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Noah AM, Spendlove J, Tu Z, Proudlock F, Constantinescu CS, Gottlob I, Auer DP, Dineen RA, Moppett IK. Retinal imaging with hand-held optical coherence tomography in older people with or without postoperative delirium after hip fracture surgery: A feasibility study. PLoS One 2024; 19:e0305964. [PMID: 39012893 PMCID: PMC11251583 DOI: 10.1371/journal.pone.0305964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/07/2024] [Indexed: 07/18/2024] Open
Abstract
INTRODUCTION Postoperative delirium in older people may result from the interaction between intrinsic brain vulnerability (e.g. neurodegeneration) and precipitating factors (e.g. surgery induced cytokines). Intrinsic brain vulnerability may be overt (e.g. Alzheimer's disease) or preclinical. In cognitively intact older people presenting for surgery, identification of preclinical neurodegeneration using bedside tools could aid postoperative delirium risk stratification. Thinning of the circumpapillary retinal nerve fibre layer thickness is associated with neurodegenerative disorders e.g. Alzheimer's disease. We propose that thinning of the retinal nerve fibre layer may be present some older people with postoperative delirium due to preclinical neurodegeneration, albeit to a lesser extent than in overt dementia. OBJECTIVES The primary objective: Feasibility of acquiring usable retinal images with the hand-held optical coherence device, at the bedside of older, hip fracture surgery patients. Secondary objective: Comparison of the circumpapillary retinal nerve fibre layer thickness between people who did/did not have postoperative delirium. Proportion of exclusions due to retinal pathology. METHOD Feasibility study involving 30, cognitively intact, older people recovering from hip fracture surgery. Retinal images were obtained using the hand-held optical coherence tomography device at the participants' bedside. Imaging was deferred in participants who had postoperative delirium. RESULTS Retinal images that could be assessed for circumpapillary retinal nerve fibre layer thickness were obtained in 26 participants (22 no postoperative delirium, 4 postoperative delirium). The mean circumpapillary retinal nerve fibre layer thickness was lower in the participants who had postoperative delirium compared to those who did not experience postoperative delirium (Mean (95% CI) of 76.50 (62.60-90.40) vs 89.19 (85.41-92.97) respectively). CONCLUSION Retinal imaging at the patient's bedside, using hand-held OCT is feasible. Our data suggests that the circumpapillary retinal nerve fibre layer may be thinner in older people who experience postoperative delirium compared to those who do not. Further studies are required.
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Affiliation(s)
- Abiodun M. Noah
- Anaesthesia and Critical Care, Injury, Recovery and Inflammation Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Jennie Spendlove
- Anaesthesia and Critical Care, Injury, Recovery and Inflammation Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Zhanhan Tu
- Ulverscroft Eye Unit, Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom
| | - Frank Proudlock
- Ulverscroft Eye Unit, Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom
| | - Cris S. Constantinescu
- Clinical Neurology, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, United Kingdom
- Cooper Neurological Institute, Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Irene Gottlob
- Ulverscroft Eye Unit, Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom
- Cooper Neurological Institute, Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Dorothee P. Auer
- Radiological Sciences, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, United Kingdom
- Nottingham NIHR BRC, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Rob A. Dineen
- Radiological Sciences, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, United Kingdom
- Nottingham NIHR BRC, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Iain K. Moppett
- Anaesthesia and Critical Care, Injury, Recovery and Inflammation Sciences, University of Nottingham, Nottingham, United Kingdom
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Chen CY, Ding H, Wang SS. Effectiveness of Roy Adaptation Model-Based Cognitive Stimulation Therapy in Elderly Patients with Non-Small Cell Lung Cancer Undergoing Curative Resection. TOHOKU J EXP MED 2024; 263:27-34. [PMID: 38220169 DOI: 10.1620/tjem.2023.j108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
This study aimed to investigate the effects of a Roy adaptation model (RAM)-based cognitive stimulation therapy (CST) intervention on elderly patients diagnosed with primary non-small cell lung cancer (NSCLC) undergoing curative resection. A total of 280 patients diagnosed with primary NSCLC were randomized into RAM-based CST group and control group. Outcomes were assessed at three intervals: pre-surgery, discharge, and one-month post-discharge. Cognitive function was evaluated using Mini-Cognitive test. Postoperative delirium prevalence was determined within 48 hours post-surgery using Nursing Delirium Screening Scale. The Hospital Anxiety and Depression Scale evaluated anxiety and depression symptoms, while Quality of Life (QoL) was assessed via Short Form-36 (SF36) Health Survey. The RAM-based CST group demonstrated significantly higher Mini-Cog test scores than the control group upon discharge and post-intervention. Patients with RAM-based CST exhibited a decrease in postoperative delirium compared to the control group. The RAM-based CST intervention yielded an improvement in anxiety and depression at discharge and 1-month post-discharge compared to preoperative levels. Additionally, the RAM-based CST group exhibited substantial enhancements in SF36 subcategory scores at 1-month post-discharge compared to pre-surgery. At post-intervention, the RAM-based CST group demonstrated significantly higher scores than the control group across various health-related domains, including role limitations due to emotional problems, mental health, general health perception, bodily pain, and role limitations due to physical problems. The RAM-based CST intervention in elderly NSCLC patients undergoing curative resection yielded significant enhancements in cognitive function, reduced delirium incidence, improved emotional well-being, and better QoL postoperatively.
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Affiliation(s)
| | | | - Shang-Shang Wang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine
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Pecorella G, De Rosa F, Licchelli M, Panese G, Carugno JT, Morciano A, Tinelli A. Postoperative cognitive disorders and delirium in gynecologic surgery: Which surgery and anesthetic techniques to use to reduce the risk? Int J Gynaecol Obstet 2024. [PMID: 38557928 DOI: 10.1002/ijgo.15464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 02/13/2024] [Accepted: 02/25/2024] [Indexed: 04/04/2024]
Abstract
Despite their general good health, an increasing proportion of elderly individuals require surgery due to an increase in average lifespan. However, because of their increased vulnerability, these patients need to be handled carefully to make sure that surgery does not cause more harm than good. Age-related postoperative cognitive disorders (POCD) and postoperative delirium (POD), two serious consequences that are marked by adverse neuropsychologic alterations after surgery, are particularly dangerous for the elderly. In the context of gynecologic procedures, POCD and POD are examined in this narrative review. The main question is how to limit the rates of POCD and POD in older women undergoing gynecologic procedures by maximizing the risk-benefit balance. Three crucial endpoints are considered: (1) surgical procedures to lower the rates of POCD and POD, (2) anesthetic techniques to lessen the occurrence and (3) the identification of individuals at high risk for post-surgery cognitive impairments. Risks associated with laparoscopic gynecologic procedures include the Trendelenburg posture and CO2 exposure during pneumoperitoneum, despite statistical similarities in POD and POCD frequency between laparoscopic and laparotomy techniques. Numerous risk factors are associated with surgical interventions, such as blood loss, length of operation, and position holding, all of which reduce the chance of complications when they are minimized. In order to emphasize the essential role that anesthesia and surgery play in patient care, anesthesiologists are vital in making sure that anesthesia is given as sparingly and quickly as feasible. In addition, people who are genetically predisposed to POCD may be more susceptible to the disorder. The significance of a thorough strategy combining surgical and anesthetic concerns is highlighted in this article, in order to maximize results for senior patients having gynecologic surgery.
