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Varpaei HA, Farhadi K, Mohammadi M, Khafaee Pour Khamseh A, Mokhtari T. Postoperative cognitive dysfunction: a concept analysis. Aging Clin Exp Res 2024; 36:133. [PMID: 38902462 PMCID: PMC11189971 DOI: 10.1007/s40520-024-02779-7] [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: 10/28/2023] [Accepted: 02/17/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Post-operative cognitive dysfunction (POCD) is a concern for clinicians that often presents post-surgery where generalized anesthesia has been used. Its prevalence ranges from 36.6% in young adults to 42.4% in older individuals. Conceptual clarity for POCD is lacking in the currently body literature. Our two-fold purpose of this concept analysis was to (1) critically appraise the various definitions, while also providing the best definition, of POCD and (2) narratively synthesize the attributes, surrogate or related terms, antecedents (risk factors), and consequences of the concept. METHOD The reporting of our review was guided by the PRISMA statement and the 6-step evolutionary approach to concept analysis developed by Rodgers. Three databases, including Medline, CINAHL, and Web of Science, were searched to retrieve relevant literature on the concept of POCD. Two independent reviewers conducted abstract and full-text screening, data extraction, and appraisal. The review process yielded a final set of 86 eligible articles. RESULT POCD was defined with varying severities ranging from subtle-to-extensive cognitive changes (1) affecting single or multiple cognitive domains that manifest following major surgery (2), is transient and reversible, and (3) may last for several weeks to years. The consequences of POCD may include impaired quality of life, resulting from withdrawal from the labor force, increased patients' dependencies, cognitive decline, an elevated risk of dementia, rising healthcare costs, and eventual mortality. CONCLUSION This review resulted in a refined definition and comprehensive analysis of POCD that can be useful to both researchers and clinicians. Future research is needed to refine the operational definitions of POCD so that they better represent the defining attributes of the concept.
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Affiliation(s)
| | - Kousha Farhadi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Tahereh Mokhtari
- Department of Gynecology, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Wang Z, Dong J, Zhang M, Wang S, Wu J, Wang S, Luo Y, Wang Y, Yin Y. Sevoflurane-induced overexpression of extrasynaptic α5-GABA AR via the RhoA/ROCK2 pathway impairs cognitive function in aged mice. Aging Cell 2024:e14209. [PMID: 38825816 DOI: 10.1111/acel.14209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/24/2024] [Accepted: 05/08/2024] [Indexed: 06/04/2024] Open
Abstract
Perioperative neurocognitive disorder (PND) is a serious neurologic complication in aged patients and might be associated with sevoflurane exposure. However, the specific pathogenesis is still unclear. The distribution of α5-GABAAR, a γ-aminobutyric acid type A receptor (GABAAR) subtype, at extrasynaptic sites is influenced by the anchor protein radixin, whose phosphorylation is regulated via the RhoA/ROCK2 signaling pathway and plays a crucial role in cognition. However, whether sevoflurane affects the ability of radixin phosphorylation to alter extrasynaptic receptor expression is unknown. Aged mice were exposed to sevoflurane to induce cognitive impairment. Both total proteins and membrane proteins were extracted for analysis. Cognitive function was evaluated using the Morris water maze and fear conditioning test. Western blotting was used to determine the expression of ROCK2 and the phosphorylation of radixin. Furthermore, the colocalization of p-radixin and α5-GABAAR was observed. To inhibit ROCK2 activity, either an adeno-associated virus (AAV) or fasudil hydrochloride was administered. Aged mice treated with sevoflurane exhibited significant cognitive impairment accompanied by increased membrane expression of α5-GABAAR. Moreover, the colocalization of α5-GABAAR and p-radixin increased after treatment with sevoflurane, and this change was accompanied by an increase in ROCK2 expression and radixin phosphorylation. Notably, inhibiting the RhoA/ROCK2 pathway significantly decreased the distribution of extrasynaptic α5-GABAAR and improved cognitive function. Sevoflurane activates the RhoA/ROCK2 pathway and increases the phosphorylation of radixin. Excess α5-GABAAR is anchored to extrasynaptic sites and impairs cognitive ability in aged mice. Fasudil hydrochloride administration improves cognitive function.
