1
|
Relander K, Hietanen M, Ijäs P, Nuotio K, Vikatmaa P, Koskinen SM, Ala-Kauhaluoma M, Paajanen TI, Virkkala J, Lindsberg PJ, Soinne L. Long-term cognitive and neurovascular changes after carotid endarterectomy. J Neurol Sci 2024; 459:122981. [PMID: 38569375 DOI: 10.1016/j.jns.2024.122981] [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: 12/04/2023] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Carotid endarterectomy (CEA) has been associated with both cognitive decline and improvement, but the underlying neurovascular mechanisms are unclear. The aim of this study was to investigate the relationship between neurovascular indices and cognitive changes after CEA. METHODS We studied 55 patients with severe (≥70%) symptomatic or asymptomatic carotid stenosis before and six months after CEA. A wide array of neuropsychological tests was arranged in eight cognitive domains and cognitive functions specific to hemisphere ipsilateral to operation. Differences in cognitive performance between patients and 38 matching healthy controls were studied with linear mixed models. Neurovascular functioning and microembolic signals were assessed with transcranial Doppler ultrasound of the middle cerebral artery. Associations between neurovascular indices and cognitive change were assessed with linear regression analyses. RESULTS On group level, the CEA patients improved more than controls in working memory, whereas no cognitive deterioration was detected. Also on individual level, improvement was most frequently observed in working memory. Worse preoperative cerebrovascular reactivity was related with improvement in cognitive functions of the ipsilateral hemisphere. Low preoperative pulsatility index was associated with improvement in executive functioning and ipsilateral cognitive functions. Poorer preoperative blood flow velocity associated with improvement in complex attention. Microembolic signals were rare. CONCLUSION The present findings suggest that CEA may have beneficial long-term effects on cognition. These effects may specifically involve patients with impaired preoperative circulatory adaptive mechanisms.
Collapse
Affiliation(s)
- Kristiina Relander
- Neuropsychology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland.
| | - Marja Hietanen
- Neuropsychology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Petra Ijäs
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Krista Nuotio
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Pirkka Vikatmaa
- Vascular Surgery, HUS Abdominal center, University of Helsinki and Helsinki University Hospital, Finland
| | - Suvi M Koskinen
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Marianne Ala-Kauhaluoma
- Ophthalmology, HUS Head and Neck Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Teemu I Paajanen
- Finnish Institute of Occupational Health, Work Ability and Working Careers Unit, Helsinki, Finland
| | - Jussi Virkkala
- Clinical Neurophysiology and Clinical Neurosciences, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Perttu J Lindsberg
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| | - Lauri Soinne
- Neurology, HUS Neurocenter, University of Helsinki and Helsinki University Hospital, Finland
| |
Collapse
|
2
|
Maheshwari K, Yalcin EK, Wang D, Mascha EJ, Rosenfeldt A, Alberts JL, Turan A, Sessler DI, Cummings III KC. Processing speed test and 30-day readmission in elderly non-cardiac surgery patients- A retrospective study. Indian J Anaesth 2023; 67:620-627. [PMID: 37601924 PMCID: PMC10436707 DOI: 10.4103/ija.ija_176_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/31/2023] [Accepted: 06/12/2023] [Indexed: 08/22/2023] Open
Abstract
Background and Aims Preoperative cognitive function screening can help identify high-risk patients, but resource-intensive testing limits its widespread use. A novel self-administered tablet computer-based Processing Speed Test (PST) was used to assess cognitive "executive" function in non-cardiac surgery patients, but the relationship between preoperative test scores and postoperative outcomes is unclear. The primary outcome was a composite of 30-day readmission/death. The secondary outcome was a collapsed composite of discharge to a long-term care facility/death. Exploratory outcomes were 1) time to discharge alive, 2) 1-year mortality and 3) a collapsed composite of postoperative complications. Methods This retrospective study, after approval, was conducted in elective non-cardiac surgery patients ≥65 years old. We assessed the relationship between processing speed test scores and primary/secondary outcomes using multivariable logistic regression, adjusting for potential confounding variables. Results Overall 1568 patients completed the PST, and the mean ± standard deviation test score was 33 ± 10. The higher PST score is associated with better executive function. A 10-unit increase in the test score was associated with an estimated 19% lower 30-day readmission/death odds, with an odds ratio (OR) and 95% confidence interval (CI) of 0.81 (0.68, 0.96) (P = 0.015). Similarly, 10-unit increase in test score was associated with an estimated 26% lower odds of long-term care need/death, with OR (95% CI) of 0.74 (0.61, 0.91) (P = 0.004). We also found statistically significant associations between the test scores and time to discharge alive and to 1-year mortality, however, not with a composite of postoperative complications. Conclusion Elderly non-cardiac surgery patients with better PST scores were less likely to be readmitted, need long-term care after discharge or die within 30 days. Preoperative assessment of cognitive function using a simple self-administered test is feasible and may guide perioperative care.
