelteon demonstrated statistically significant reductions in delirium; however, the reliability of the results in answering the review question was limited by the research design. The use of bright light therapy (BLT) and dynamic light application had mixed results, with issues with the research design and outcomes measured limiting the validity of the findings. CONCLUSION Multi-component non-pharmacological interventions, such as noise and light control, can reduce delirium in critical care, whereas other interventions, such as BLT, have mixed outcomes. Melatonin, as a drug, may be a useful alternative to sedative-hypnotics. RELEVANCE TO CLINICAL PRACTICE Chronotherapy can reduce the incidence of delirium within critical care, although further research is warranted. Staff education is essential in the implementation of chronotherapy.
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Affiliation(s)
- Roseanne Luther
- Acute Care Unit, Homerton University Hospital, Homerton NHS Trust, London, UK
| | - Anne McLeod
- Senior Lecturer in Critical Care, School of Health Sciences City, University of London, Northampton Square, London, UK
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Inoue R, Sumitani M, Ogata T, Chikuda H, Matsubara T, Kato S, Shimojo N, Uchida K, Yamada Y. Direct evidence of central nervous system axonal damage in patients with postoperative delirium: A preliminary study of pNF-H as a promising serum biomarker. Neurosci Lett 2017; 653:39-44. [PMID: 28504118 DOI: 10.1016/j.neulet.2017.05.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/10/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Approximately 50-80% patients experience postoperative delirium, an acute cognitive dysfunction associated with prolonged hospitalization, increased mortality, excess healthcare costs, and persistent cognitive impairment. Elucidation of the mechanism of delirium and associated diagnostic and therapeutic measures are urgently required. Here we investigated the role of phosphorylated neurofilament heavy subunit (pNF-H), a major structural protein in axons, as a predictive maker of postoperative delirium. MATERIAL AND METHODS Twenty-three patients who underwent surgery for abdominal cancer were screened for postoperative delirium, and they were assessed for its severity using the memorial delirium assessment scale (MDAS) at and 48h after delirium onset. Serum pNF-H levels were also measured at both time points. The patients were divided into two groups according to the presence or absence of pNF-H. Clinical variables were compared between groups using the Mann-Whitney U test, and the relationship between pNF-H levels and delirium severity was analyzed using the exponential curve fitting. RESULTS Fifteen of the 23 (65.2%) patients tested positive for pNF-H, and these patients exhibited significantly higher MDAS scores compared with the pNF-H-negative patients only at the onset of delirium. Although the MDAS score significantly improved over time in the positive group, pNF-H positivity persisted. There was a correlation between the maximum pNF-H level and maximum MDAS score (R2=0.31, p=0.013). CONCLUSIONS More severe postoperative delirium was directly related to higher serum pNF-H levels, suggesting the potential application of pNF-H as a quantitative biomarker of neural damage in postoperative delirium.
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Affiliation(s)
- Reo Inoue
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan.