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Affiliation(s)
- Zhun Wang
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Jinpeng Dong
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Mengxue Zhang
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Sixuan Wang
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Jiangnan Wu
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shengran Wang
- State Key Laboratory of Toxicology and Medical Countermeasures, Academy of Military Medical Sciences, Beijing, China
| | - Yuan Luo
- State Key Laboratory of Toxicology and Medical Countermeasures, Academy of Military Medical Sciences, Beijing, China
| | - Yongan Wang
- State Key Laboratory of Toxicology and Medical Countermeasures, Academy of Military Medical Sciences, Beijing, China
| | - Yiqing Yin
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
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Hshieh TT, Gou RY, Jones RN, Leslie DL, Marcantonio ER, Xu G, Travison TG, Fong TG, Schmitt EM, Inouye SK. One-year Medicare costs associated with delirium in older hospitalized patients with and without Alzheimer's disease dementia and related disorders. Alzheimers Dement 2023; 19:1901-1912. [PMID: 36354163 PMCID: PMC10169545 DOI: 10.1002/alz.12826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 09/02/2022] [Accepted: 09/19/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION One-year health-care costs associated with delirium in older hospitalized patients with and without Alzheimer's disease and related dementias (ADRD) have not been examined previously. METHODS Medicare costs were determined prospectively at discharge, and at 30, 90, and 365 days in a cohort (n = 311) of older adults after hospital admission. RESULTS Seventy-six (24%) patients had ADRD and were more likely to develop delirium (51% vs. 24%, P < 0.001) and die within 1 year (38% vs. 21%, P = 0.002). In ADRD patients with versus without delirium, adjusted mean difference in costs associated with delirium were $34,828; most of the excess costs were incurred between 90 and 365 days (P = 0.03). In non-ADRD patients, delirium was associated with increased costs at all timepoints. Excess costs associated with delirium in ADRD patients increased progressively over 1 year, whereas in non-ADRD patients the increase was consistent across time periods. DISCUSSION Our findings highlight the complexity of health-care costs for ADRD patients who develop delirium, a potentially preventable source of expenditures. HIGHLIGHTS Novel examination of health-care costs of delirium in persons with and without Alzheimer's disease and related dementias (ADRD). Increased 1-year costs of $34,828 in ADRD patients with delirium (vs. without). Increased costs for delirium in ADRD occur later during the 365-day study period. For ADRD patients, cost differences between those with and without delirium increased over 1 year. For non-ADRD patients, the parallel cost differences were consistent over time.
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Affiliation(s)
- Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ray Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Douglas L Leslie
- Center for Applied Studies in Health Economics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Edward R Marcantonio
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Guoquan Xu
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Thomas G Travison
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Murty DVPS, Manikandan K, Kumar WS, Ramesh RG, Purokayastha S, Nagendra B, ML A, Balakrishnan A, Javali M, Rao NP, Ray S. Stimulus-induced gamma rhythms are weaker in human elderly with mild cognitive impairment and Alzheimer's disease. eLife 2021; 10:e61666. [PMID: 34099103 PMCID: PMC8238507 DOI: 10.7554/elife.61666] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 05/23/2021] [Indexed: 12/16/2022] Open
Abstract
Alzheimer's disease (AD) in elderly adds substantially to socioeconomic burden necessitating early diagnosis. While recent studies in rodent models of AD have suggested diagnostic and therapeutic value for gamma rhythms in brain, the same has not been rigorously tested in humans. In this case-control study, we recruited a large population (N = 244; 106 females) of elderly (>49 years) subjects from the community, who viewed large gratings that induced strong gamma oscillations in their electroencephalogram (EEG). These subjects were classified as healthy (N = 227), mild cognitively impaired (MCI; N = 12), or AD (N = 5) based on clinical history and Clinical Dementia Rating scores. Surprisingly, stimulus-induced gamma rhythms, but not alpha or steady-state visually evoked responses, were significantly lower in MCI/AD subjects compared to their age- and gender-matched controls. This reduction was not due to differences in eye movements or baseline power. Our results suggest that gamma could be used as a potential screening tool for MCI/AD in humans.