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Affiliation(s)
- Giovanni Pecorella
- Department of Gynecology, Obstetrics and Reproduction Medicine, Saarland University, Homburg, Germany
| | - Filippo De Rosa
- Department of Anesthesia and Intensive Care, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Martina Licchelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Gaetano Panese
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Josè Tony Carugno
- Obstetrics and Gynecology Department, Minimally Invasive Gynecology Division, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Andrea Morciano
- Panico Pelvic Floor Center, Department of Gynecology and Obstetrics, Pia Fondazione "Card. G. Panico", Tricase, Lecce, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
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Vasunilashorn SM, Lunardi N, Newman JC, Crosby G, Acker L, Abel T, Bhatnagar S, Cunningham C, de Cabo R, Dugan L, Hippensteel JA, Ishizawa Y, Lahiri S, Marcantonio ER, Xie Z, Inouye SK, Terrando N, Eckenhoff RG. Preclinical and translational models for delirium: Recommendations for future research from the NIDUS delirium network. Alzheimers Dement 2023; 19:2150-2174. [PMID: 36799408 PMCID: PMC10576242 DOI: 10.1002/alz.12941] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 02/18/2023]
Abstract
Delirium is a common, morbid, and costly syndrome that is closely linked to Alzheimer's disease (AD) and AD-related dementias (ADRD) as a risk factor and outcome. Human studies of delirium have advanced our knowledge of delirium incidence and prevalence, risk factors, biomarkers, outcomes, prevention, and management. However, understanding of delirium neurobiology remains limited. Preclinical and translational models for delirium, while challenging to develop, could advance our knowledge of delirium neurobiology and inform the development of new prevention and treatment approaches. We discuss the use of preclinical and translational animal models in delirium, focusing on (1) a review of current animal models, (2) challenges and strategies for replicating elements of human delirium in animals, and (3) the utility of biofluid, neurophysiology, and neuroimaging translational markers in animals. We conclude with recommendations for the development and validation of preclinical and translational models for delirium, with the goal of advancing awareness in this important field.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nadia Lunardi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - John C. Newman
- Department of Medicine, University of California, San Francisco, California, USA
- Buck Institute for Research on Aging, Novato, California, USA
| | - Gregory Crosby
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Leah Acker
- Department of Anesthesiology, Duke University, Durham, Massachusetts, USA
| | - Ted Abel
- Department of Neuroscience and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Seema Bhatnagar
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Dublin, Ireland
- Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Rafael de Cabo
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA
| | - Laura Dugan
- Vanderbilt Brain Institute, Vanderbilt University, Nashville, Tennessee, USA
- Division of Geriatric Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Joseph A. Hippensteel
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Yumiko Ishizawa
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shouri Lahiri
- Department of Neurology, Neurosurgery, and Biomedical Sciences, Cedar-Sinai Medical Center, Los Angeles, California, USA
| | - Edward R. Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Zhongcong Xie
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sharon K. Inouye
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Cell Biology, Duke University, Durham, North Carolina, USA
- Department of Immunology, Duke University, Durham, North Carolina, USA
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, USA
| | - Roderic G. Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Au E, Thangathurai G, Saripella A, Yan E, Englesakis M, Nagappa M, Chung F. Postoperative Outcomes in Elderly Patients Undergoing Cardiac Surgery With Preoperative Cognitive Impairment: A Systematic Review and Meta-Analysis. Anesth Analg 2023; 136:1016-1028. [PMID: 36728298 DOI: 10.1213/ane.0000000000006346] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Older patients with preoperative cognitive impairment are at risk for increased postoperative complications after noncardiac surgery. This systematic review and meta-analysis aimed to determine the association between preoperative cognitive impairment and dementia and postoperative outcomes in older surgical patients after cardiac surgery. METHODS Eight electronic databases were searched from inception to January 4, 2022. Inclusion criteria were cardiac surgery patients ≥60 years of age; preoperative cognitive impairment; ≥1 postoperative complication reported; comparator group with no preoperative cognitive impairment; and written in English. Using a random-effects model, we calculated effect sizes as odds ratio (OR) and standardized mean differences (SMDs). Risk of random error was assessed by applying trial sequential analysis. RESULTS Sixteen studies (62,179 patients) were included. Preoperative cognitive impairment was associated with increased risk of delirium in older patients after cardiac surgery (70.0% vs 20.5%; OR, 8.35; 95% confidence interval [CI], 4.25-16.38; I2, 0%; P < .00001). Cognitive impairment was associated with increased hospital length of stay (LOS; SMD, 0.36; 95% CI, 0.20-0.51; I2, 22%; P < .00001) and intensive care unit (ICU) LOS (SMD, 0.39; 95% CI, 0.09-0.68; I2, 70%; P = .01). No significant association was seen for 30-day mortality (1.7% vs 1.1%; OR, 2.58; 95% CI, 0.64-10.44; I2, 55%; P = .18). CONCLUSIONS In older patients undergoing cardiac surgery, cognitive impairment was associated with an 8-fold increased risk of delirium, a 5% increase in absolute risk of major postoperative bleeding, and an increase in hospital and ICU LOS by approximately 0.4 days. Further research on the feasibility of implementing routine neurocognitive testing is warranted.
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Affiliation(s)
- Emily Au
- From the Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Aparna Saripella
- From the Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ellene Yan
- From the Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Marina Englesakis
- Department of Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St Joseph Health Care, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Frances Chung
- From the Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Chen Y, Liang S, Wu H, Deng S, Wang F, Lunzhu C, Li J. Postoperative delirium in geriatric patients with hip fractures. Front Aging Neurosci 2022; 14:1068278. [PMID: 36620772 PMCID: PMC9813601 DOI: 10.3389/fnagi.2022.1068278] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.