| | - Toru Ogata
- Research Institute, National Rehabilitation Center for Persons with Disabilities, Saitama, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Takehiro Matsubara
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - So Kato
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Nobutake Shimojo
- Department of Critical Care Medicine, Tsukuba University Hospital, Ibaraki, Japan
| | - Kanji Uchida
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitsugu Yamada
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
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Potentially modifiable factors contributing to sepsis-associated encephalopathy. Intensive Care Med 2017; 43:1075-1084. [PMID: 28466149 DOI: 10.1007/s00134-017-4807-z] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 04/17/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Identifying modifiable factors for sepsis-associated encephalopathy may help improve patient care and outcomes. METHODS We conducted a retrospective analysis of a prospective multicenter database. Sepsis-associated encephalopathy (SAE) was defined by a score on the Glasgow coma scale (GCS) <15 or when features of delirium were noted. Potentially modifiable risk factors for SAE at ICU admission and its impact on mortality were investigated using multivariate logistic regression analysis and Cox proportional hazard modeling, respectively. RESULTS We included 2513 patients with sepsis at ICU admission, of whom 1341 (53%) had sepsis-associated encephalopathy. After adjusting for baseline characteristics, site of infection, and type of admission, the following factors remained independently associated with sepsis-associated encephalopathy: acute renal failure [adjusted odds ratio (aOR) = 1.41, 95% confidence interval (CI) 1.19-1.67], hypoglycemia <3 mmol/l (aOR = 2.66, 95% CI 1.27-5.59), hyperglycemia >10 mmol/l (aOR = 1.37, 95% CI 1.09-1.72), hypercapnia >45 mmHg (aOR = 1.91, 95% CI 1.53-2.38), hypernatremia >145 mmol/l (aOR = 2.30, 95% CI 1.48-3.57), and S. aureus (aOR = 1.54, 95% CI 1.05-2.25). Sepsis-associated encephalopathy was associated with higher mortality, higher use of ICU resources, and longer hospital stay. After adjusting for age, comorbidities, year of admission, and non-neurological SOFA score, even mild alteration of mental status (i.e., a score on the GCS of 13-14) remained independently associated with mortality (adjusted hazard ratio = 1.38, 95% CI 1.09-1.76). CONCLUSIONS Acute renal failure and common metabolic disturbances represent potentially modifiable factors contributing to sepsis-associated encephalopathy. However, a true causal relationship has yet to be demonstrated. Our study confirms the prognostic significance of mild alteration of mental status in patients with sepsis.
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Abstract
Neurologic complications in polytrauma can be classified by etiology and clinical manifestations: neurovascular, delirium, and spinal or neuromuscular problems. Neurovascular complications include ischemic strokes, intracranial hemorrhage, or the development of traumatic arteriovenous fistulae. Delirium and encephalopathy have a reported incidence of 67-92% in mechanically ventilated polytrauma patients. Causes include sedation, analgesia/pain, medications, sleep deprivation, postoperative state, toxic ingestions, withdrawal syndromes, organ system dysfunction, electrolyte/metabolic abnormalities, and infections. Rapid identification and treatment of the underlying cause are imperative. Benzodiazepines increase the risk of delirium, and alternative agents are preferred sedatives. Pharmacologic treatment of agitated delirium can be achieved with antipsychotics. Nonconvulsive seizures and status epilepticus are not uncommon in surgical/trauma intensive care unit (ICU) patients, require electroencephalography for diagnosis, and need timely management. Spinal cord ischemia is a known complication in patients with traumatic aortic dissections or blunt aortic injury requiring surgery. Thoracic endovascular aortic repair has reduced the paralysis rate. Neuromuscular complications include nerve and plexus injuries, and ICU-acquired weakness. In polytrauma, the neurologic examination is often confounded by pain, sedation, mechanical ventilation, and distracting injuries. Regular sedation pauses for examination and maintaining a high index of suspicion for neurologic complications are warranted, particularly because early diagnosis and management can improve outcomes.
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138
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Numan T, Slooter AJC, van der Kooi AW, Hoekman AML, Suyker WJL, Stam CJ, van Dellen E. Functional connectivity and network analysis during hypoactive delirium and recovery from anesthesia. Clin Neurophysiol 2017; 128:914-924. [PMID: 28402867 DOI: 10.1016/j.clinph.2017.02.022] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 02/08/2017] [Accepted: 02/25/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To gain insight in the underlying mechanism of reduced levels of consciousness due to hypoactive delirium versus recovery from anesthesia, we studied functional connectivity and network topology using electroencephalography (EEG). METHODS EEG recordings were performed in age and sex-matched patients with hypoactive delirium (n=18), patients recovering from anesthesia (n=20), and non-delirious control patients (n=20), all after cardiac surgery. Functional and directed connectivity were studied with phase lag index and directed phase transfer entropy. Network topology was characterized using the minimum spanning tree (MST). A random forest classifier was calculated based on all measures to obtain discriminative ability between the three groups. RESULTS Non-delirious control subjects showed a back-to-front information flow, which was lost during hypoactive delirium (p=0.01) and recovery from anesthesia (p<0.01). The recovery from anesthesia group had more integrated network in the delta band compared to non-delirious controls. In contrast, hypoactive delirium showed a less integrated network in the alpha band. High accuracy for discrimination between hypoactive delirious patients and controls (86%) and recovery from anesthesia and controls (95%) were found. Accuracy for discrimination between hypoactive delirium and recovery from anesthesia was 73%. CONCLUSION Loss of functional and directed connectivity were observed in both hypoactive delirium and recovery from anesthesia, which might be related to the reduced level of consciousness in both states. These states could be distinguished in topology, which was a less integrated network during hypoactive delirium. SIGNIFICANCE Functional and directed connectivity are similarly disturbed during a reduced level of consciousness due to hypoactive delirium and sedatives, however topology was differently affected.