Collapse
Affiliation(s)
- Kamal Maheshwari
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Dong Wang
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward J. Mascha
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jay L. Alberts
- Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alparslan Turan
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | |
Collapse
|
3
|
Kunicki ZJ, Ngo LH, Marcantonio ER, Tommet D, Feng Y, Fong TG, Schmitt EM, Travison TG, Jones RN, Inouye SK. Six-Year Cognitive Trajectory in Older Adults Following Major Surgery and Delirium. JAMA Intern Med 2023; 183:442-450. [PMID: 36939716 PMCID: PMC10028541 DOI: 10.1001/jamainternmed.2023.0144] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/19/2023] [Indexed: 03/21/2023]
Abstract
Importance The study results suggest that delirium is the most common postoperative complication in older adults and is associated with poor outcomes, including long-term cognitive decline and incident dementia. Objective To examine the patterns and pace of cognitive decline up to 72 months (6 years) in a cohort of older adults following delirium. Design, Setting, and Participants This was a prospective, observational cohort study with long-term follow-up including 560 community-dwelling older adults (older than 70 years) in the ongoing Successful Aging after Elective Surgery study that began in 2010. The data were analyzed from 2021 to 2022. Exposure Development of incident delirium following major elective surgery. Main Outcomes and Measures Delirium was assessed daily during hospitalization using the Confusion Assessment Method, which was supplemented with medical record review. Cognitive performance using a comprehensive battery of neuropsychological tests was assessed preoperatively and across multiple points postoperatively to 72 months of follow-up. We evaluated longitudinal cognitive change using a composite measure of neuropsychological performance called the general cognitive performance (GCP), which is scaled so that 10 points on the GCP is equivalent to 1 population SD. Retest effects were adjusted using cognitive test results in a nonsurgical comparison group. Results The 560 participants (326 women [58%]; mean [SD] age, 76.7 [5.2] years) provided a total of 2637 person-years of follow-up. One hundred thirty-four participants (24%) developed postoperative delirium. Cognitive change following surgery was complex: we found evidence for differences in acute, post-short-term, intermediate, and longer-term change from the time of surgery that were associated with the development of postoperative delirium. Long-term cognitive change, which was adjusted for practice and recovery effects, occurred at a pace of about -1.0 GCP units (95% CI, -1.1 to -0.9) per year (about 0.10 population SD units per year). Participants with delirium showed significantly faster long-term cognitive change with an additional -0.4 GCP units (95% CI, -0.1 to -0.7) or -1.4 units per year (about 0.14 population SD units per year). Conclusions and Relevance This cohort study found that delirium was associated with a 40% acceleration in the slope of cognitive decline out to 72 months following elective surgery. Because this is an observational study, we cannot be sure whether delirium directly causes subsequent cognitive decline, or whether patients with preclinical brain disease are more likely to develop delirium. Future research is needed to understand the causal pathway between delirium and cognitive decline.
