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Ethanol concentration induces production of 3,4-dihydroxyphenylacetic acid and homovanillic acid in mouse brain through activation of monoamine oxidase pathway. Neurosci Lett 2022; 782:136689. [DOI: 10.1016/j.neulet.2022.136689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022]
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2
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Dunne SS, Coffey JC, Konje S, Gasior S, Clancy CC, Gulati G, Meagher D, Dunne CP. Biomarkers in delirium: A systematic review. J Psychosom Res 2021; 147:110530. [PMID: 34098376 DOI: 10.1016/j.jpsychores.2021.110530] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delirium is a common neuropsychiatric disorder associated with prolonged hospital stays, and increased morbidity and mortality. Diagnosis is frequently missed due to varying disease presentation and lack of standardized testing. We examined biomarkers as diagnostic or prognostic indicators of delirium, and provide a rational basis for future studies. METHOD Systematic review of literature published between Jan 2000 and June 2019. Searches included: PubMed; Web of Science; CINAHL; EMBASE; COCHRANE and Medline. Additional studies were identified by searching bibliographies of eligible articles. RESULTS 2082 relevant papers were identified from all sources. Seventy-three met the inclusion criteria, all of which were observational. These assessed a range of fourteen biomarkers. All papers included were in the English language. Assessment methods varied between studies, including: DSM criteria; Confusion Assessment Method (CAM) or CAM-Intensive Care Unit (ICU). Delirium severity was measured using the Delirium Rating Scale (DRS). Delirium was secondary to post-operative dysfunction or acute medical conditions. CONCLUSION Evidence does not currently support the use of any one biomarker. However, certain markers were associated with promising results and may warrant evaluation in future studies. Heterogeneity across study methods may have contributed to inconclusive results, and more clarity may arise from standardization of methods of clinical assessment. Adjusting for comorbidities may improve understanding of the pathophysiology of delirium, in particular the role of confounders such as inflammation, cognitive disorders and surgical trauma. Future research may also benefit from inclusion of other diagnostic modalities such as EEG as well as analysis of genetic or epigenetic factors.
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Affiliation(s)
- Suzanne S Dunne
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - J Calvin Coffey
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Swiri Konje
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Sara Gasior
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Conor C Clancy
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Gautam Gulati
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - David Meagher
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland; Cognitive Impairment Research Group, School of Medicine, University of Limerick, Limerick, Ireland
| | - Colum P Dunne
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland; Cognitive Impairment Research Group, School of Medicine, University of Limerick, Limerick, Ireland.
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3
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Urso D, Gnoni V, Filardi M, Logroscino G. Delusion and Delirium in Neurodegenerative Disorders: An Overlooked Relationship? Front Psychiatry 2021; 12:808724. [PMID: 35115974 PMCID: PMC8804700 DOI: 10.3389/fpsyt.2021.808724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/24/2021] [Indexed: 12/04/2022] Open
Abstract
Delusions are part of the neuropsychiatric symptoms that patients suffering from neurodegenerative conditions frequently develop at some point of the disease course and are associated with an increased risk of cognitive and functional decline. Delirium is a syndrome characterized by acute onset of deficits in attention, awareness, and cognition that fluctuate in severity over a short time period. Delusions and delirium are frequently observed in the context of neurodegeneration, and their presence can easily mislead clinicians toward a misdiagnosis of psychiatric disorder further delaying the proper treatment. Risk factors for developing delusion and delirium in neurodegenerative conditions have been investigated separately while the possible interplay between these two conditions has not been explored so far. With this study, we aim to achieve a more comprehensive picture of the relationship between delusions and delirium in neurodegeneration by analyzing prevalence and subtypes of delusions in different neurodegenerative disorders; providing an overview of clinical tools to assess delusions in neurodegenerative patients and how delusions are covered by delirium assessment tools and discussing the possible common pathophysiology mechanisms between delusion and delirium in neurodegenerative patients. A more extensive characterization of the relationship between delusions and delirium may help to understand whether delusions may constitute a risk factor for delirium and may ameliorate the management of both conditions in patients with neurodegenerative disorders.