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Affiliation(s)
- Tianne Numan
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Arendina W van der Kooi
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Annemieke M L Hoekman
- Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Willem J L Suyker
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Heidelberglaan 100, The Netherlands
| | - Cornelis J Stam
- Department of Clinical Neurophysiology and MEG Center, Neuroscience Campus Amsterdam, VU University Medical Center, De Boelelaan 1085, Amsterdam, The Netherlands
| | - Edwin van Dellen
- Department of Psychiatry, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
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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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Matsumoto-Miyazaki J, Ushikoshi H, Miyata S, Miyazaki N, Nawa T, Okada H, Ojio S, Ogura S, Minatoguchi S. Acupuncture and Traditional Herbal Medicine Therapy Prevent Deliriumin Patients with Cardiovascular Disease in Intensive Care Units. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2017; 45:255-268. [PMID: 28231740 DOI: 10.1142/s0192415x17500161] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to determine the effect of combination therapy consisting of acupuncture and traditional herbal medicine (Kampo medicine) for reducing the incidence rate of delirium in patients with cardiovascular (CV) disease in ICUs. Twenty-nine patients who had been urgently admitted to the ICU in the control period were treated with conventional intensive care. Thirty patients in the treatment period received conventional therapy plus a combination therapy consisting of acupuncture and herbal medicine. Acupuncture treatment was performed once a day, and the herbal formula was administered orally three times a day during the first week of the ICU stay. The standard acupuncture points were GV20, Ex-HN3, HT7, LI4, Liv3, and KI3, and the main herbal preparation was Kamikihito. The incident rates of delirium, assessed using the confusion assessment method for ICU, in the treatment and control period were compared. The incidence rate of delirium was significantly lower in the treatment group than in the control group (6.6% vs. 37.9%, [Formula: see text]). Moreover, sedative drugs and non-pharmacological approaches against aggressive behavior of patients who were delirious were used less in the treatment group than in the control group. No serious adverse events were observed in the treatment group. Combination therapy consisting of acupuncture and herbal medicine was found to be effective in lowering the incidence of delirium in patients with CV disease in ICUs. Further studies with a large sample size and parallel randomized controlled design would be required to establish the effects of this therapy.
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Affiliation(s)
| | - Hiroaki Ushikoshi
- * Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan.,‡ Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Shusaku Miyata
- * Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan.,‡ Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan.,§ Department of Cardiology, Gifu Municipal Hospital, Gifu, Japan
| | - Nagisa Miyazaki
- * Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan.,¶ Department of Internal Medicine, Asahi University, Gifu, Japan
| | - Takahide Nawa
- * Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hideshi Okada
- † Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,‡ Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Shinsuke Ojio
- * Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan.,‡ Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan.,§ Department of Cardiology, Gifu Municipal Hospital, Gifu, Japan
| | - Shinji Ogura
- † Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,‡ Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Shinya Minatoguchi
- * Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
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Pierrakos C, Attou R, Decorte L, Velissaris D, Cudia A, Gottignies P, Devriendt J, Tsolaki M, De Bels D. Cerebral perfusion alterations and cognitive decline in critically ill sepsis survivors. Acta Clin Belg 2017; 72:39-44. [PMID: 27352195 DOI: 10.1080/17843286.2016.1191851] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION We investigated the association between cerebral perfusion perturbations in sepsis with possible cognitive decline (CD) after patients' discharge from the intensive care unit (ICU). METHODS We studied 28 patients with sepsis and Lawton's Instrumental Activities of Daily Living scale (IADL) scores ≥5 who were discharged from a university ICU institution. We evaluated cerebral circulatory parameters (pulsatility index (PI) and cerebral blood flow index (CBFi) was calculated based on the measured velocity of the middle cerebral artery. Use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) test was performed daily, and either the Mini Mental State Examination test (MMSE) or Clock Drawing test was performed at ICU discharge. CD was categorized as persistent coma, positive CAM-ICU test at discharge, MMSE <24, or an abnormal Clock test. RESULTS Patients had a median pre-ICU IADL score of 6.3 (95% CI 5.9-6.7). Fourteen patients (50%) had CD at discharge. Two were in persistent coma despite sepsis resolution. Information recall was the most affected mental function of the other 12 patients. Only on the first day, patients with CD had higher PI and lower CBFi compared to those without CD (2.2 ± 0.7 vs. 1.4 ± 0.5, p = 0.02; 363 ± 170 vs. 499 ± 133, p = 0.03, respectively). Multivariable analysis revealed delirium, but not PI, as an independent prognostic factor for CD (OR: 29.62, 95%CI 1.91-458.01, p = 0.01). CONCLUSION Delirium, but not cerebral perfusion alterations, is an independent risk factor for cognitive impairment in septic patients who were discharged from the ICU.