Collapse
Affiliation(s)
- Zachary J. Kunicki
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Long H. Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Edward R. Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School and Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Douglas Tommet
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Yi Feng
- Department of Measurement, Statistics, and Evaluation, University of Maryland, College Park
| | - Tamara G. Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School and Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Eva M. Schmitt
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Thomas G. Travison
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School and Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School and Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| |
Collapse
|
4
|
Chen Z, Wang S, Meng Z, Ye Y, Shan G, Wang X, Zhao X, Jin Y. Tau protein plays a role in the mechanism of cognitive disorders induced by anesthetic drugs. Front Neurosci 2023; 17:1145318. [PMID: 36937655 PMCID: PMC10015606 DOI: 10.3389/fnins.2023.1145318] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/13/2023] [Indexed: 03/08/2023] Open
Abstract
Cognitive disorders are mental health disorders that can affect cognitive ability. Surgery and anesthesia have been proposed to increase the incidence of cognitive dysfunction, including declines in memory, learning, attention and executive function. Tau protein is a microtubule-associated protein located in the axons of neurons and is important for microtubule assembly and stability; its biological function is mainly regulated by phosphorylation. Phosphorylated tau protein has been associated with cognitive dysfunction mediated by disrupting the stability of the microtubule structure. There is an increasing consensus that anesthetic drugs can cause cognitive impairment. Herein, we reviewed the latest literature and compared the relationship between tau protein and cognitive impairment caused by different anesthetics. Our results substantiated that tau protein phosphorylation is essential in cognitive dysfunction caused by anesthetic drugs, and the possible mechanism can be summarized as "anesthetic drugs-kinase/phosphatase-p-Tau-cognitive impairment".
Collapse
|
5
|
Relander K, Hietanen M, Rämö J, Vento A, Tikkala I, Roine RO, Lindsberg PJ, Soinne L. Differential Cognitive Functioning and Benefit From Surgery in Patients Undergoing Coronary Artery Bypass Grafting and Carotid Endarterectomy. Front Neurol 2022; 13:824486. [PMID: 35350398 PMCID: PMC8957972 DOI: 10.3389/fneur.2022.824486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Stenosing atherosclerosis in both coronary and carotid arteries can adversely affect cognition. Also their surgical treatments, coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA), are associated with cognitive changes, but the mechanisms of cognitive decline or improvement may not be the same. This study was designed to compare the cognitive profile and outcome in patients undergoing surgical treatment for coronary or carotid disease. Methods A total of 100 CABG patients and 44 CEA patients were recruited in two previously reported studies. They were subjected to a comprehensive neuropsychological examination prior to surgery and in the acute (3-8 days) and stable (3 months) phase after operation. A group of 17 matched healthy controls were assessed with similar intervals. We used linear mixed models to compare cognitive trajectories within six functional domains between the CABG, CEA and control groups. Postoperative cognitive dysfunction (POCD) and improvement (POCI) were determined with the reliable change index method in comparison with healthy controls. Results Before surgery, the CEA patients performed worse than CABG patients or healthy controls in the domains of executive functioning and processing speed. The CABG patients exhibited postoperative cognitive dysfunction more often than the CEA patients in most cognitive domains in the acute phase but had regained their performance in the stable phase. The CEA patients showed more marked postoperative improvement in executive functioning than the CABG group in the acute phase, but the difference did not reach significance in the stable phase. Conclusion Our findings suggest that anterior cerebral dysfunction in CEA patients impairs preoperative cognition more severely than global brain dysfunction in CABG patients. However, CEA may have more beneficial effects on cognition than CABG, specifically in executive functions mainly operated by the prefrontal lobes. In addition, the results underline that POCD is a heterogeneous condition and dependent on type of revascularization surgery.