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Affiliation(s)
- Daniele Urso
- Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, Pia Fondazione Cardinale G. Panico, University of Bari Aldo Moro, Bari, Italy.,Department of Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Valentina Gnoni
- Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, Pia Fondazione Cardinale G. Panico, University of Bari Aldo Moro, Bari, Italy.,Department of Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Marco Filardi
- Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, Pia Fondazione Cardinale G. Panico, University of Bari Aldo Moro, Bari, Italy.,Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Giancarlo Logroscino
- Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, Pia Fondazione Cardinale G. Panico, University of Bari Aldo Moro, Bari, Italy.,Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari Aldo Moro, Bari, Italy
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4
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Dopaminergic Hyperactivity in Neurological Patients with Delirium. Arch Med Res 2020; 50:477-483. [PMID: 32018069 DOI: 10.1016/j.arcmed.2019.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 10/23/2019] [Accepted: 11/12/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Delirium has important etiological, prognostic, and therapeutic implications. The study of neurochemical markers in this condition is relevant to the understanding of its pathophysiology. The assessment of the dopamine system is particularly relevant, as dopamine antagonists are the most used drugs in delirium. AIM To analyze neurotransmission markers in patients with delirium, focusing in the dopamine metabolite, homovanillic acid. METHODS A case-control study was performed at the National Institute of Neurology and Neurosurgery, Mexico, including hospitalized patients in which lumbar puncture was obtained for diagnostic purposes. Cases were selected if they fulfilled DSM-5 criteria for delirium. Age-paired controls were patients in which delirium was ruled out, selected at the same clinical scenario, during the same period. Neurological and systemic diagnoses were registered. Delirium was assessed using the DRS-98-R instrument. The dopamine metabolite, homovanillic acid (HVA), was measured by means of high-performance liquid chromatography. Other neurotransmission markers were also measured (5-hydroxyindoleacetic acid, glutamate, aspartate, GABA, glycine, arginine, citrulline, nitrites, and nitrates). A logistic regression model was used to determine pathogenic factors associated with the presence of delirium. RESULTS 68 neurological patients with delirium and 68 patients without delirium were included. Higher homovanillic acid levels in cerebrospinal fluid were significantly associated with delirium. This result was significant after a subanalysis in patients without exposure to antipsychotics. Male gender and autoimmune limbic encephalitis were also associated with the presence of delirium. CONCLUSIONS In hospitalized neurological patients, dopaminergic hyperactivity and autoimmune limbic encephalitis are pathogenic factors associated with the presence of delirium.
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Hall RJ, Watne LO, Cunningham E, Zetterberg H, Shenkin SD, Wyller TB, MacLullich AMJ. CSF biomarkers in delirium: a systematic review. Int J Geriatr Psychiatry 2018; 33:1479-1500. [PMID: 28585290 DOI: 10.1002/gps.4720] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/16/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In recent years, there has been a blossoming of studies examining cerebrospinal fluid (CSF) as a method of studying the pathophysiology of delirium. We systematically reviewed the literature for CSF studies in delirium and provide here a summary of the implications for our understanding of delirium pathophysiology. We also summarise the methods used for CSF analysis and discuss challenges and implications for future studies. METHODS In this systematic review, we screened MEDLINE, EMBASE, PsycINFO, Web of Science, PubMed and the Cochrane Library for articles on CSF biomarkers in delirium, published on 3 September 2016. Studies were required to use Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria for delirium or a validated tool. We excluded case reports. There were no other restrictions on study type. RESULTS We identified 3280 articles from our initial search, and 22 articles were included in this review. All studies were prospective, including over 400 patients with delirium and 700 controls. More than 70 different biomarkers were studied. Studies could not be compared with each other for meta-analysis because of their heterogeneity and varied widely in their risk of bias and quality assessments. CONCLUSIONS The 22 studies identified in this review reveal a small but growing literature, in which many of the important hypotheses in delirium pathogenesis have been examined, but from which few firm conclusions can currently be drawn. Nevertheless, the overall interpretation of the literature supports the vulnerable brain concept, that is, that biomarker evidence of, for example, Alzheimer's disease pathology and/or neuroinflammation, is associated with delirium.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Emma Cunningham
- Centre for Public Health, Queen's University of Belfast, Belfast, Ireland
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Susan D Shenkin
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
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Jin Z, Piazza O, Ma D, Scarpati G, De Robertis E. Xenon anesthesia and beyond: pros and cons. Minerva Anestesiol 2018; 85:83-89. [PMID: 30019577 DOI: 10.23736/s0375-9393.18.12909-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Xenon is a colorless and odorless noble gas, licensed for human use as an anesthetic gas as well as a radiological marker. The MAC of this gas is about 63% but xenon anesthesia is associated with fast recovery of cognitive function and cardiovascular stability. Nevertheless, postoperative nausea and vomiting (PONV) incidence for xenon anesthesia is very high. It has been reported that Xenon has cytoprotective effects that may have therapeutic values in both CNS protection, and in organ graft preservation. Currently, there are few studies about the effect of xenon on ischemia reperfusion injury of transplantable organs and insufficient clinical data upon its effect on intracranial and cerebral perfusion pressure. We shortly review the pros and cons of xenon as an anesthetic agent.