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Affiliation(s)
- Charalampos Pierrakos
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Rachid Attou
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Laurence Decorte
- Geriatrics Department, Brugmann University Hospital, Université Libre de Bruxelles,Bruxelles, Belgium
| | | | - Antonella Cudia
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Philippe Gottignies
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Jacques Devriendt
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Magda Tsolaki
- 3rd Department of Neurology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - David De Bels
- Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
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Abstract
Delirium is common in critically ill patients and associated with increased length of stay in the intensive care unit (ICU) and long-term cognitive impairment. The pathophysiology of delirium has been explained by neuroinflammation, an aberrant stress response, neurotransmitter imbalances, and neuronal network alterations. Delirium develops mostly in vulnerable patients (e.g., elderly and cognitively impaired) in the throes of a critical illness. Delirium is by definition due to an underlying condition and can be identified at ICU admission using prediction models. Treatment of delirium can be improved with frequent monitoring, as early detection and subsequent treatment of the underlying condition can improve outcome. Cautious use or avoidance of benzodiazepines may reduce the likelihood of developing delirium. Nonpharmacologic strategies with early mobilization, reducing causes for sleep deprivation, and reorientation measures may be effective in the prevention of delirium. Antipsychotics are effective in treating hallucinations and agitation, but do not reduce the duration of delirium. Combined pain, agitation, and delirium protocols seem to improve the outcome of critically ill patients and may reduce delirium incidence.
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Affiliation(s)
- A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - R R Van De Leur
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Brain-Defective Insulin Signaling Is Associated to Late Cognitive Impairment in Post-Septic Mice. Mol Neurobiol 2016; 55:435-444. [PMID: 27966074 DOI: 10.1007/s12035-016-0307-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 11/16/2016] [Indexed: 12/26/2022]
Abstract
Sepsis survivors frequently develop late cognitive impairment. Because little is known on the mechanisms of post-septic memory deficits, there are no current effective approaches to prevent or treat such symptoms. Here, we subjected mice to severe sepsis induced by cecal ligation and puncture (CLP) and evaluated the sepsis-surviving animals in the open field, novel object recognition (NOR), and step-down inhibitory avoidance (IA) task at different times after surgery. Post-septic mice (30 days post-surgery) failed in the NOR and IA tests but exhibited normal performance when re-evaluated 45 days after surgery. Cognitive impairment in post-septic mice was accompanied by reduced hippocampal levels of proteins involved in synaptic plasticity, including synaptophysin, cAMP response element-binding protein (CREB), CREB phosphorylated at serine residue 133 (CREBpSer133), and GluA1 phosphorylated at serine residue 845 (GluA1pSer845). Expression of tumor necrosis factor α (TNF-α) was increased and brain insulin signaling was disrupted, as indicated by increased hippocampal IRS-1 phosphorylation at serine 636 (IRS-1pSer636) and decreased phosphorylation of IRS-1 at tyrosine 465 (IRS-1pTyr465), in the hippocampus 30 days after CLP. Phosphorylation of Akt at serine 473 (AktpSer473) and of GSK3 at serine 9 (GSK3βpSer9) were also decreased in hippocampi of post-septic animals, further indicating that brain insulin signaling is disrupted by sepsis. We then treated post-septic mice with liraglutide, a GLP-1 receptor agonist with insulinotropic activity, or TDZD-8, a GSK3β inhibitor, which rescued NOR memory. In conclusion, these results establish that hippocampal inflammation and disrupted insulin signaling are induced by sepsis and are linked to late memory impairment in sepsis survivors.