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Affiliation(s)
- Yang Chen
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shuai Liang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Huiwen Wu
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shihao Deng
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Fangyuan Wang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Ciren Lunzhu
- Department of Orthopedics, Shannan City People’s Hospital, Shannan, China
| | - Jun Li
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China,*Correspondence: Jun Li,
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7
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Guran E, Hu J, Wefel JS, Chung C, Cata JP. Perioperative considerations in patients with chemotherapy-induced cognitive impairment: a narrative review. Br J Anaesth 2022; 129:909-922. [PMID: 36270848 DOI: 10.1016/j.bja.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/01/2022] [Accepted: 08/23/2022] [Indexed: 11/02/2022] Open
Abstract
Patients with cancer may suffer from a decline in their cognitive function after various cancer therapies, including surgery, radiation, and chemotherapy, and in some cases, this decline in cognitive function persists even years after completion of treatment. Chemobrain or chemotherapy-induced cognitive impairment, a well-established clinical syndrome, has become an increasing concern as the number of successfully treated cancer patients has increased significantly. Chemotherapy-induced cognitive impairment can originate from direct neurotoxicity, neuroinflammation, and oxidative stress, resulting in alterations in grey matter volume, white matter integrity, and brain connectivity. Surgery has been associated with exacerbating the inflammatory response associated with chemotherapy and predisposes patients to develop postoperative cognitive dysfunction. As the proportion of patients living longer after these therapies increases, the magnitude of impact and growing concern of post-treatment cognitive dysfunction in these patients has also come to the fore. We review the clinical presentation, potential mechanisms, predisposing factors, diagnostic methods, neuropsychological testing, and imaging findings of chemotherapy-induced cognitive impairment and its intersection with postoperative cognitive dysfunction.
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Affiliation(s)
- Ekin Guran
- Department of Anaesthesiology and Reanimation, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey; Anaesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Jian Hu
- Department of Cancer Biology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caroline Chung
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan P Cata
- Anaesthesiology and Surgical Oncology Research Group, Houston, TX, USA; Department of Anaesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Postoperative Delirium in Lung Cancer Anatomical Resection-Analysis of Risk Factors and Prognosis. World J Surg 2022; 46:1196-1206. [PMID: 35028705 DOI: 10.1007/s00268-022-06442-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND The incidence of postoperative delirium after anatomical lung resection ranges from 5 to 16%. This study aimed to analyze the risk factors and prognosis of postoperative delirium in anatomical lung resection for lung cancer. METHODS This study included 1351 patients undergoing anatomical lung resection between April 2010 and October 2020. We analyzed the perioperative risk factors of postoperative delirium. We also compared postoperative complications and survival between the delirium and non-delirium groups. RESULTS Postoperative delirium was identified in 44 (3.3%) of 1351 patients who underwent anatomical lung resection for lung cancer. Age, peripheral vascular disease, depression, and current smoking status were independent risk factors for postoperative delirium in the multivariate analysis. The percentage of postoperative delirium was 0.6% in never smokers and 6.0% in current smokers. The delirium and non-delirium groups showed significant differences in overall survival (p = 0.0144) and non-disease-specific survival (p = 0.0080). After propensity score matching, the two groups did not significantly differ in overall survival (p = 0.9136), non-disease-specific survival (p = 0.8146), or disease-specific survival (p = 0.6804). CONCLUSIONS Age, peripheral vascular disease, depression, and current smoking status were considered independent risk factors for postoperative delirium in anatomical lung resection for lung cancer. Smoking cessation for at least four weeks before surgery is recommended for reducing incidence of post-operative delirium.
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Pendlebury ST, Thomson RJ, Welch SJV, Kuker W, Rothwell PM. Utility of white matter disease and atrophy on routinely acquired brain imaging for prediction of long-term delirium risk: population-based cohort study. Age Ageing 2022; 51:6427231. [PMID: 34793588 PMCID: PMC8753040 DOI: 10.1093/ageing/afab200] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/04/2021] [Indexed: 12/15/2022] Open
Abstract
Background brain imaging done as part of standard care may have clinical utility beyond its immediate indication. Using delirium as an exemplar, we determined the predictive value of baseline brain imaging variables [white matter changes (WMC) and atrophy] for delirium risk on long-term follow-up after transient ischemic attack (TIA)/stroke in a population-based cohort study. Methods surviving TIA/stroke participants in the Oxford Vascular Study (OXVASC) were assessed prospectively for delirium during all hospitalisations over 6 months (2013–14). Using logistic regression, independent associations were determined between baseline OXVASC computed tomography or magnetic resonance brain imaging measures of WMC and cerebral atrophy (none/mild versus moderate/severe) and delirium adjusted for age, sex, baseline stroke severity, depression, illness severity and pre-admission cognition. Results among 1,565 TIA/stroke survivors with 194 hospital admissions (158 patients, mean/standard deviation age at admission = 79.2/11.5 years), delirium occurred in 59 (37%). WMC and atrophy on baseline imaging were associated with delirium [odds ratio (OR) = 3.41, 1.21–5.85, P = 0.001 and OR = 2.50, 1.23–5.08, P = 0.01 (unadjusted) and OR = 2.67, 1.21–5.85, P = 0.02 and OR = 2.18, 1.00–4.73, P = 0.05 (adjusted age and sex)]. Associations were strengthened when analyses were restricted to patients hospitalised within 5 years of baseline brain imaging [OR = 6.04, 2.39–15.24, P < 0.0001 and OR = 4.64, 1.46–14.82, P = 0.009 (unadjusted)] but only WMC remained significant after adjustment for all covariates including pre-admission cognition (OR = 4.83, 1.29–18.13, P = 0.02 for Mini-Mental State Examination and OR = 5.15, 1.26–21.09, P = 0.02 for Montreal Cognitive Assessment). Conclusions WMC and atrophy on brain imaging done up to 5 years earlier predicted delirium and may have clinical utility in risk stratification. Associations with WMC but not atrophy were independent of pre-admission cognitive impairment.
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Affiliation(s)
- Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Departments of General (Internal) Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ross J Thomson
- Department of Cardiology, Royal Free Hospital, London, UK
| | - Sarah J V Welch
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
| | - Wilhelm Kuker
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
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Noah AM, Almghairbi D, Evley R, Moppett IK. Preoperative inflammatory mediators and postoperative delirium: systematic review and meta-analysis. Br J Anaesth 2021; 127:424-434. [PMID: 34218905 DOI: 10.1016/j.bja.2021.04.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Postoperative delirium has eluded attempts to define its complex aetiology and describe specific risk factors. The role of neuroinflammation as a risk factor, determined by measuring blood levels of preoperative 'innate' inflammatory mediator levels, has been investigated. However, results have been conflicting. We conducted a systematic review and meta-analysis of the evidence on associations between preoperative blood levels of inflammatory mediators and postoperative delirium in the older person. Influence of type of surgery was also assessed. METHODS Original, low risk of bias studies, published in peer-reviewed journals, which fulfilled the eligibility criteria were included. Seventeen articles fulfilled study criteria. Data extraction, synthesis, and risk of bias analysis were guided by Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and quality in prognostic studies guidelines. Meta-analyses used a random-effects model. Inflammatory mediators included C-reactive protein, interleukin-6, -8, and -10, tumour necrosis factor-α, insulin-like growth factor-1, cortisol, and neopterin. Surgical groups were cardiac, noncardiac, and hip fracture. RESULTS Higher preoperative interleukin-6 was associated with postoperative delirium with a standardised mean difference (95% confidence interval) of 0.33 (0.11-0.56) and P=0.003. Higher neopterin was also associated with postoperative delirium. CONCLUSIONS The association of preoperative blood levels of inflammatory mediators with postoperative delirium may be influenced by the type of surgery and the specific mediator. The potential modulating effect of type of surgery, intrinsic brain vulnerability, and the complex interactions between inflammatory mediators and binding proteins will need to be considered in future studies. CLINICAL TRIAL REGISTRATION CRD42019159471 (PROSPERO).