Collapse
Affiliation(s)
- Kristiina Relander
- Division of Neuropsychology, Neurocenter, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marja Hietanen
- Division of Neuropsychology, Neurocenter, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juhani Rämö
- Division of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Vento
- Division of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Irene Tikkala
- Division of Neuropsychology, Neurocenter, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Risto O Roine
- University of Turku and Turku University Hospital, Turku, Finland
| | - Perttu J Lindsberg
- Department of Neurology, Neurocenter, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Lauri Soinne
- Department of Neurology, Neurocenter, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| |
Collapse
|
6
|
Huai X, Jiao Y, Gu X, Zhu H, Chen L, Fan Y, Yu W, Su D, Xie H. Preoperative Chronic Pain as a Risk Factor for Early Postoperative Cognitive Dysfunction in Elderly Patients Undergoing Hip Joint Replacement Surgery: A Prospective Observational Cohort Study. Front Neurosci 2022; 15:747362. [PMID: 34975369 PMCID: PMC8718925 DOI: 10.3389/fnins.2021.747362] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/30/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Although major joint replacement surgery has a high overall success rate, postoperative cognitive dysfunction (POCD) is a common complication after anesthesia and surgery, increasing morbidity and mortality. Identifying POCD risk factors would be helpful to prevent and decrease the occurrence of POCD. We hypothesized that preoperative chronic pain increases the risk of POCD. Methods: A single-center, observational, prospective cohort study was conducted from January 2018 to March 2020. All consecutive elderly patients (>65 years) who underwent elective total hip arthroplasty or hemiarthroplasty with general anesthesia by the same surgeon were enrolled. The patients underwent neuropsychological testing preoperatively and at 7 days and 2 months after surgery. To determine POCD, a nonsurgical control group was recruited from the general community. Results: Of the 141 patients who finished the neuropsychological testing 7 days after surgery, 61 (43.2%) had preoperative chronic pain. Of the 61 patients, 17 (27.9%) developed POCD; of the 79 patients with no chronic pain, 10 (12.7%) had developed POCD by 7 days after surgery. Multivariate logistic regression analysis identified preoperative chronic pain as a risk factor of POCD assessed 7 days after surgery (odds ratio 6.527; P = 0.009). There was no significant difference in the POCD incidence 2 months after surgery between patients with and without preoperative chronic pain. Conclusion: Preoperative chronic pain was a risk factor of developing POCD within 7 days after surgery in elderly patients following hip joint replacement surgery. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [NCT03393676].
Collapse
Affiliation(s)
- Xiaorong Huai
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yingfu Jiao
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiyao Gu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Huichen Zhu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lingke Chen
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yichen Fan
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Diansan Su
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hong Xie
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| |
Collapse
|
7
|
Assessment of a digital game as a neuropsychological test for postoperative cognitive dysfunction. Braz J Anesthesiol 2021; 72:7-12. [PMID: 34332955 PMCID: PMC9373221 DOI: 10.1016/j.bjane.2021.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/07/2021] [Accepted: 06/20/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Postoperative cognitive dysfunction may result from worsening in a condition of previous impairment. It causes greater difficulty in recovery, longer hospital stays, and consequent delay in returning to work activities. Digital games have a potential neuromodulatory and rehabilitation effect. In this study, a digital game was used as a neuropsychological test to assess postoperative cognitive dysfunction, with preoperative patient performance as control. METHODS It was a non-controlled study, with patients selected among candidates for elective non-cardiac surgery, evaluated in the pre- and postoperative periods. The digital game used has six phases developed to evaluate selective attention, alternating attention, visuoperception, inhibitory control, short-term memory, and long-term memory. The digital game takes about 25 minutes. Scores are the sum of correct answers in each cognitive domain. Statistical analysis compared these cognitive functions pre- and post-surgery using a generalized linear mixed model (ANCOVA). RESULTS Sixty patients were evaluated, 40% male and 60% female, with a mean age of 52.7 ± 13.5 years. Except for visuoperception, a reduction in post-surgery scores was found in all phases of the digital game. CONCLUSION The digital game was able to detect decline in several cognitive functions postoperatively. As its completion is faster than in conventional tests on paper, this digital game may be a potentially recommended tool for assessing patients, especially the elderly and in the early postoperative period.