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Affiliation(s)
- Zhaosheng Jin
- Anesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Ornella Piazza
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Daqing Ma
- Anesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Giuliana Scarpati
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Edoardo De Robertis
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy -
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Zhang Z, Tachikawa M, Uchida Y, Terasaki T. Drug Clearance from Cerebrospinal Fluid Mediated by Organic Anion Transporters 1 (Slc22a6) and 3 (Slc22a8) at Arachnoid Membrane of Rats. Mol Pharm 2018; 15:911-922. [PMID: 29436232 DOI: 10.1021/acs.molpharmaceut.7b00852] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Although arachnoid mater epithelial cells form the blood-arachnoid barrier (BAB), acting as a blood-CSF interface, it has been generally considered that the BAB is impermeable to water-soluble substances and plays a largely passive role. Here, we aimed to clarify the function of transporters at the BAB in regulating CSF clearance of water-soluble organic anion drugs based on quantitative targeted absolute proteomics (QTAP) and in vivo analyses. Protein expression levels of 61 molecules, including 19 ATP-binding-cassette (ABC) transporters and 32 solute-carrier (SLC) transporters, were measured in plasma membrane fraction of rat leptomeninges using QTAP. Thirty-three proteins were detected; others were under the quantification limits. Expression levels of multidrug resistance protein 1 (Mdr1a/P-gp/Abcb1a) and breast cancer resistance protein (Bcrp/Abcg2) were 16.6 and 3.27 fmol/μg protein (51.9- and 9.82-fold greater than in choroid plexus, respectively). Among those organic anion transporters detected only at leptomeninges, not choroid plexus, organic anion transporter 1 (oat1/Slc22a6) showed the greatest expression (2.73 fmol/μg protein). On the other hand, the protein expression level of oat3 at leptomeninges was 6.65 fmol/μg protein, and the difference from choroid plexus was within two-fold. To investigate oat1's role, we injected para-aminohippuric acid (PAH) with or without oat1 inhibitors into cisterna magna (to minimize the contribution of choroid plexus function) of rats. A bulk flow marker, FITC-inulin, was not taken up from CSF up to 15 min, whereas uptake clearance of PAH was 26.5 μL/min. PAH uptake was completely blocked by 3 mM cephalothin (inhibits both oat1 and oat3), while 17% of PAH uptake was inhibited by 0.2 mM cephalothin (selectively inhibits oat3). These results indicate that oat1 and oat3 at the BAB provide a distinct clearance pathway of organic anion drugs from CSF independently of choroid plexus.
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Affiliation(s)
- Zhengyu Zhang
- Division of Membrane Transport and Drug Targeting, Graduate School of Pharmaceutical Sciences , Tohoku University , Sendai 980-8578 , Japan
| | - Masanori Tachikawa
- Division of Membrane Transport and Drug Targeting, Graduate School of Pharmaceutical Sciences , Tohoku University , Sendai 980-8578 , Japan
| | - Yasuo Uchida
- Division of Membrane Transport and Drug Targeting, Graduate School of Pharmaceutical Sciences , Tohoku University , Sendai 980-8578 , Japan
| | - Tetsuya Terasaki
- Division of Membrane Transport and Drug Targeting, Graduate School of Pharmaceutical Sciences , Tohoku University , Sendai 980-8578 , Japan
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Veselinović T, Vernaleken I, Cumming P, Henning U, Winkler L, Kaleta P, Paulzen M, Luckhaus C, Gründer G. Antidopaminergic medication in healthy subjects provokes subjective and objective mental impairments tightly correlated with perturbation of biogenic monoamine metabolism and prolactin secretion. Neuropsychiatr Dis Treat 2018; 14:1125-1138. [PMID: 29731635 PMCID: PMC5927059 DOI: 10.2147/ndt.s148557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Off-label prescription of antipsychotics to patients without psychotic symptoms has become a routine matter for many psychiatrists and also some general practitioners. Nonetheless, little is known about the possibly detrimental effects of antidopaminergic medications on general psychopathology, subjective mental state, or a possible association with physiological parameters in nonpsychotic individuals. METHODS In this randomized, single-blinded study, groups of healthy volunteers (n=18) received low doses of reserpine, aripiprazole, haloperidol, or placebo on 7 successive days. Relevant physiological parameters (plasma prolactin, concentrations of catecholamine metabolites in plasma, and 24-hour urine) and each subject's mental state (Positive and Negative Syndrome Scale, Hamilton Rating Scale for Depression, visual analogue scale, Beck Depression Inventory II) were assessed at the start and end of the trial. RESULTS Of the three active treatments, only reserpine caused a significant increase in some plasma- and urine-catecholamine metabolites, but all three medications evoked objective and subjective changes in general psychopathology scores, which correlated with individual increases in plasma homovanillic acid concentrations. Both objective and subjective impairments were significantly more pronounced in the subgroup with greatest increase of plasma prolactin. Subjects experiencing the most pronounced side effects under haloperidol, which compelled them to drop out, showed significantly higher prolactin concentration increases than those who tolerated haloperidol well. CONCLUSION We found consistent associations between altered markers of dopamine transmission and several objective and subjective mental impairments in healthy volunteers after 1 week's treatment with antidopaminergic medications. These findings should draw attention to a more intensive risk-benefit evaluation in cases of off-label prescription of antipsychotic medications.