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Affiliation(s)
- Abiodun M Noah
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK
| | - Dalal Almghairbi
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK
| | - Rachel Evley
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK
| | - Iain K Moppett
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK.
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11
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Abstract
An aging-related reduction in the brain's functional reserve may explain why delirium is more frequent in the elderly than in younger people insofar as the reserve becomes inadequate to cover the metabolic requirements that are critically increased by stressors. The aim of this paper is to review the normal aging-related changes that theoretically compromise complex mental activities, neuronal and synaptic densities, and the neurocomputational flexibility of the functional reserve. A pivotal factor is diminished connectivity, which is substantially due to the loss of synapses and should specifically affect association systems and cholinergic fibres in delirious patients. However, micro-angiopathy with impaired blood flow autoregulation, increased blood/brain barrier permeability, changes in cerebrospinal fluid dynamics, weakened mitochondrial performance, and a pro-inflammatory involution of the immune system may also jointly affect neurons and their synaptic assets, and even cause the progression of delirium to dementia regardless of the presence of co-existing plaques, tangles, or other pathological markers. On the other hand, the developmental growth in functional reserve during childhood and adolescence makes the brain increasingly resistant to delirium, and residual reserve can allow the elderly to recover. These data support the view that functional reserve is the variable that confronts stressors and governs the risk and intensity of and recovery from delirium. Although people of any age are at risk of delirium, the elderly are at greater risk because aging and age-dependent structural changes inevitably affect the brain's functional reserve.
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12
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Kant IMJ, de Bresser J, van Montfort SJT, Mutsaerts HJMM, Witkamp TD, Buijsrogge M, Spies C, Hendrikse J, Slooter AJC. Preoperative brain MRI features and occurrence of postoperative delirium. J Psychosom Res 2021; 140:110301. [PMID: 33260072 DOI: 10.1016/j.jpsychores.2020.110301] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 10/18/2020] [Accepted: 11/12/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Delirium is a frequent complication after surgery with important negative outcomes for affected patients and society. However, it is still largely unknown why some patients have a predisposition for delirium and others not. To increase our understanding of the neural substrate of postoperative delirium, we studied the association between preoperative brain MRI features and the occurrence of delirium after major surgery. METHODS A group of 413 patients without dementia (Mean 72 years, SD: 5) was included in a prospective observational two-center study design. The study was conducted at Charité Universitätsmedizin (Berlin, Germany) and the University Medical Center Utrecht (Utrecht, The Netherlands). We measured preoperative brain volumes (total brain, gray matter, white matter), white matter hyperintensity volume and shape, brain infarcts and cerebral perfusion, and used logistic regression analysis adjusted for age, sex, intracranial volume, study center and type of surgery. RESULTS Postoperative delirium was present in a total of 70 patients (17%). Preoperative cortical brain infarcts increased the risk of postoperative delirium, although this did not reach statistical significance (OR (95%CI): 1.63 (0.84-3.18). Furthermore, we found a trend for an association of a more complex shape of white matter hyperintensities with occurrence of postoperative delirium (OR (95%CI): 0.97 (0.95-1.00)). Preoperative brain volumes, white matter hyperintensity volume, and cerebral perfusion were not associated with occurrence of postoperative delirium. CONCLUSION Our study suggests that patients with preoperative cortical brain infarcts and those with a more complex white matter hyperintensity shape may have a predisposition for developing delirium after major surgery.
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Affiliation(s)
- Ilse M J Kant
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands; Department of Radiology and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Simone J T van Montfort
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
| | - Henri J M M Mutsaerts
- Department of Radiology and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
| | - Theo D Witkamp
- Department of Radiology and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands
| | - Marc Buijsrogge
- Department of Cardiothoracic Surgery, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM,CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Jeroen Hendrikse
- Department of Radiology and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
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13
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Personalized risk prediction of postoperative cognitive impairment – rationale for the EU-funded BioCog project. Eur Psychiatry 2020; 50:34-39. [DOI: 10.1016/j.eurpsy.2017.10.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/09/2017] [Accepted: 10/09/2017] [Indexed: 12/21/2022] Open
Abstract
AbstractPostoperative cognitive impairment is among the most common medical complications associated with surgical interventions – particularly in elderly patients. In our aging society, it is an urgent medical need to determine preoperative individual risk prediction to allow more accurate cost–benefit decisions prior to elective surgeries. So far, risk prediction is mainly based on clinical parameters. However, these parameters only give a rough estimate of the individual risk. At present, there are no molecular or neuroimaging biomarkers available to improve risk prediction and little is known about the etiology and pathophysiology of this clinical condition. In this short review, we summarize the current state of knowledge and briefly present the recently started BioCog project (Biomarker Development for Postoperative Cognitive Impairment in the Elderly), which is funded by the European Union. It is the goal of this research and development (R&D) project, which involves academic and industry partners throughout Europe, to deliver a multivariate algorithm based on clinical assessments as well as molecular and neuroimaging biomarkers to overcome the currently unsatisfying situation.
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Postoperative delirium after lung resection for primary lung cancer: Risk factors, risk scoring system, and prognosis. PLoS One 2019; 14:e0223917. [PMID: 31738751 PMCID: PMC6860435 DOI: 10.1371/journal.pone.0223917] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/01/2019] [Indexed: 11/19/2022] Open
Abstract
Delirium is a common post-surgical complication, but few studies have examined postoperative delirium following lung cancer surgery. The purpose of this study was to clarify the risk factors of postoperative delirium, to construct a useful scoring system, and to clarify the relationship between delirium and prognosis after lung cancer surgery. We retrospectively analyzed data from 570 patients who underwent surgery for primary lung cancer. Logistic regression analysis was used to determine the effects of various factors on the onset of delirium. Kaplan–Meier analysis was performed to determine the relationship between delirium and prognosis. Postoperative delirium occurred in 6.7% of the patients. Three risk factors were identified, and the risk scores were determined as follows: 2×(cerebrovascular disease history) + 1×(squamous cell carcinoma) + 1×(age older than 75 years). Scores 0–1 denoted low risk, 2 denoted intermediate risk, and 3–4 denoted high risk. Additionally, we found that patients who developed delirium had significantly shorter overall survival. However, there was no difference in the frequency between cancer-related death and non-cancer related death when comparing the delirium and non-delirium groups. We identified the risk factors, i.e., cerebrovascular disease history, squamous cell carcinoma, and age older than 75 years, that determine the onset of delirium after lung cancer surgery and constructed a useful scoring system. In addition, although the prognosis of the delirium group was poor, the factor that determines prognosis may not be cancer per se but vulnerability in the patient background.