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Cognitive Impairment After Trauma and Orthopedic Injury: Key Issues, Identification, and Treatment. Tech Orthop 2016. [DOI: 10.1097/bto.0000000000000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kolanowski A, Fick D, Litaker M, Mulhall P, Clare L, Hill N, Mogle J, Boustani M, Gill D, Yevchak-Sillner A. Effect of Cognitively Stimulating Activities on Symptom Management of Delirium Superimposed on Dementia: A Randomized Controlled Trial. J Am Geriatr Soc 2016; 64:2424-2432. [PMID: 27861718 DOI: 10.1111/jgs.14511] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether cognitively stimulating activities would reduce duration and severity of delirium and improve cognitive and physical function to a greater extent than usual care. DESIGN Single-blind randomized clinical trial. SETTING Eight post-acute care (PAC) facilities. PARTICIPANTS Community-dwelling older adults with dementia and delirium (N = 283). INTERVENTION Research staff provided cognitively stimulating activities daily for up to 30 days. MEASUREMENTS Primary outcomes were delirium duration (Confusion Assessment Method) and delirium severity (Delirium Rating Scale). Secondary outcomes were cognitive function (Digits Forward, Montreal Cognitive Assessment, CLOX) and physical function (Barthel Index). RESULTS Mean percentage of delirium-free days (intervention: 64.8%, 95% confidence interval (CI) = 59.6-70.1; control: 68.7%, 95% CI = 63.9-73.6; P = .37, Wilcoxon rank sum test) and delirium severity (range 0-39: intervention: 10.77, 95% CI = 10.10-11.45; control: 11.15, 95% CI = 10.50-11.80; difference 0.37, 95% CI = 0.56-1.31, P = .43) were similar in both groups. Significant differences for secondary outcomes favoring intervention were found (executive function (range 0-15): intervention: 6.58, 95% CI = 6.12-7.04; control: 5.89, 95% CI = 5.45-6.33; difference -0.69, 95% CI = 1.33 to -0.06, P = .03; constructional praxis (range 0-15): intervention: 8.84, 95% CI = 8.83-9.34; control: 7.53, 95% CI = 7.04-8.01; difference -1.31, 95% CI = 2.01 to -0.61, P < .001). After adjusting for baseline constructional praxis, the group comparison was no longer significant. Average length of stay was shorter in the intervention (36.09 days) than the control (53.13 days) group (standard error = 0.15, P = .01, negative binomial regression). CONCLUSION Cognitively stimulating activities did not improve delirium but improved executive function and reduced length of stay. Resolution of delirium may require more-intense nonpharmacological management when the individual has dementia.