Collapse
|
8
|
Relander K, Hietanen M, Nuotio K, Ijäs P, Tikkala I, Saimanen E, Lindsberg PJ, Soinne L. Cognitive Dysfunction and Mortality After Carotid Endarterectomy. Front Neurol 2021; 11:593719. [PMID: 33519678 PMCID: PMC7840953 DOI: 10.3389/fneur.2020.593719] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/02/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Carotid endarterectomy (CEA) has been associated with both postoperative cognitive dysfunction (POCD) and improvement (POCI). However, the prognostic significance of postoperative cognitive changes related to CEA is largely unknown. The aim of this study was to examine the associations between postoperative cognitive changes after CEA and long-term survival. Methods: We studied 43 patients 1 day before CEA as well as 4 days and 3 months after surgery with an extensive neuropsychological test array, and followed them for up to 14 years. POCD and POCI relative to baseline were determined with the reliable change index derived from 17 healthy controls. Associations between POCD/POCI and mortality within the patient group were studied with Cox regression analyses adjusted for confounders. Results: POCD in any functional domain was evident in 28% of patients 4 days after surgery and in 33% of patients 3 months after surgery. POCI was shown in 23% of patients at 4 days and in 44% of patients at 3 months. POCD at 3 months was associated with higher long-term mortality (hazard ratio 5.0, 95% CI 1.8–13.9, p = 0.002) compared with patients with no cognitive decline. Conclusions: Our findings suggest that POCD in a stable phase, 3 months after CEA predicts premature death. Evaluation of postoperative cognitive changes is essential, and POCD in a stable phase after CEA should prompt scrutiny of underlying factors and better adherence to therapies to prevent recurrences and to promote early intervention in imminent deterioration.
Collapse
Affiliation(s)
- Kristiina Relander
- Neuropsychology, Neurocenter, Helsinki University Hospital, Helsinki, Finland.,Clinical Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland
| | - Marja Hietanen
- Neuropsychology, Neurocenter, Helsinki University Hospital, Helsinki, Finland.,Clinical Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland
| | - Krista Nuotio
- Clinical Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland.,Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| | - Petra Ijäs
- Clinical Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland.,Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| | - Irene Tikkala
- Neuropsychology, Neurocenter, Helsinki University Hospital, Helsinki, Finland.,Clinical Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland
| | - Eija Saimanen
- Department of Surgery, South Karelia Central Hospital, Lappeenranta, Finland
| | - Perttu J Lindsberg
- Clinical Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland.,Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| | - Lauri Soinne
- Clinical Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland.,Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
9
|
Resveratrol Mitigates Hippocampal Tau Acetylation and Cognitive Deficit by Activation SIRT1 in Aged Rats following Anesthesia and Surgery. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:4635163. [PMID: 33381265 PMCID: PMC7758127 DOI: 10.1155/2020/4635163] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/09/2020] [Accepted: 11/28/2020] [Indexed: 12/14/2022]
Abstract
Postoperative cognitive dysfunction (POCD) is a sever postsurgical neurological complication in the elderly population. As the global acceleration of population ageing, POCD is proved to be a great challenge to the present labor market and healthcare system. In the present study, our findings showed that tau acetylation mediated by SIRT1 deficiency resulted in tau hyperphosphorylation in the hippocampus of the aged POCD model and consequently contributed to cognitive impairment. Interestingly, pretreatment with resveratrol almost restored the expression of SIRT1, reduced the levels of acetylated tau and hyperphosphorylated tau in the hippocampus, and improved the cognitive performance in the behavioral tests. What is more, we observed that microglia-derived neuroinflammation resulting from SIRT1 inhibition in microglia probably aggravated the tau acetylation in cultured neurons in vitro. Our findings supported the notion that activation SIRT1 provided dually beneficial effect in the aged POCD model. Taken together, our findings provided the initial evidence that tau acetylation was associated with cognitive impairment in the aged POCD model and paved a promising avenue to prevent POCD by inhibiting tau acetylation in a SIRT1-dependent manner.