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Affiliation(s)
- Tanja Veselinović
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Faculty of Medicine, RWTH Aachen University, Aachen.,Translational Brain Medicine, Jülich Aachen Research Alliance (JARA), Jülich, Germany
| | - Ingo Vernaleken
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Faculty of Medicine, RWTH Aachen University, Aachen.,Translational Brain Medicine, Jülich Aachen Research Alliance (JARA), Jülich, Germany
| | - Paul Cumming
- IHBI, School of Psychology and Counselling, Queensland University of Technology.,QIMR Berghofer Institute, Brisbane, Australia
| | - Uwe Henning
- Neurobiochemical Research Unit, Department of Psychiatry, Heinrich Heine University, Düsseldorf
| | - Lina Winkler
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Faculty of Medicine, RWTH Aachen University, Aachen.,Translational Brain Medicine, Jülich Aachen Research Alliance (JARA), Jülich, Germany
| | - Peter Kaleta
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Faculty of Medicine, RWTH Aachen University, Aachen.,Translational Brain Medicine, Jülich Aachen Research Alliance (JARA), Jülich, Germany
| | - Michael Paulzen
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Faculty of Medicine, RWTH Aachen University, Aachen.,Translational Brain Medicine, Jülich Aachen Research Alliance (JARA), Jülich, Germany
| | - Christian Luckhaus
- LWL University Hospital Bochum, Department of Psychiatry, Division of Cognitive Neuropsychiatry and Psychiatric Preventive Medicine, Ruhr University Bochum, Bochum
| | - Gerhard Gründer
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Faculty of Medicine, RWTH Aachen University, Aachen.,Translational Brain Medicine, Jülich Aachen Research Alliance (JARA), Jülich, Germany.,Department of Molecular Neuroimaging, Central Institute of Mental Health, Mannheim, Germany
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Aslaner MA, Boz M, Çelik A, Ahmedali A, Eroğlu S, Metin Aksu N, Eroğlu SE. Etiologies and delirium rates of elderly ED patients with acutely altered mental status: a multicenter prospective study. Am J Emerg Med 2016; 35:71-76. [PMID: 27765479 DOI: 10.1016/j.ajem.2016.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 09/28/2016] [Accepted: 10/03/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Altered mental status (AMS) is a challenging diagnosis in older patients and has a large range of etiologies. The aim of this study was to investigate the nature of such etiologies for physicians to be better aware of AMS backgrounds and hence improve outcomes and mortality rates. METHODS This prospective observational study was conducted at 4 emergency departments. Patients 65 years and older who presented to the emergency department with acute AMS (≤1 week), with symptoms ranging from comas and combativeness, were eligible for inclusion in this study. The outcomes, etiologies, Richmond Agitation and Sedation Scale scores, and the presence of delirium were recorded. RESULTS Among 822 older patients with AMS, infection (39.5%) and neurological diseases (36.5%) were the most common etiologies. The hospital admission and mortality rates were 73.7% (n = 606) and 24.7% (n = 203), respectively. The mortality rate rose if AMS persisted for more than 3 days. Delirium was observed in 55.7% of the patients; these individuals had higher durations of AMS than those without delirium (median, 24 hours; interquartile range, 3-48 hours; median 6 hours, interquartile range, 3-48 hours, respectively; P = .010). Notably, delirium was observed in more than two-thirds of neurological patients. CONCLUSIONS The most common causes of AMS were infection and neurological diseases. Delirium was associated with AMS in nearly half the patients. Moreover, the rates of hospitalization and mortality remained high.