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Affiliation(s)
- Ann Kolanowski
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Donna Fick
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Mark Litaker
- School of Dentistry, University of Alabama, Birmingham, Alabama
| | - Paula Mulhall
- Prevention Research Center, College of Health and Human Development, Pennsylvania State University, University Park, Pennsylvania
| | - Linda Clare
- Centre for Research in Ageing and Cognitive Health, Washington Singer Laboratories, Exeter, United Kingdom
| | - Nikki Hill
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Jacqueline Mogle
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Malaz Boustani
- School of Medicine and Aging Brain Center, Indiana University, Indianapolis, Indiana
| | - David Gill
- Rochester Regional Health, University of Rochester, Rochester, New York.,Department of Neurology, University of Rochester, Rochester, New York
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Goodson CM, Rosenblatt K, Rivera-Lara L, Nyquist P, Hogue CW. Cerebral Blood Flow Autoregulation in Sepsis for the Intensivist: Why Its Monitoring May Be the Future of Individualized Care. J Intensive Care Med 2016; 33:63-73. [PMID: 27798314 DOI: 10.1177/0885066616673973] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cerebral blood flow (CBF) autoregulation maintains consistent blood flow across a range of blood pressures (BPs). Sepsis is a common cause of systemic hypotension and cerebral dysfunction. Guidelines for BP management in sepsis are based on historical concepts of CBF autoregulation that have now evolved with the availability of more precise technology for its measurement. In this article, we provide a narrative review of methods of monitoring CBF autoregulation, the cerebral effects of sepsis, and the current knowledge of CBF autoregulation in sepsis. Current guidelines for BP management in sepsis are based on a goal of maintaining mean arterial pressure (MAP) above the lower limit of CBF autoregulation. Bedside tools are now available to monitor CBF autoregulation continuously. These data reveal that individual BP goals determined from CBF autoregulation monitoring are more variable than previously expected. In patients undergoing cardiac surgery with cardiopulmonary bypass, for example, the lower limit of autoregulation varied between a MAP of 40 to 90 mm Hg. Studies of CBF autoregulation in sepsis suggest patients frequently manifest impaired CBF autoregulation, possibly a result of BP below the lower limit of autoregulation, particularly in early sepsis or with sepsis-associated encephalopathy. This suggests that the present consensus guidelines for BP management in sepsis may expose some patients to both cerebral hypoperfusion and cerebral hyperperfusion, potentially resulting in damage to brain parenchyma. The future use of novel techniques to study and clinically monitor CBF autoregulation could provide insight into the cerebral pathophysiology of sepsis and offer more precise treatments that may improve functional and cognitive outcomes for survivors of sepsis.
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Affiliation(s)
- Carrie M Goodson
- 1 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathryn Rosenblatt
- 2 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lucia Rivera-Lara
- 2 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul Nyquist
- 2 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles W Hogue
- 4 Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Qiu Y, Chen D, Huang X, Huang L, Tang L, Jiang J, Chen L, Li S. Neuroprotective effects of HTR1A antagonist WAY-100635 on scopolamine-induced delirium in rats and underlying molecular mechanisms. BMC Neurosci 2016; 17:66. [PMID: 27760517 PMCID: PMC5070354 DOI: 10.1186/s12868-016-0300-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 10/05/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Limited surveys have assessed the performance of 5-hydroxytreptamine receptor 1A and its antagonist WAY-100635 in pharmacological manipulations targeting delirium therapies. The purpose of this paper was to assess the central pharmacological activity of WAY-100635 in a rat model of scopolamine-induced delirium and its underlying mechanism. RESULTS A delirium rat model was established by intraperitoneal injection of scopolamine and behavioral changes evaluated through open field and elevated plus maze experiments. Concentrations of monoamines in the hippocampus and amygdalae were detected by high performance liquid chromatography. The effect of WAY-100635 on the recovery of rats from delirium was assessed by stereotactic injection of WAY-100635 and its mechanism of action determined by measuring mRNA and protein expression via real time PCR and western blotting methods. The total distance and the number of crossing and rearing in the elevated plus maze test and the time spent in the light compartment in the dark/light test of scopolamine-treated rats were significantly increased while the percentage of time spent in the open arms was decreased, showing the validity of the established delirium rat model. The measurement of the concentrations of noradrenaline, 3,4-dihydroxyphenylacetic acid, the homovanillic acid, 5-hydroxy-3-indoleacetic acid and serotonin concentrations in the cerebrospinal fluid (CSF) of scopolamine-induced delirium rats were significantly increased. The intra-hippocampus and intra-BLA injections of WAY-100635 improved the delirium-like behavior of rats by significantly reducing the expression of NLRP3 inflammasome and the release of IL1-β and IL8 into CSF. CONCLUSIONS Taken together, these findings indicate that WAY-100635 may exert a therapeutic effect on post-operative delirium by controlling neurotransmission as well as suppressing neuroinflammation in the central nervous system.