Collapse
|
10
|
Relander K, Hietanen M, Rantanen K, Rämö J, Vento A, Saastamoinen KP, Roine RO, Soinne L. Postoperative cognitive change after cardiac surgery predicts long-term cognitive outcome. Brain Behav 2020; 10:e01750. [PMID: 32681544 PMCID: PMC7507551 DOI: 10.1002/brb3.1750] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Postoperative cognitive dysfunction (POCD) is a common consequence of coronary artery bypass grafting. However, domain-specific associations between postoperative changes and long-term performance are poorly known. The aim of this study was to investigate whether domain-specific cognitive changes after cardiac surgery predict long-term cognitive outcome. MATERIALS AND METHODS We assessed 100 patients (86 men, mean age 60) before coronary artery bypass grafting, with re-examinations after one week, three months, and a mean of 6.7 years. The extensive neuropsychological test battery was organized into seven functional cognitive domains. Cognitive decline and improvement were defined with the reliable change index derived from 17 matching healthy controls. Analyses were adjusted for baseline cognitive performance, age, gender, education and cardiovascular risks factors. RESULTS On group level, one week after surgery 71% patients showed cognitive decline and 9% improvement in any functional domain, as compared to preoperative results. Three months postsurgery, decline was observed in 47% and improvement in 25% of patients. Executive functioning was the most sensitive domain to both decline and improvement. Postoperative dysfunction predicted long-term cognitive deterioration six years after operation, particularly in the domain of executive functioning. CONCLUSIONS POCD after coronary artery bypass grafting is an essential risk factor for long-term deterioration and an indication for neuropsychological follow-up. Assessment of change in executive functioning after coronary artery bypass grafting may help to identify patients at risk for unfavorable long-term outcome.
Collapse
Affiliation(s)
- Kristiina Relander
- Clinical Neurosciences, Neuropsychology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marja Hietanen
- Clinical Neurosciences, Neuropsychology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juhani Rämö
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Vento
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kari-Pekka Saastamoinen
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Risto O Roine
- University of Turku and Turku University Hospital, Turku, Finland
| | - Lauri Soinne
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
11
|
Belrose JC, Noppens RR. Anesthesiology and cognitive impairment: a narrative review of current clinical literature. BMC Anesthesiol 2019; 19:241. [PMID: 31881996 PMCID: PMC6933922 DOI: 10.1186/s12871-019-0903-7] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022] Open
Abstract
Background The impact of general anesthesia on cognitive impairment is controversial and complex. A large body of evidence supports the association between exposure to surgery under general anesthesia and development of delayed neurocognitive recovery in a subset of patients. Existing literature continues to debate whether these short-term effects on cognition can be attributed to anesthetic agents themselves, or whether other variables are causative of the observed changes in cognition. Furthermore, there is conflicting data on the relationship between anesthesia exposure and the development of long-term neurocognitive disorders, or development of incident dementia in the patient population with normal preoperative cognitive function. Patients with pre-existing cognitive impairment present a unique set of anesthetic considerations, including potential medication interactions, challenges with cooperation during assessment and non-general anesthesia techniques, and the possibility that pre-existing cognitive impairment may impart a susceptibility to further cognitive dysfunction. Main body This review highlights landmark and recent studies in the field, and explores potential mechanisms involved in perioperative cognitive disorders (also known as postoperative cognitive dysfunction, POCD). Specifically, we will review clinical and preclinical evidence which implicates alterations to tau protein, inflammation, calcium dysregulation, and mitochondrial dysfunction. As our population ages and the prevalence of Alzheimer’s disease and other forms of dementia continues to increase, we require a greater understanding of potential modifiable factors that impact perioperative cognitive impairment. Conclusions Future research should aim to further characterize the associated risk factors and determine whether certain anesthetic approaches or other interventions may lower the potential risk which may be conferred by anesthesia and/or surgery in susceptible individuals.