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Affiliation(s)
| | - Mustafa Boz
- Hacettepe University Faculty of Medicine, Emergency Medicine, Ankara, Turkey
| | - Ali Çelik
- Marmara University Pendik Research and Training Hospital, Emergency Medicine, İstanbul, Turkey
| | | | - Sercan Eroğlu
- Ahi Evran University Training and Research Hospital, Emergency Department, Kırsehir, Turkey
| | - Nalan Metin Aksu
- Hacettepe University Faculty of Medicine, Emergency Medicine, Ankara, Turkey
| | - Serkan Emre Eroğlu
- Marmara University Pendik Research and Training Hospital, Emergency Medicine, İstanbul, Turkey
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10
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Watne LO, Idland AV, Fekkes D, Raeder J, Frihagen F, Ranhoff AH, Chaudhry FA, Engedal K, Wyller TB, Hassel B. Increased CSF levels of aromatic amino acids in hip fracture patients with delirium suggests higher monoaminergic activity. BMC Geriatr 2016; 16:149. [PMID: 27484129 PMCID: PMC4970288 DOI: 10.1186/s12877-016-0324-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/28/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To examine whether delirium in hip fracture patients was associated with changes in the levels of amino acids and/or monoamine metabolites in cerebrospinal fluid (CSF) and serum. METHODS In this prospective cohort study, 77 patients admitted with an acute hip fracture to Oslo University Hospital, Norway, were studied. The concentrations of amino acids in CSF and serum were determined by high performance liquid chromatography. The patients were assessed daily for delirium by the Confusion Assessment Method (pre-operatively and post-operative day 1-5 (all) or until discharge (delirious patients)). Pre-fracture dementia status was decided by an expert panel. Serum was collected pre-operatively and CSF immediately before spinal anesthesia. RESULTS Fifty-three (71 %) hip fracture patients developed delirium. In hip fracture patients without dementia (n = 39), those with delirium had significantly higher CSF levels of tryptophan (40 % higher), tyrosine (60 % higher), phenylalanine (59 % higher) and the monoamine metabolite 5-hydroxyindoleacetate (23 % higher) compared to those without delirium. The same amino acids were also higher in CSF in delirious patients with dementia (n = 38). The correlations between serum and CSF amino acid levels were poor. CONCLUSION Higher CSF levels of monoamine precursors in hip fracture patients with delirium suggest a higher monoaminergic activity in the central nervous system during delirium in this patient group.
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Affiliation(s)
- Leiv Otto Watne
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway. .,Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO BOX 4950, Nydalen, N-0424, Oslo, Norway. .,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway. .,Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, Scotland, UK.
| | - Ane-Victoria Idland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO BOX 4950, Nydalen, N-0424, Oslo, Norway
| | - Durk Fekkes
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Johan Raeder
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Anette Hylen Ranhoff
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Knut Engedal
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Norwegian National Advisory Unit on Ageing and Health, Vestfold Health Trust, Tønsberg, Norway
| | - Torgeir Bruun Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO BOX 4950, Nydalen, N-0424, Oslo, Norway
| | - Bjørnar Hassel
- Department of Complex Neurology and Neurohabilitation, Oslo University Hospital, N-0027, Oslo, Norway. .,Norwegian Defense Research Establishment (FFI), Kjeller, Norway.
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Egberts A, Fekkes D, Wijnbeld EHA, van der Ploeg MA, van Saase JLCM, Ziere G, van der Cammen TJM, Mattace-Raso FUS. Disturbed Serotonergic Neurotransmission and Oxidative Stress in Elderly Patients with Delirium. Dement Geriatr Cogn Dis Extra 2015; 5:450-8. [PMID: 26955379 PMCID: PMC4777943 DOI: 10.1159/000440696] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Oxidative stress and disturbances in serotonergic and dopaminergic neurotransmission may play a role in the pathophysiology of delirium. Aims In this study, we investigated levels of amino acids, amino acid ratios and levels of homovanillic acid (HVA) as indicators for oxidative stress and disturbances in neurotransmission. Methods Plasma levels of amino acids, amino acid ratios and HVA were determined in acutely ill patients aged ≥65 years admitted to the wards of Internal Medicine and Geriatrics of the Erasmus University Medical Center and the ward of Geriatrics of the Havenziekenhuis, Rotterdam, The Netherlands. Differences in the biochemical parameters between patients with and without delirium were investigated by analysis of variance in models adjusted for age, gender and comorbidities. Results Of the 86 patients included, 23 had delirium. In adjusted models, higher mean phenylalanine/tyrosine ratios (1.34 vs. 1.14, p = 0.028), lower mean tryptophan/large neutral amino acids ratios (4.90 vs. 6.12, p = 0.021) and lower mean arginine levels (34.8 vs. 45.2 µmol/l, p = 0.022) were found in patients with delirium when compared to those without. No differences were found in HVA levels between patients with and without delirium. Conclusion The findings of this study suggest disturbed serotonergic neurotransmission and an increased status of oxidative stress in patients with delirium.