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15
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Cerebral microbleeds are not associated with postoperative delirium and postoperative cognitive dysfunction in older individuals. PLoS One 2019; 14:e0218411. [PMID: 31199858 PMCID: PMC6568413 DOI: 10.1371/journal.pone.0218411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/31/2019] [Indexed: 11/19/2022] Open
Abstract
Background Cerebral microbleeds (CMB) occur in the context of cerebral small vessel disease. Other brain MRI markers of cerebral small vessel disease are associated with the occurrence of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD), but for CMB this is unknown. We aimed to study the association between CMB and the occurrence of POD and POCD in older individuals. Methods The current study consists of 65 patients (72±5 years) from the BIOCOG study, which is a prospective, observational study of patients who underwent an elective surgery of at least 60 minutes. Patients in the current study received a preoperative cerebral MRI scan including a 3D susceptibility-weighted imaging sequence to detect CMB. The occurrence of POD was screened for twice a day until postoperative day 7 by using the DSM-5, NuDesc, CAM, and CAM-ICU. The occurrence of POCD was determined by the reliable change index model at 7 days after surgery or discharge, respectively, and 3 months after surgery. Statistical analyses consisted of logistic regression adjusted for age and gender. Results A total of 39 CMB were detected in 17 patients (26%) prior to surgery. POD occurred in 14 out of 65 patients (22%). POCD at 7 days after surgery occurred in 11 out of 54 patients (20%) and in 3 out of 40 patients at the 3 month follow-up (8%). Preoperative CMB were not associated with the occurrence of POD (OR (95%-CI): 0.28 (0.05, 1.57); p = 0.147) or POCD at 7 days after surgery (0.76 (0.16, 3.54); p = 0.727) or at 3 months follow-up (0.61 (0.03, 11.64); p = 0.740). Conclusion We did not find an association between preoperative CMB and the occurrence of POD or POCD. Trial registration clinicaltrials.gov (NCT02265263) on 23 September 2014.
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Ayob F, Lam E, Ho G, Chung F, El-Beheiry H, Wong J. Pre-operative biomarkers and imaging tests as predictors of post-operative delirium in non-cardiac surgical patients: a systematic review. BMC Anesthesiol 2019; 19:25. [PMID: 30797230 PMCID: PMC6387490 DOI: 10.1186/s12871-019-0693-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 02/08/2019] [Indexed: 02/06/2023] Open
Abstract
Background Post-operative delirium (POD) is a common post-operative complication in elderly individuals and imposes a significant health and financial burden. Identifying predictive biomarkers may help understand the pathophysiology of POD. Our objective is to summarize the evidence of pre-operative biomarkers and imaging tests to predict POD in patients undergoing non-cardiac surgery. Methods A systematic search of English language articles in MEDLINE, EMBASE, Cochrane Database, PsychINFO, PubMed and ClinicalTrials. Gov up to January 2018 was performed. Studies that used biomarkers or imaging tests to predict POD and a validated POD assessment tool were included. Animal studies, paediatric, cardiac and intracranial surgery were excluded. Risk of bias was assessed using the Quality In Prognosis Study tool. Results Thirty-four prospective cohort studies involving 4424 patients were included. Nineteen studies described serum tests [Interleukin-6, Insulin-like Growth Factor 1, C-Reactive Protein (CRP), cholinesterases, apolipoprotein-E genotype, leptin, hypovitaminosis, hypoalbuminaemia, gamma-amino butyric acid], 10 described cerebral-spinal fluid tests (monoamine precursor, melatonin, acute phase proteins, S100B and neurofibrillary tangles), and 5 described imaging tests. Two studies had high risk of bias due to unclear outcome measurement and study participation. CRP was significantly associated with POD in 5 studies. Other biomarkers were either examined by only a single study or two or more studies with conflicting results. Conclusion CRP is the most promising biomarker associated with POD. However, we are still in the early stages in identifying biomarkers and imaging tests that may further understanding of the pathophysiology of POD. Electronic supplementary material The online version of this article (10.1186/s12871-019-0693-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Farrah Ayob
- Department of Anesthesia, Toronto Western Hospital, University Health Network, 2-434 McLaughlin Wing, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Enoch Lam
- Department of Anesthesia, Toronto Western Hospital, University Health Network, 2-434 McLaughlin Wing, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - George Ho
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Medical Sciences Building, Room 2109, Toronto, ON, M5S 1A8, Canada
| | - Frances Chung
- Department of Anesthesia, Toronto Western Hospital, University Health Network, 2-434 McLaughlin Wing, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Hossam El-Beheiry
- Department of Anesthesia, Trillium Health Partners, Mississauga Hospital, 100 Queensway, West, Mississauga, ON, L5B 1B, Canada
| | - Jean Wong
- Department of Anesthesia, Toronto Western Hospital, University Health Network, 2-434 McLaughlin Wing, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. .,Women's College Hospital, Toronto, Ontario, 76 Grenville St, Toronto, ON, M5S 1B2, Canada.
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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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Abstract
The brain is both the orchestrator as well as the target of the innate immune system's response to the aseptic trauma of surgery. When trauma-induced inflammation is not appropriately regulated persistent neuro-inflammation interferes with the synaptic plasticity that underlies the learning and memory aspects of cognition. The complications that ensue, include postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) at two poles of a constellation that is now termed perioperative neurocognitive disorders. While the relationship of acute POD to the more indolent POCD is not completely understood both can be further complicated by earlier-onset of dementia and higher mortality. How and why these disorders occur is the focus of this report. The innate immune system response to peripheral trauma signals to the brain through a regulated cascade of cellular and molecular actors producing a teleological defense mechanism, "sickness behavior," to curtail further injury and initiate repair. Sickness behavior, including disordered cognition, is terminated by neural and humoral pathways that restore homeostasis and launch the organism on a path to good health. With so many "moving parts" the innate immune system is vulnerable in clinical settings that include advanced age and lifestyle-induced diseases such as "unhealthy" obesity and the inevitable insulin resistance. Under these conditions, inflammation may become exaggerated and long-lived. Consideration is provided how to identify the high-risk surgical patient and both pharmacological (including biological compounds) and non-pharmacological strategies to customize care.
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Affiliation(s)
- Sarah Saxena
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, UCSF; Department of anesthesia, Université Libre de Bruxelles, Belgium
| | - Mervyn Maze
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, UCSF.