Collapse
Affiliation(s)
- Jillian C Belrose
- Department of Anesthesia & Perioperative Medicine, Western University, London Health Sciences Center, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Ruediger R Noppens
- Department of Anesthesia & Perioperative Medicine, Western University, London Health Sciences Center, 339 Windermere Rd, London, ON, N6A 5A5, Canada.
| |
Collapse
|
12
|
He X, Long G, Quan C, Zhang B, Chen J, Ouyang W. Insulin Resistance Predicts Postoperative Cognitive Dysfunction in Elderly Gastrointestinal Patients. Front Aging Neurosci 2019; 11:197. [PMID: 31440156 PMCID: PMC6694405 DOI: 10.3389/fnagi.2019.00197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/15/2019] [Indexed: 01/01/2023] Open
Abstract
Background Members of the aging population who undergo surgery are at risk of postoperative cognitive dysfunction (POCD). Exploring an effective and reliable early predictor of POCD is essential to the identification of high-risk patients and to making prospective decisions. The purpose of this study was to examine whether preoperative insulin resistance is an independent predictor of POCD. Methods A total of 124 patients aged 60 years and older and who were scheduled for gastrointestinal surgery were enrolled in a prospective observational clinical study. All participants completed a battery of neuropsychological tests before surgery and 7 days later. POCD was defined as a decline of at least 1.5 SD on two or more of neuropsychological tests. Plasma concentration of the tumor necrosis factor α (TNF-α), C-reactive protein (CRP), and S-100β protein were measured. The status of insulin resistance was assessed by Homeostasis Model Assessment–Insulin Resistance (HOMA-IR). The relationship between HOMA-IR and POCD was assessed by Multivariable logistic regression models and the receiver operating characteristic (ROC) curve. Results Fifty one patients (41.1%) were diagnosed with POCD at 7 days after surgery. Preoperative HOMA-IR values of the POCD group were significantly higher than the non-POCD group. Furthermore, CRP and TNF-α levels of the POCD group were significantly higher at each postoperative time point (P < 0.05). The preoperative HOMA-IR value was an independent predictor of POCD (adjusted OR 1.88, 95% CI, 1.18–2.99) even after adjust for confounding variables, and when dichotomized, individuals above the HOMA-IR threshold (HOMA-IR > 2.6) had a three-times higher risk of POCD (OR 3.26; 95% CI, 1.07–9.91) compared to individuals below the threshold. The areas under the ROC curve of HOMA-IR was 0.804 (95% CI, 0.725–0.883; P < 0.001). The optimal cut-off value was found to be 0.583, with a sensitivity of 84.3% and specificity of 74%. The HOMA-IR value was positively associated with the TNF-α concentration at baseline (R2 = 0.43, P < 0.01) and 1 day after surgery (R2 = 0.3861, P < 0.01). Conclusion Preoperative insulin resistance is an effective predictor for the occurrence of POCD. Targeted prevention and treatment strategies of insulin resistance may be effective interventions of patients at risk for POCD.
Collapse
Affiliation(s)
- Xi He
- Department of Anesthesia, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Ge Long
- Department of Anesthesia, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Chengxuan Quan
- Department of Anesthesia, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Bin Zhang
- Department of Anesthesia, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jia Chen
- Department of Anesthesia, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Wen Ouyang
- Department of Anesthesia, The Third Xiangya Hospital of Central South University, Changsha, China
| |
Collapse
|
13
|
Serum Phosphorylated Neurofilament Heavy Subunit-H, a Potential Predictive Biomarker for Postoperative Cognitive Dysfunction in Elderly Subjects Undergoing Hip Joint Arthroplasty. J Arthroplasty 2019; 34:1602-1605. [PMID: 31029495 DOI: 10.1016/j.arth.2019.03.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/08/2019] [Accepted: 03/27/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD), which refers to a cognitive impairment subsequent to surgical procedures, is a common complication in the elderly subjects. This study aimed to investigate potential risk factors for POCD in elderly subjects undergoing hip joint arthroplasty. METHODS Consecutive elderly osteoarthritis patients who were scheduled to undergo hip arthroplasty under epidural anesthesia were enrolled into this single-center, prospective observational study. Serum phosphorylated neurofilament heavy subunit-H (pNF-H) was measured by the enzyme-linked immunosorbent assay method. A level of >70.5 pg/mL was accepted as pNF-H positivity. Neuropsychological assessment at baseline (1 day before the surgery) and postoperative day 7 was conducted. POCD was defined according to the calculated Z scores. Risk factors for POCD were evaluated by univariate and multivariate logistic regression analyses. RESULTS In final, 287 patients were enrolled, and 55 had suffered POCD within postoperative 7 days with an incidence of 19.2%. The final multiple logistic regression analysis revealed a higher pNF-H positivity was the only independent risk factor for POCD (odds ratio: 2.03, 95% confidence interval: 1.21-3.29, P = .012). CONCLUSIONS Our results revealed an increased preoperative serum pNF-H expression was an independent risk factor for POCD development in elderly subjects undergoing hip joint arthroplasty, suggesting the close association between anatomical damage in central nervous system and POCD.