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Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Durk Fekkes
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eline H A Wijnbeld
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Milly A van der Ploeg
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan L C M van Saase
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gijsbertus Ziere
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tischa J M van der Cammen
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol 2015; 14:823-832. [PMID: 26139023 DOI: 10.1016/s1474-4422(15)00101-5] [Citation(s) in RCA: 338] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/27/2015] [Accepted: 05/18/2015] [Indexed: 02/02/2023]
Abstract
Delirium and dementia are two of the most common causes of cognitive impairment in older populations, yet their interrelation remains poorly understood. Previous studies have shown that dementia is the leading risk factor for delirium and that delirium is an independent risk factor for subsequent development of dementia. However, a major area of controversy is whether delirium is simply a marker of vulnerability to dementia, whether the effect of delirium is solely related to its precipitating factors, or whether delirium itself can cause permanent neuronal damage and lead to dementia. Ultimately, all of these hypotheses are likely to be true. Emerging evidence from epidemiological, clinicopathological, neuroimaging, biomarker, and experimental studies lends support to a strong relation between delirium and dementia, and to both shared and distinct pathological mechanisms. New preventive and therapeutic approaches that target delirium might offer a sought-after opportunity for early intervention, preservation of cognitive reserve, and prevention of irreversible cognitive decline in ageing.
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Affiliation(s)
- Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, UCL, London, UK
| | - Matthew E Growdon
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
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Maclullich AMJ, Anand A, Davis DHJ, Jackson T, Barugh AJ, Hall RJ, Ferguson KJ, Meagher DJ, Cunningham C. New horizons in the pathogenesis, assessment and management of delirium. Age Ageing 2013; 42:667-74. [PMID: 24067500 PMCID: PMC3809721 DOI: 10.1093/ageing/aft148] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Delirium is one of the foremost unmet medical needs in healthcare. It affects one in eight hospitalised patients and is associated with multiple adverse outcomes including increased length of stay, new institutionalisation, and considerable patient distress. Recent studies also show that delirium strongly predicts future new-onset dementia, as well as accelerating existing dementia. The importance of delirium is now increasingly being recognised, with a growing research base, new professional international organisations, increased interest from policymakers, and greater prominence of delirium in educational and audit programmes. Nevertheless, the field faces several complex research and clinical challenges. In this article we focus on selected areas of recent progress and/or uncertainty in delirium research and practice. (i) Pathogenesis: recent studies in animal models using peripheral inflammatory stimuli have begun to suggest mechanisms underlying the delirium syndrome as well as its link with dementia. A growing body of blood and cerebrospinal fluid studies in humans have implicated inflammatory and stress mediators. (ii) Prevention: delirium prevention is effective in the context of research studies, but there are several unresolved issues, including what components should be included, the role of prophylactic drugs, and the overlap with general best care for hospitalised older people. (iii) Assessment: though there are several instruments for delirium screening and assessment, detection rates remain dismal. There are no clear solutions but routine screening embedded into clinical practice, and the development of new rapid screening instruments, offer potential. (iv) Management: studies are difficult given the heterogeneity of delirium and currently expert and comprehensive clinical care remains the main recommendation. Future studies may address the role of drugs for specific elements of delirium. In summary, though facing many challenges, the field continues to make progress, with several promising lines of enquiry and an expanding base of interest among researchers, clinicians and policymakers.
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Affiliation(s)
- Alasdair M J Maclullich
- Edinburgh Delirium Research Group, Geriatric Medicine Unit, University of Edinburgh, Room S1642, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
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Fitzgerald JM, Adamis D, Trzepacz PT, O'Regan N, Timmons S, Dunne C, Meagher DJ. Delirium: a disturbance of circadian integrity? Med Hypotheses 2013; 81:568-76. [PMID: 23916192 DOI: 10.1016/j.mehy.2013.06.032] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 05/07/2013] [Accepted: 06/30/2013] [Indexed: 11/19/2022]
Abstract
Delirium is a serious neuropsychiatric syndrome of acute onset that occurs in approximately one in five general hospital patients and is associated with serious adverse outcomes that include loss of adaptive function, persistent cognitive problems and increased mortality. Recent studies indicate a three-domain model for delirium that includes generalised cognitive impairment, disturbed executive cognition, and disruption of behaviours that are under circadian control such as sleep-wake cycle and motor activity levels. As a consequence, attention has focused upon the possible role of the circadian timing system (CTS) in the pathophysiology of delirium. We explored this possibility by reviewing evidence that (1) many symptoms that occur in delirium are influenced by circadian rhythms, (2) many features of recognised circadian rhythm disorders are similar to characteristic features of delirium, (3) common risk factors for delirium are known to disrupt circadian systems, (4) physiological disturbances of circadian systems have been noted in delirious patients, and (5) positive effects in the treatment of delirium have been demonstrated for melatonin and related agents that influence the circadian timing system. A programme of future studies that can help to clarify the relevance of circadian integrity to delirium is described. Such work can provide a better understanding of the pathophysiology of delirium while also identifying opportunities for more targeted therapeutic efforts.