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Affiliation(s)
| | | | | | | | | | | | - Abhishek ML
- Centre for Neuroscience, Indian Institute of ScienceBengaluruIndia
| | | | - Mahendra Javali
- MS Ramaiah Medical College & Memorial HospitalBengaluruIndia
| | | | - Supratim Ray
- Centre for Neuroscience, Indian Institute of ScienceBengaluruIndia
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Helfand BKI, D'Aquila ML, Tabloski P, Erickson K, Yue J, Fong TG, Hshieh TT, Metzger ED, Schmitt EM, Boudreaux ED, Inouye SK, Jones RN. Detecting Delirium: A Systematic Review of Identification Instruments for Non-ICU Settings. J Am Geriatr Soc 2020; 69:547-555. [PMID: 33135780 DOI: 10.1111/jgs.16879] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/14/2020] [Accepted: 09/20/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND/OBJECTIVES Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated all delirium identification instruments according to their psychometric properties and frequency of citation in published research. DESIGN We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords "delirium" and "instruments," along with their known synonyms. We selected only systematic reviews, meta-analyses, or narrative literature reviews including multiple delirium identification instruments. MEASUREMENTS Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) framework. RESULTS Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III through DSM-5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM-5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98, and Memorial Delirium Assessment Scale. CONCLUSION Four commonly used and well-validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium.
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Affiliation(s)
- Benjamin K I Helfand
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Madeline L D'Aquila
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Patricia Tabloski
- William F. Connell School of Nursing, Boston College, Boston, Massachusetts, USA
| | - Kristen Erickson
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Tamara G Fong
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tammy T Hshieh
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Division of Gerontology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eran D Metzger
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Edwin D Boudreaux
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard N Jones
- Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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Hshieh TT, Fong TG, Schmitt EM, Marcantonio ER, Xu G, Gou YR, Travison TG, Metzger ED, Jones RN, Inouye SK. Does Alzheimer's Disease and Related Dementias Modify Delirium Severity and Hospital Outcomes? J Am Geriatr Soc 2020; 68:1722-1730. [PMID: 32255521 DOI: 10.1111/jgs.16420] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We examined the association between delirium severity and outcomes of delirium among persons with and without Alzheimer's disease and related dementias (ADRD). DESIGN Prospective cohort study. SETTING Academic tertiary medical center. PARTICIPANTS A total of 352 medical and surgical patients. MEASUREMENTS Delirium incidence and severity were rated daily using the Confusion Assessment Method (CAM) and CAM-Severity (CAM-S) score during hospitalization. Severe delirium was defined as a CAM-S Short Form score in the highest tertile (3-7 points out of 7). ADRD status was determined by a clinical consensus process. Clinical outcomes included prolonged length of stay (>6 d), discharge to post-acute nursing facility, any decline in activities of daily living (ADLs) at 1 month from prehospital baseline, ongoing nursing facility stay, and mortality. RESULTS Patients with ADRD (n = 85 [24%]) had a significantly higher relative risk (RR) for incident delirium (RR = 2.31; 95% confidence interval [CI] = 1.64-3.28) and higher peak CAM-S scores (mean difference = 1.24 points; CI = .83-1.65; P < .001). Among patients with ADRD, severe delirium significantly increased the RR for nursing facility stay (RR = 2.22; CI = 1.05-4.69; P = .04) and increased the RR for mortality (RR = 2.10; CI = .89-4.98; P = .09). Among patients without ADRD, severe delirium was associated with a significantly increased risk for all poor outcomes except mortality including prolonged length of stay in the hospital (RR = 1.47; CI = 1.18-1.82) and discharge to a post-acute nursing facility (RR = 2.17; CI = 1.58-2.98) plus decline in ADLs (RR = 1.30; CI = 1.05-1.60) and nursing facility stay at 1 month (RR = 1.93; CI = 1.31-2.83). CONCLUSION Severe delirium is associated with increased risk for poor clinical outcomes in patients with and without ADRD. In both groups, severe delirium increased risk of nursing home placement. In patients with ADRD, delirium was more severe and associated with a trend toward increased mortality at 1 month. Although the increased risk remains substantial by RR, the study had limited power to examine the rarer outcome of death. J Am Geriatr Soc 68:1722-1730, 2020.