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19
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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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20
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Ono H, Doki Y, Miyata H, Yamasaki M, Takahashi T, Endo Y, Umeshita K. Postoperative Delirium After Esophagectomy: The Efficacy of Continual Monitoring Using the NEECHAM Confusion Scale. SAGE Open Nurs 2018; 4:2377960818756799. [PMID: 33415189 PMCID: PMC7774406 DOI: 10.1177/2377960818756799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/13/2017] [Accepted: 12/29/2017] [Indexed: 11/25/2022] Open
Abstract
Abstract Background Although a majority of nurses understand that delirium is a major issue in perioperative care, professional barriers to routine monitoring using delirium assessment tools exist. The aim of this study was to assess the effectiveness of continual monitoring of postoperative delirium in patients that have undergone esophagectomy using the Neelon and Champagne (NEECHAM) Confusion Scale (NCS). Methods Demographic data and case histories were obtained from medical records. We conducted NCS scoring for 1 week after surgery and verified the daily changes in scores. Patients were classified into normal, neurocognitive-change, and complication groups for the analysis of the influence of preoperative neurocognitive changes and postoperative complications. Results Data from 19 patients were analyzed. NCS scores decreased sharply on the first day and then significantly recovered each day. The normal group exhibited a steady recovery process, but the other groups deviated from this progression. The incidence of delirium was highest on the first day. The incidence in the normal group decreased each day, but other groups developed delirium for an extended time. In the NCS subscale score analyses, the information processing score was low in the neurocognitive-change group. The complication group exhibited delayed recovery of the physiologic control score. Conclusions We observed the recovery process of mental function after esophagectomy as well as the impact of preoperative neurocognitive changes and postoperative complications. Continual monitoring of postoperative mental function may predict postoperative delirium. For early detection and prevention of delirium, nurses should monitor postoperative mental function via daily observation.
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Affiliation(s)
- Hiroshi Ono
- College of Nursing Art and Science University of Hyogo, Kobe, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | | | - Makoto Yamasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tsuyoshi Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yoshimi Endo
- Department of Health Care Science, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Koji Umeshita
- Department of Health Care Science, Graduate School of Medicine, Osaka University, Suita, Japan
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MRI Markers of Neurodegenerative and Neurovascular Changes in Relation to Postoperative Delirium and Postoperative Cognitive Decline. Am J Geriatr Psychiatry 2017; 25:1048-1061. [PMID: 28760515 DOI: 10.1016/j.jagp.2017.06.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/08/2017] [Accepted: 06/20/2017] [Indexed: 12/17/2022]
Abstract
Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common in elderly patients. The aim of the present review was to explore the association of neurodegenerative and neurovascular changes with the occurrence of POD and POCD. Fifteen MRI studies were identified by combining multiple search terms for POD, POCD, and brain imaging. These studies described a total of 1,422 patients and were all observational in design. Neurodegenerative changes (global and regional brain volumes) did not show a consistent association with the occurrence of POD (four studies) or POCD (two studies). In contrast, neurovascular changes (white matter hyperintensities and cerebral infarcts) were more consistently associated with the occurrence of POD (seven studies) and POCD (five studies). In conclusion, neurovascular changes appear to be consistently associated with the occurrence of POD and POCD, and may identify patients at increased risk of these conditions. Larger prospective studies are needed to study the consistency of these findings and to unravel the underlying pathophysiological mechanisms.
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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: 21] [Impact Index Per Article: 3.0] [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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Hshieh TT, Dai W, Cavallari M, Guttmann CR, Meier DS, Schmitt EM, Dickerson BC, Press DZ, Marcantonio ER, Jones RN, Gou YR, Travison TG, Fong TG, Ngo L, Inouye SK, Alsop DC. Cerebral blood flow MRI in the nondemented elderly is not predictive of post-operative delirium but is correlated with cognitive performance. J Cereb Blood Flow Metab 2017; 37:1386-1397. [PMID: 27401806 PMCID: PMC5453459 DOI: 10.1177/0271678x16656014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Three-dimensional Arterial Spin Labeling (ASL) MRI was performed before surgery in a cohort of 146 prospectively enrolled subjects ≥ 70 years old scheduled to undergo elective surgery. We investigated the prospective association between ASL-derived measures of cerebral blood flow (CBF) before surgery with postoperative delirium incidence and severity using whole-brain and globally normalized voxel-wise analysis. We also investigated the cross-sectional association of CBF with patients' baseline performance on specific neuropsychological tests, and with a composite general cognitive performance measure (GCP). Out of 146 subjects, 32 (22%) developed delirium. We found no significant association between global and voxel-wise CBF with delirium incidence or severity. We found the most significant positive associations between CBF of the posterior cingulate and precuneus and the Hopkins Verbal Learning Test - Revised total score, Visual Search and Attention Test (VSAT) score and the GCP composite. VSAT score was also strongly associated with right parietal lobe CBF. ASL can be employed in a large, well-characterized older cohort to examine associations between CBF and age-related cognitive performance. Although ASL CBF measures in regions previously associated with preclinical Alzheimer's Disease were correlated with cognition, they were not found to be indicators of baseline pathology that may increase risk for delirium.
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Affiliation(s)
- Tammy T Hshieh
- 1 Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Weiying Dai
- 3 Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,4 Department of Computer Science, State University of New York at Binghamton, Binghamton, NY, USA
| | - Michele Cavallari
- 5 Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charles Rg Guttmann
- 5 Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dominik S Meier
- 5 Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eva M Schmitt
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Bradford C Dickerson
- 6 Martinos Center for Biomedical Imaging, Psychiatric Neuroimaging Division, Department of Psychiatry, and Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Daniel Z Press
- 7 Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Edward R Marcantonio
- 8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard N Jones
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,9 Departments of Psychiatry and Human Behavior and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Yun Ray Gou
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Thomas G Travison
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tamara G Fong
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,7 Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Long Ngo
- 8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sharon K Inouye
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David C Alsop
- 3 Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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24
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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34:192-214. [DOI: 10.1097/eja.0000000000000594] [Citation(s) in RCA: 491] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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25
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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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26
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Simplified comorbidity score for elderly patients undergoing thoracoscopic surgery for lung cancer. Surg Today 2016; 47:718-725. [DOI: 10.1007/s00595-016-1427-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 09/06/2016] [Indexed: 10/20/2022]
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27
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Shioiri A, Kurumaji A, Takeuchi T, Nemoto K, Arai H, Nishikawa T. A Decrease in the Volume of Gray Matter as a Risk Factor for Postoperative Delirium Revealed by an Atlas-based Method. Am J Geriatr Psychiatry 2016; 24:528-36. [PMID: 26654288 DOI: 10.1016/j.jagp.2015.09.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/25/2015] [Accepted: 09/09/2015] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Delirium is a common syndrome in older patients after surgery. Although an atrophic change in the whole brain may be a potential risk factor for postoperative delirium, the anatomically specific change related to the vulnerability still remains a significant issue. DESIGN Prospective study. SETTING University hospital. PARTICIPANTS 116 consecutive patients who underwent elective cardiac operations. MEASUREMENTS Before the surgery, magnetic resonance imaging (MRI) was evaluated. The MRI data were processed to calculate the absolute volumes of the predefined region of interest using Statistical Parametrical Mapping 8 with an atlas-based method. The evaluated volume was expressed as the fraction (%) of the total intracranial volume. Postoperative delirium was diagnosed according to the DSM-IV criteria for delirium. RESULTS Delirium developed in 19 of 116 patients (16.4%) with an age range from 58 to 84 years. Based on a comparison with the age-controlled non-delirium patients (over 57 years; n = 65), a statistically significant reduction in the gray matter volume of the delirium patients was observed in the defined gyri of the temporal and limbic lobes. Moreover, a moderate value (>0.8) of area under the curve to predict postoperative delirium was revealed by receiver operating characteristic curve analysis of the gyri of temporal lobe. CONCLUSIONS The decreased volume of gray matter could be associated with the vulnerability to delirium after surgery. The atlas-based method would be a potential tool to pre-screen the brain structure of individual patients for the prediction of postoperative delirium.