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Affiliation(s)
- James M Fitzgerald
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland
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Martins S, Fernandes L. Delirium in elderly people: a review. Front Neurol 2012; 3:101. [PMID: 22723791 PMCID: PMC3377955 DOI: 10.3389/fneur.2012.00101] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 06/01/2012] [Indexed: 01/12/2023] Open
Abstract
The present review aims to highlight this intricate syndrome, regarding diagnosis, pathophysiology, etiology, prevention, and management in elderly people. The diagnosis of delirium is based on clinical observations, cognitive assessment, physical, and neurological examination. Clinically, delirium occurs in hyperactive, hypoactive, or mixed forms, based on psychomotor behavior. As an acute confusional state, it is characterized by a rapid onset of symptoms, fluctuating course and an altered level of consciousness, global disturbance of cognition or perceptual abnormalities, and evidence of a physical cause. Although pathophysiological mechanisms of delirium remain unclear, current evidence suggests that disruption of neurotransmission, inflammation, or acute stress responses might all contribute to the development of this ailment. It usually occurs as a result of a complex interaction of multiple risk factors, such as cognitive impairment/dementia and current medical or surgical disorder. Despite all of the above, delirium is frequently under-recognized and often misdiagnosed by health professionals. In particular, this happens due to its fluctuating nature, its overlap with dementia and the scarcity of routine formal cognitive assessment in general hospitals. It is also associated with multiple adverse outcomes that have been well documented, such as increased hospital stay, function/cognitive decline, institutionalization and mortality. In this context, the early identification of delirium is essential. Timely and optimal management of people with delirium should be performed with identification of any possible underlying causes, dealing with a suitable care environment and improving education of health professionals. All these can be important factors, which contribute to a decrease in adverse outcomes associated with delirium.
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Affiliation(s)
- Sónia Martins
- Research and Education Unit on Aging, UNIFAI/ICBAS, University of PortoPorto, Portugal
| | - Lia Fernandes
- Research and Education Unit on Aging, UNIFAI/ICBAS, University of PortoPorto, Portugal
- Clinical Neuroscience and Mental Health Department, Faculty of Medicine, University of PortoPorto, Portugal
- Psychiatry Service, S. João HospitalPorto, Portugal
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Hall RJ, Shenkin SD, Maclullich AMJ. A systematic literature review of cerebrospinal fluid biomarkers in delirium. Dement Geriatr Cogn Disord 2012; 32:79-93. [PMID: 21876357 DOI: 10.1159/000330757] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2011] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) analysis has great potential to advance understanding of delirium pathophysiology. METHODS A systematic literature review of CSF studies of DSM or ICD delirium was performed. RESULTS In 8 studies of 235 patients, delirium was associated with: elevated serotonin metabolites, interleukin-8, cortisol, lactate and protein, and reduced somatostatin, β-endorphin and neuron-specific enolase. Elevated acetylcholinesterase predicted poor outcome after delirium and higher dopamine metabolites were associated with psychotic features. CONCLUSIONS No clear conclusions emerged, but the current literature suggests multiple areas for further investigation with more detailed studies.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences and Community Health, UK. roanna.hall @ ed.ac.uk
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Persistent nigrostriatal dopaminergic abnormalities in ex-users of MDMA ('Ecstasy'): an 18F-dopa PET study. Neuropsychopharmacology 2011; 36:735-43. [PMID: 21160467 PMCID: PMC3037848 DOI: 10.1038/npp.2010.201] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Ecstasy (±3,4-methylenedioxymethamphetamine, MDMA) is a popular recreational drug with known serotonergic neurotoxicity. Its long-term effects on dopaminergic function are less certain. Studying the long-term effects of ecstasy is often confounded by concomitant polydrug use and the short duration of abstinence. We used (18)F-dopa positron emission tomography (PET) to investigate the long-term effects of ecstasy on nigrostriatal dopaminergic function in a group of male ex-recreational users of ecstasy who had been abstinent for a mean of 3.22 years. We studied 14 ex-ecstasy users (EEs), 14 polydrug-using controls (PCs) (matched to the ex-users for other recreational drug use), and 12 drug-naive controls (DCs). Each participant underwent one (18)F-dopa PET, cognitive assessments, and hair and urinary analyses to corroborate drug-use history. The putamen (18)F-dopa uptake of EEs was 9% higher than that of DCs (p=0.021). The putamen uptake rate of PCs fell between the other two groups, suggesting that the hyperdopaminergic state in EEs may be due to the combined effects of ecstasy and polydrug use. There was no relationship between the amount of ecstasy used and striatal (18)F-dopa uptake. Increased putaminal (18)F-dopa uptake in EEs after an abstinence of >3 years (mean) suggests that the effects are long lasting. Our findings suggest potential long-term effects of ecstasy use, in conjunction with other recreational drugs, on nigrostriatal dopaminergic functions. Further longitudinal studies are required to elucidate the significance of these findings as they may have important public health implications.