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Affiliation(s)
- Yimin Qiu
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiaotong University, 800 Dongchuan Rd., Minhang District, Shanghai, 200080 China
| | - Dongmei Chen
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiaotong University, 800 Dongchuan Rd., Minhang District, Shanghai, 200080 China
| | - Xiaojing Huang
- Department of Pain Management, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Lina Huang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiaotong University, 800 Dongchuan Rd., Minhang District, Shanghai, 200080 China
| | - Liang Tang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiaotong University, 800 Dongchuan Rd., Minhang District, Shanghai, 200080 China
| | - Jihong Jiang
- Department of Pain Management, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Lianhua Chen
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiaotong University, 800 Dongchuan Rd., Minhang District, Shanghai, 200080 China
| | - Shitong Li
- Department of Anesthesiology and Pain Management, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
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148
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Abstract
A growing body of literature has shown that survivors of critical illness often struggle with cognitive impairment that persists months to years after hospital discharge. We describe the epidemiology of this form of cognitive impairment-which we refer to as critical illness brain injury-and review the history and maturation of the investigation of this previously unrecognized, yet common problem. We then review the characteristics of critical illness brain injury, which can vary in severity and typically affects multiple domains of cognition. Finally, we examine known risk factors for critical illness brain injury and, based on these data, suggest approaches to patient management.
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Affiliation(s)
- Timothy D Girard
- Division of Allergy, Pulmonary, and Critical Care Medicine.,Center for Health Services Research, and.,Geriatric Research, Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee 37212
| | - Robert S Dittus
- Center for Health Services Research, and.,Division of General Internal Medicine and Public Health in the Department of Medicine and The Institute for Medicine and Public Health at the Vanderbilt University School of Medicine, Nashville, Tennessee 37232; .,Geriatric Research, Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee 37212
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine.,Center for Health Services Research, and.,Geriatric Research, Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee 37212
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149
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Under Pressure: Reduced Cerebral Perfusion as a Risk Factor for Postoperative Delirium in Lung Transplant Recipients. Ann Am Thorac Soc 2016; 13:156-7. [PMID: 26848597 DOI: 10.1513/annalsats.201512-796ed] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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150
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Anderson BJ, Reilly JP, Shashaty MGS, Palakshappa JA, Wysoczanski A, Dunn TG, Kazi A, Tommasini A, Mikkelsen ME, Schweickert WD, Kolson DL, Christie JD, Meyer NJ. Admission plasma levels of the neuronal injury marker neuron-specific enolase are associated with mortality and delirium in sepsis. J Crit Care 2016; 36:18-23. [PMID: 27546742 DOI: 10.1016/j.jcrc.2016.06.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/13/2016] [Accepted: 06/13/2016] [Indexed: 12/30/2022]
Abstract
PURPOSE Neuron-specific enolase (NSE) concentrations are prognostic following traumatic and anoxic brain injury and may provide a method to quantify neuronal injury in other populations. We determined the association of admission plasma NSE concentrations with mortality and delirium in critically ill septic patients. METHODS We performed a retrospective analysis of 124 patients from a larger sepsis cohort. Plasma NSE was measured in the earliest blood draw at intensive care unit admission. Primary outcomes were 30-day mortality and intensive care unit delirium determined by chart review. RESULTS Sixty-one patients (49.2%) died within 30 days, and delirium developed in 34 (31.5%) of the 108 patients who survived at least 24 hours and were not persistently comatose. Each doubling of the NSE concentration was associated with a 7.3% (95% confidence interval [CI] 2.5-12.0, P= .003) increased risk of 30-day mortality and a 5.2% (95% CI 3.2-7.2, P< .001) increased risk of delirium. An NSE concentration >12.5 μg/L was independently associated with a 23.3% (95% CI 6.7-39.9, P= .006) increased risk of 30-day mortality and a 29.3% (95% CI 8.8-49.8, P= .005) increased risk of delirium. CONCLUSIONS Higher plasma NSE concentrations were associated with mortality and delirium in critically ill septic patients, suggesting that NSE may have utility as a marker of neuronal injury in sepsis.
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Affiliation(s)
- Brian J Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Jessica A Palakshappa
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Alex Wysoczanski
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Altaf Kazi
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Anna Tommasini
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - William D Schweickert
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Dennis L Kolson
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
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