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Affiliation(s)
- Akiko Shioiri
- Section of Psychiatry and Behavioral Sciences, Tokyo Medical and Dental University Graduate School, Tokyo, Japan.
| | - Akeo Kurumaji
- Section of Psychiatry and Behavioral Sciences, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Takashi Takeuchi
- Section of Psychiatry and Behavioral Sciences, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Kiyotaka Nemoto
- Department of NeuropsychiatryInstitute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Toru Nishikawa
- Section of Psychiatry and Behavioral Sciences, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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28
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Cavallari M, Dai W, Guttmann CRG, Meier DS, Ngo LH, Hshieh TT, Callahan AE, Fong TG, Schmitt E, Dickerson BC, Press DZ, Marcantonio ER, Jones RN, Inouye SK, Alsop DC. Neural substrates of vulnerability to postsurgical delirium as revealed by presurgical diffusion MRI. Brain 2016; 139:1282-94. [PMID: 26920674 DOI: 10.1093/brain/aww010] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/16/2015] [Indexed: 12/20/2022] Open
Abstract
Despite the significant impact of postoperative delirium on surgical outcomes and the long-term prognosis of older patients, its neural basis has not yet been clarified. In this study we investigated the impact of premorbid brain microstructural integrity, as measured by diffusion tensor imaging before surgery, on postoperative delirium incidence and severity, as well as the relationship among presurgical cognitive performance, diffusion tensor imaging abnormalities and postoperative delirium. Presurgical diffusion tensor imaging scans of 136 older (≥70 years), dementia-free subjects from the prospective Successful Aging after Elective Surgery study were analysed blind to the clinical data and delirium status. Primary outcomes were postoperative delirium incidence and severity during the hospital stay, as assessed by the Confusion Assessment Method. We measured cognition before surgery using general cognitive performance, a composite score based on a battery of neuropsychological tests. We investigated the association between presurgical diffusion tensor imaging parameters of brain microstructural integrity (i.e. fractional anisotropy, axial, mean and radial diffusivity) with postoperative delirium incidence and severity. Analyses were adjusted for the following potential confounders: age, gender, vascular comorbidity status, and general cognitive performance. Postoperative delirium occurred in 29 of 136 subjects (21%) during hospitalization. Presurgical diffusion tensor imaging abnormalities of the cerebellum, cingulum, corpus callosum, internal capsule, thalamus, basal forebrain, occipital, parietal and temporal lobes, including the hippocampus, were associated with delirium incidence and severity, after controlling for age, gender and vascular comorbidities. After further controlling for general cognitive performance, diffusion tensor imaging abnormalities of the cerebellum, hippocampus, thalamus and basal forebrain still remained associated with delirium incidence and severity. This study raises the intriguing possibility that structural dysconnectivity involving interhemispheric and fronto-thalamo-cerebellar networks, as well as microstructural changes of structures involved in limbic and memory functions predispose to delirium under the stress of surgery. While the diffusion tensor imaging abnormalities observed in the corpus callosum, cingulum, and temporal lobe likely constitute the neural substrate for the association between premorbid cognition, as measured by general cognitive performance, and postoperative delirium, the microstructural changes observed in the cerebellum, hippocampus, thalamus and basal forebrain seem to constitute a separate phenomenon that predisposes to postsurgical delirium independent of presurgical cognitive status.
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Affiliation(s)
- Michele Cavallari
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Weiying Dai
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA Department of Computer Science, State University of New York at Binghamton, Binghamton, NY, USA
| | - Charles R G Guttmann
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dominik S Meier
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Long H Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Tammy T Hshieh
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Amy E Callahan
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eva Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Bradford C Dickerson
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, 149 13th St., Charlestown, MA, USA Psychiatric Neuroimaging Division, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 149 13th St., Charlestown, MA, USA Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 149 13th St., Charlestown, MA, USA
| | - Daniel Z Press
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Richard N Jones
- Departments of Psychiatry and Human Behavior and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - David C Alsop
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Brown C, Faigle R, Klinker L, Bahouth M, Max L, LaFlam A, Neufeld KJ, Mandal K, Gottesman R, Hogue C. The Association of Brain MRI Characteristics and Postoperative Delirium in Cardiac Surgery Patients. Clin Ther 2015; 37:2686-2699.e9. [PMID: 26621626 PMCID: PMC5384473 DOI: 10.1016/j.clinthera.2015.10.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/15/2015] [Accepted: 10/27/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE Delirium is common after cardiac surgery and is associated with adverse consequences, including cognitive decline. Identification of vulnerable older adults might allow for early implementation of delirium-prevention strategies. Brain MRI findings provide insight into structural brain changes that may identify vulnerable patients. The purpose of this study was to examine the association between brain MRI characteristics potentially associated with delirium vulnerability and the development of postoperative delirium in a nested cohort of patients undergoing cardiac surgery. METHODS We identified 79 cardiac surgery patients who had brain MRI imaging after cardiac surgery, as part of an ongoing randomized trial evaluating the efficacy of blood pressure management based on cerebral autoregulation monitoring versus standard management for improving neurological outcomes. Cerebral lateral ventricular size, cortical sulcal width, and white matter hyperintensities (WMH) on brain MRI scans were graded on a validated 0 to 9 scale, and categorized into tertiles. New ischemic lesions were characterized as present or absent. Delirium was assessed using a validated chart-review. Neuropsychological testing performed before surgery was used to establish preoperative cognitive baseline. Multivariable logistic regression was used to assess the independent association between MRI characteristics and postoperative delirium. FINDINGS The average age of patients was 70.1 ± 7.8 years old, and 72% were male. Twenty-eight of 79 (35.4%) patients developed postoperative delirium. Patients with delirium had higher unadjusted ventricular size (median 4 vs. 3, P = 0.003), and there was a trend towards higher sulcal sizes and WMH grades. Increasing tertiles of ventricular size (Odds Ratio [OR] 3.59; 95% Confidence Interval [CI] 1.59-8.12; P = 0.002) and sulcal size (OR 2.15; 95%CI 1.13-4.12; P = 0.02) were associated with postoperative delirium, with a trend for tertiles of WMH grade (OR 1.91; 95%CI 0.99-3.68; P = 0.05). In multivariable models adjusted for logistic EuroSCORE, baseline cognitive status, bypass time, and any postoperative complication, each tertile of ventricular size was associated with increased odds of postoperative delirium (OR 3.23 per tertile increase in ventricular size; 95%CI 1.21-8.60; P = 0.02). There were no differences in odds of delirium by tertiles of sulcal grade, tertiles of white matter grade, or presence of new ischemic lesions, in adjusted models. IMPLICATIONS Increased brain ventricular size was independently associated with delirium after cardiac surgery. These results suggest that cerebral atrophy may contribute to increased vulnerability for postoperative delirium. Baseline brain MRIs may be useful in identifying cardiac surgery patients at high risk for postoperative delirium, who might benefit from targeted perioperative approaches to prevent delirium. ClinicalTrials.gov identifier: NCT00981474.