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Affiliation(s)
- Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Guoquan Xu
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Yun R Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Thomas G Travison
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Eran D Metzger
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.,Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Relationship between Surgery under General Anesthesia and the Development of Dementia: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3234013. [PMID: 32337238 PMCID: PMC7165327 DOI: 10.1155/2020/3234013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/02/2020] [Accepted: 03/18/2020] [Indexed: 12/22/2022]
Abstract
Objective To investigate the association between exposure to general anesthesia and the development of Alzheimer's disease (AD) and dementia by reviewing and integrating the evidence from epidemiological studies published to date. Methods We searched MEDLINE, EMBASE, and Google Scholar to identify all relevant articles up to April 2018 reporting the risk of AD/dementia following exposure to general anesthesia and finally updated in February 2020. We included patients older than 60 or 65 years who had not been diagnosed with dementia or AD before the study period. The overall pooled effect size (ES) was evaluated with a random-effect model. Subgroup analyses were conducted and possibility of publication bias was assessed. Results A total of 23 studies with 412253 patients were included in our analysis. A statistically significant positive association between exposure to general anesthesia and the occurrence of AD was detected in the overall analysis (pooled ES = 1.11, 95%confidence interval = 1.07–1.15), but with substantial heterogeneity (pχ2 < 0.001, I2 = 79.4). Although the overall analysis revealed a significant association, the results of the subgroup analyses were inconsistent, and the possibility of publication bias was detected. Conclusion s. This meta-analysis demonstrated a significant positive association between general anesthesia and AD. However, considering other results, our meta-analysis must be interpreted with caution. Particularly, it should be considered that it was nearly impossible to discriminate the influence of general anesthesia from the effect of surgery itself on the development of AD. Further, large-scale studies devised to reduce the risk of bias are needed to elucidate the evidence of association between general anesthesia and AD. Trial registration. PROSPERO International prospective register of systematic reviews CRD42017073790.
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Apolipoprotein E genotype and the association between C-reactive protein and postoperative delirium: Importance of gene-protein interactions. Alzheimers Dement 2020; 16:572-580. [PMID: 31761478 DOI: 10.1016/j.jalz.2019.09.080] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Apolipoprotein E (APOE) status may modify the risk of postoperative delirium conferred by inflammation. METHODS We tested whether APOE modifies the established association between C-reactive protein (CRP) and delirium incidence, severity, and duration in 553 noncardiac surgical patients aged 70 and older. High postoperative plasma CRP (≥234.12 mg/L) was defined by the highest sample-based quartile. Delirium was determined using the Confusion Assessment Method and chart review, and severity was determined by the Confusion Assessment Method-Severity score. RESULTS APOE ε4 carrier prevalence was 19%, and postoperative delirium occurred in 24%. The relationship between CRP and delirium incidence, severity, and duration differed by ε4 status. Among ε4 carriers, there was a strong relationship between high CRP (vs. low CRP) and delirium incidence (relative risk [95% confidence interval], 3.0 [1.4-6.7]); however, no significant association was observed among non-ε4 carriers (relative risk [95% CI], 1.2 [0.8-1.7]). DISCUSSION Our findings raise the possibility that APOE ε4 carrier status may modify the relationship between postoperative day 2 CRP levels and postoperative delirium.