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Imbalance Between Nitric Oxide and Dopamine May Underly Aggression in Acute Neurological Patients. Neurochem Res 2010; 35:1659-65. [DOI: 10.1007/s11064-010-0227-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2010] [Indexed: 10/19/2022]
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Pearson A, de Vries A, Middleton SD, Gillies F, White TO, Armstrong IR, Andrew R, Seckl JR, MacLullich AM. Cerebrospinal fluid cortisol levels are higher in patients with delirium versus controls. BMC Res Notes 2010; 3:33. [PMID: 20181121 PMCID: PMC2829583 DOI: 10.1186/1756-0500-3-33] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 02/08/2010] [Indexed: 08/18/2023] Open
Abstract
Background High plasma cortisol levels can cause acute cognitive and neuropsychiatric dysfunction, and have been linked with delirium. CSF cortisol levels more closely reflect brain exposure to cortisol, but there are no studies of CSF cortisol levels in delirium. In this pilot study we acquired CSF specimens at the onset of spinal anaesthesia in patients undergoing hip fracture surgery, and compared CSF and plasma cortisol levels in delirium cases versus controls. Findings Delirium assessments were performed the evening before or on the morning of operation with a standard battery comprising cognitive tests, mental status assessments and the Confusion Assessment Method. CSF and plasma samples were obtained at the onset of the operation and cortisol levels measured. Twenty patients (15 female, 5 male) aged 62 - 93 years were studied. Seven patients were diagnosed with delirium. The mean ages of cases (81.4 (SD 7.2)) and controls (80.5 (SD 8.7)) were not significantly different (p = 0.88). The median (interquartile range) CSF cortisol levels were significantly higher in cases (63.9 (40.4-102.1) nmol/L) than controls (31.4 (21.7-43.3) nmol/L; Mann-Whitney U, p = 0.029). The median (interquartile range) of plasma cortisol was also significantly higher in cases (968.8 (886.2-1394.4) nmol/L, than controls (809.4 (544.0-986.4) nmol/L; Mann Whitney U, p = 0.036). Conclusions These findings support an association between higher CSF cortisol levels and delirium. This extends previous findings linking higher plasma cortisol and delirium, and suggests that more definitive studies of the relationship between cortisol levels and delirium are now required.
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Affiliation(s)
- Andrew Pearson
- Geriatric Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
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Tabet N, Howard R. Pharmacological treatment for the prevention of delirium: review of current evidence. Int J Geriatr Psychiatry 2009; 24:1037-44. [PMID: 19226527 DOI: 10.1002/gps.2220] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Delirium is a very common and serious disorder with high morbidity and mortality. Despite symptomatic treatment the outcome can be poor for some especially when no underlying cause is identified. As a result, various strategies for delirium prevention have been assessed. Pharmacological agents such as antipsychotics, acetylcholinesterase inhibitors, sleep-wake cycle regulators, anti-inflammatories and others have been advocated for a potential role in delirium prevention. The aim of this paper is to review the available evidence for their use in the prevention of delirium. METHODS An electronic search was carried out using Medline, EMBASE and Cochrane for randomised controlled trials (RCTs) and other studies. The words delirium, prevention, intervention, pharmacological, prophylactic, antipsychotics, acetylcholinesterase inhibitors, sleep and anti-inflammatories were used. References from selected papers were also searched. RESULTS No multi-centre RCT has been identified. Few trials and other studies have been published so far assessing the prophylactic role of antipsychotics, acetylcholinesterase inhibitors, hypnotics, melatonin, and gabapentin. As these studies tested different drugs, regimes and protocols in diverse populations no meaningful comparison can be made. CONCLUSION To date there is conflicting and inconsistent data regarding the efficacy of pharmacological treatment for delirium prevention. Positive reports in few of the studies justify further assessment of the potential for some pharmacological agents in the prevention of delirium. Well designed and appropriately powered RCTs are now needed. However, based on available evidence so far, no recommendation can be made to justify the routine clinical prophylactic use of any pharmacological agent in the prevention of delirium.
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Affiliation(s)
- Naji Tabet
- Institute of Postgraduate Medicine, Brighton & Sussex Medical School, Brighton, UK.
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