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Affiliation(s)
- Charles Brown
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America, , 410 955 7519
| | - Roland Faigle
- Phipps 484, 600 N Wolfe Street, Baltimore MD 21287, United States of America,
| | - Lauren Klinker
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America,
| | - Mona Bahouth
- 466 Phipps, 600 N. Wolfe St., Baltimore MD 21205, United States of America,
| | - Laura Max
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America,
| | - Andrew LaFlam
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America,
| | - Karin J. Neufeld
- Osler 320, 600 N. Wolfe St., Baltimore MD 21287, United States of America,
| | - Kaushik Mandal
- Zayed 7107, 1800 Orleans St., Baltimore MD 21287, United States of America,
| | | | - Charles Hogue
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America,
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Androsova G, Krause R, Winterer G, Schneider R. Biomarkers of postoperative delirium and cognitive dysfunction. Front Aging Neurosci 2015; 7:112. [PMID: 26106326 PMCID: PMC4460425 DOI: 10.3389/fnagi.2015.00112] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/28/2015] [Indexed: 01/19/2023] Open
Abstract
Elderly surgical patients frequently experience postoperative delirium (POD) and the subsequent development of postoperative cognitive dysfunction (POCD). Clinical features include deterioration in cognition, disturbance in attention and reduced awareness of the environment and result in higher morbidity, mortality and greater utilization of social financial assistance. The aging Western societies can expect an increase in the incidence of POD and POCD. The underlying pathophysiological mechanisms have been studied on the molecular level albeit with unsatisfying small research efforts given their societal burden. Here, we review the known physiological and immunological changes and genetic risk factors, identify candidates for further studies and integrate the information into a draft network for exploration on a systems level. The pathogenesis of these postoperative cognitive impairments is multifactorial; application of integrated systems biology has the potential to reconstruct the underlying network of molecular mechanisms and help in the identification of prognostic and diagnostic biomarkers.
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Affiliation(s)
- Ganna Androsova
- Bioinformatics core, Luxembourg Centre for Systems Biomedicine (LCSB), University of LuxembourgBelvaux, Luxembourg
| | - Roland Krause
- Bioinformatics core, Luxembourg Centre for Systems Biomedicine (LCSB), University of LuxembourgBelvaux, Luxembourg
| | - Georg Winterer
- Experimental and Clinical Research Center (ECRC), Department of Anesthesiology and Operative Intensive Care Medicine, Charité University Medicine BerlinBerlin, Germany
| | - Reinhard Schneider
- Bioinformatics core, Luxembourg Centre for Systems Biomedicine (LCSB), University of LuxembourgBelvaux, Luxembourg
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Cavallari M, Hshieh TT, Guttmann CRG, Ngo LH, Meier DS, Schmitt EM, Marcantonio ER, Jones RN, Kosar CM, Fong TG, Press D, Inouye SK, Alsop DC. Brain atrophy and white-matter hyperintensities are not significantly associated with incidence and severity of postoperative delirium in older persons without dementia. Neurobiol Aging 2015; 36:2122-9. [PMID: 25824618 DOI: 10.1016/j.neurobiolaging.2015.02.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 02/02/2015] [Accepted: 02/23/2015] [Indexed: 12/17/2022]
Abstract
Postoperative delirium is a common complication in older people and is associated with increased mortality, morbidity, institutionalization, and caregiver burden. Although delirium is an acute confusional state characterized by global impairments in attention and cognition, it has been implicated in permanent cognitive impairment and dementia. The pathogenesis of delirium and the mechanisms leading to these disabling consequences remain unclear. The present study is the first to address the potential predisposing role of brain morphologic changes toward postoperative delirium in a large prospective cohort of patients undergoing elective surgery using state-of-the-art magnetic resonance imaging (MRI) techniques conducted before admission. We investigated the association of MRI-derived quantitative measures of white-matter damage, global brain, and hippocampal volume with the incidence and severity of delirium. Presurgical white-matter hyperintensities (WMHs), whole brain, and hippocampal volume were measured in 146 consecutively enrolled subjects, ≥70 years old, without dementia who were undergoing elective surgery. These 3 presurgical MRI indices were tested as predictors of incidence and severity of subsequent delirium. Out of 146 subjects, 32 (22%) developed delirium. We found no statistically significant differences in WMH, whole brain, or hippocampal volume between subjects with and without delirium. Both unadjusted and adjusted (age, gender, vascular comorbidity, and general cognitive performance) regression analyses demonstrated no statistically significant association between any of the MRI measures with respect to delirium incidence or severity. In persons without dementia, preexisting cerebral WMHs, general and hippocampal atrophy may not predispose to postoperative delirium or worsen its severity.
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Affiliation(s)
- Michele Cavallari
- Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tammy T Hshieh
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Charles R G Guttmann
- Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Long H Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dominik S Meier
- Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, RI, USA; Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Cyrus M Kosar
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Press
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David C Alsop
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Korc-Grodzicki B, Root JC, Alici Y. Prevention of post-operative delirium in older patients with cancer undergoing surgery. J Geriatr Oncol 2014; 6:60-9. [PMID: 25454768 DOI: 10.1016/j.jgo.2014.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/05/2014] [Accepted: 10/07/2014] [Indexed: 12/21/2022]
Abstract
Prevention has been shown to be the most effective strategy for minimizing the occurrence of delirium as well as delirium-associated complications.(5) Therefore prevention of delirium in older adults undergoing surgery is a top research priority given the extent of the problem in this patient population. In this review, we will describe the POD syndrome, previously identified risk factors that predict POD in surgical cancer patients, long-term outcomes of POD and both non-pharmacologic and pharmacologic therapies aimed at preventing POD.
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Affiliation(s)
- Beatriz Korc-Grodzicki
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue Box 205, New York, NY 10065, United States.
| | - James C Root
- Department of Psychiatry and Behavioral Science, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
| | - Yesne Alici
- Department of Psychiatry and Behavioral Science, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
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