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Fong TG, Racine AM, Fick DM, Tabloski P, Gou Y, Schmitt EM, Hshieh TT, Metzger E, Bertrand SE, Marcantonio ER, Jones RN, Inouye SK. The Caregiver Burden of Delirium in Older Adults With Alzheimer Disease and Related Disorders. J Am Geriatr Soc 2019; 67:2587-2592. [PMID: 31605539 DOI: 10.1111/jgs.16199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To measure the burden of delirium in older adults with or without Alzheimer disease or related disorders (ADRDs). DESIGN Prospective, observational cohort. SETTING Inpatient hospital and study participants' homes. PARTICIPANTS A subset (n = 267) of older medical and surgical patients and their caregivers enrolled in the Better Assessment of Illness study. MEASUREMENTS Delirium burden was measured using the DEL-B instrument (range = 0-40, with higher scores indicating greater burden) in caregivers (DEL-B-C) and patients 1 month after hospitalization. Severity of cognitive impairment (Montreal Cognitive Assessment [MoCA]), delirium presence (Confusion Assessment Method [CAM]), and delirium severity (CAM-Severity [CAM-S]) were measured during hospitalization and at 1-month follow-up. ADRD diagnosis was determined by a clinical consensus process. RESULTS For patients with (n = 56) and without (n = 211) ADRD, both DEL-B instruments had good internal consistency. DEL-B-C scores had a median (interquartile range) among caregivers of patients with and without ADRD of 9 (5-15) and 5 (1-11), respectively (P < .05). If the patient developed delirium, caregivers experienced greater burden (β[delirium × ADRD] = -.29; P = .42), regardless of ADRD status. Further, caregiver burden was modestly correlated with patient MoCA scores (Spearman correlation coefficient, ρ = -0.18; P = .01). Patients with ADRD who developed delirium self-reported less burden than those without ADRD (β[delirium × ADRD] = -.67; P = .044). As with caregivers, delirium burden was modestly correlated with patient MoCA score (ρ = -0.18; P = .005) and correlated with the CAM-S in patients without ADRD (ρ = 0.38; P < .001) but not for patients with ADRD (ρ = -0.07; P = .61). CONCLUSIONS Delirium resulted in the same degree of increased caregiver burden regardless of whether a patient had ADRD, signifying delirium is equally stressful to caregivers, even among those with experience caring for someone with a chronic cognitive disorder. Delirium burden is only modestly associated with degree of cognitive impairment, suggesting that other aspects of delirium contribute to burden. J Am Geriatr Soc 67:2587-2592, 2019.
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Affiliation(s)
- Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Annie M Racine
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Donna M Fick
- College of Nursing and Center for Geriatric Nursing Excellence, Pennsylvania State University, University Park, Pennsylvania
| | - Patricia Tabloski
- Boston College William F. Connell School of Nursing, Boston, Massachusetts
| | - Yun Gou
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Tammy T Hshieh
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eran Metzger
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sylvie E Bertrand
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Edward R Marcantonio
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Richard N Jones
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,College of Nursing and Center for Geriatric Nursing Excellence, Pennsylvania State University, University Park, Pennsylvania
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Daiello LA, Racine AM, Gou RY, Marcantonio ER, Xie Z, Kunze LJ, Vlassakov KV, Inouye SK, Jones RN. Postoperative Delirium and Postoperative Cognitive Dysfunction: Overlap and Divergence. Anesthesiology 2019; 131:477-491. [PMID: 31166241 PMCID: PMC6692220 DOI: 10.1097/aln.0000000000002729] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Postoperative delirium and postoperative cognitive dysfunction share risk factors and may co-occur, but their relationship is not well established. The primary goals of this study were to describe the prevalence of postoperative cognitive dysfunction and to investigate its association with in-hospital delirium. The authors hypothesized that delirium would be a significant risk factor for postoperative cognitive dysfunction during follow-up. METHODS This study used data from an observational study of cognitive outcomes after major noncardiac surgery, the Successful Aging after Elective Surgery study. Postoperative delirium was evaluated each hospital day with confusion assessment method-based interviews supplemented by chart reviews. Postoperative cognitive dysfunction was determined using methods adapted from the International Study of Postoperative Cognitive Dysfunction. Associations between delirium and postoperative cognitive dysfunction were examined at 1, 2, and 6 months. RESULTS One hundred thirty-four of 560 participants (24%) developed delirium during hospitalization. Slightly fewer than half (47%, 256 of 548) met the International Study of Postoperative Cognitive Dysfunction-defined threshold for postoperative cognitive dysfunction at 1 month, but this proportion decreased at 2 months (23%, 123 of 536) and 6 months (16%, 85 of 528). At each follow-up, the level of agreement between delirium and postoperative cognitive dysfunction was poor (kappa less than .08) and correlations were small (r less than .16). The relative risk of postoperative cognitive dysfunction was significantly elevated for patients with a history of postoperative delirium at 1 month (relative risk = 1.34; 95% CI, 1.07-1.67), but not 2 months (relative risk = 1.08; 95% CI, 0.72-1.64), or 6 months (relative risk = 1.21; 95% CI, 0.71-2.09). CONCLUSIONS Delirium significantly increased the risk of postoperative cognitive dysfunction in the first postoperative month; this relationship did not hold in longer-term follow-up. At each evaluation, postoperative cognitive dysfunction was more common among patients without delirium. Postoperative delirium and postoperative cognitive dysfunction may be distinct manifestations of perioperative neurocognitive deficits.
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Affiliation(s)
- Lori A. Daiello
- Alzheimer’s Disease and Memory Disorders Center, Rhode Island Hospital, Providence, RI
- Department of Neurology, Brown University Warren Alpert Medical School, Providence RI
| | - Annie M. Racine
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ray Yun Gou
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Zhongcong Xie
- Harvard Medical School, Boston, MA
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA
| | - Lisa J Kunze
- Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kamen V. Vlassakov
- Harvard Medical School, Boston, MA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Sharon K. Inouye
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence RI
- Department of Neurology, Brown University Warren Alpert Medical School, Providence RI
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11
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Jones RN, Cizginer S, Pavlech L, Albuquerque A, Daiello LA, Dharmarajan K, Gleason LJ, Helfand B, Massimo L, Oh E, Okereke OI, Tabloski P, Rabin LA, Yue J, Marcantonio ER, Fong TG, Hshieh TT, Metzger ED, Erickson K, Schmitt EM, Inouye SK. Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review. JAMA Intern Med 2019; 179:231-239. [PMID: 30556827 PMCID: PMC6382582 DOI: 10.1001/jamainternmed.2018.6975] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition. Objectives To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments. Evidence Review This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key words delirium, severity, tests, measures, and intensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus. Findings Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method-Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale. Conclusions and Relevance The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.
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Affiliation(s)
- Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Sevdenur Cizginer
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Laura Pavlech
- Hirsh Health Sciences Library, Tufts University, Boston, Massachusetts
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Lori A Daiello
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Kumar Dharmarajan
- Center for Outcomes Research & Evaluation, Yale University School of Medicine, New Haven, Connecticut
| | - Lauren J Gleason
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Benjamin Helfand
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
- University of Massachusetts Medical School, Worcester
| | - Lauren Massimo
- Frontotemporal Degeneration Center, University of Pennsylvania School of Medicine, Philadelphia
| | - Esther Oh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olivia I Okereke
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Patricia Tabloski
- Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts
| | - Laura A Rabin
- Department of Psychology, Brooklyn College and the Graduate Center of City University of New York, Brooklyn, New York
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tammy T Hshieh
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eran D Metzger
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kristen Erickson
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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