Collapse
|
14
|
Yan L, Liu Q, Zhu Y, Zhou M, Wang H, Qin X, Wang L. Association of Preexisting Neurocognitive Impairments and Perioperative Neurocognitive Disorders for Hip Joint Replacement Surgery: A Prospective Cohort Study. Med Sci Monit 2019; 25:4617-4626. [PMID: 31227685 PMCID: PMC6604674 DOI: 10.12659/msm.914655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background The association of preexisting neurocognitive impairments with perioperative neurocognitive disorders is not well-established. The objective of this study was to record incidences of perioperative neurocognitive disorders, to record changes in perioperative neurocognition, and to analyze factors of perioperative neurocognitive changes after hip joint replacement surgeries. Material/Methods Patients scheduled for hip joint replacement surgery were included in the test group (n=499) and patients with osteoarthritis but who were not planned for any type of surgeries were included in the control group (n=499). The cognitive tests were evaluated at the time of enrollment and at 1 week, 3 months, 1 year, and 4 years after baseline. Neurocognitive disorders for the individual parameter was defined as more than 2 SD of mean below norms for that parameter. Neurocognitive disorders were defined as a significant worst condition in at least 2 parameters out of all parameters. Results Compared to baseline, after 3 months the numbers of patients with perioperative neurocognitive disorders were increased (55 vs. 81, p=0.021). After 4 years, there was a significant decline in numbers of patients with perioperative neurocognitive disorders in the test group (55 vs. 3, p<0.0001). At the end of the 3-month follow-up period, elderly patients (p=0.002) and patients with preexisting neurocognitive impairments (p=0.005) had a higher incidence of perioperative neurocognitive disorders. Conclusions Age and preexisting neurocognitive impairments are markers predicting the risk of perioperative neurocognitive disorders.
Collapse
Affiliation(s)
- Li Yan
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China (mainland)
| | - Qian Liu
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China (mainland)
| | - YangZi Zhu
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China (mainland)
| | - MeiYan Zhou
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China (mainland)
| | - HongJun Wang
- Jiangsu Key Laboratory of Anesthesiology and Jiangsu Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
| | - XiaoLing Qin
- Department of Neurology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China (mainland)
| | - LiWei Wang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, Jiangsu, China (mainland)
| |
Collapse
|
15
|
Gold S, Forryan S. Postoperative cognitive decline: A current problem with a difficult future. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2018.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
16
|
Correction for retest effects across repeated measures of cognitive functioning: a longitudinal cohort study of postoperative delirium. BMC Med Res Methodol 2018; 18:69. [PMID: 29970000 PMCID: PMC6029140 DOI: 10.1186/s12874-018-0530-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 06/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few studies have compared methods to correct for retest effects or practice effects in settings where an acute event could influence test performance, such as major surgery. Our goal in this study was to evaluate the use of different methods to correct for the effects of practice or retest on repeated test administration in the context of an observational study of older adults undergoing elective surgery. METHODS In a cohort of older surgical patients (N = 560) and a non-surgical comparison group (N = 118), we compared changes on repeated cognitive testing using a summary measure of general cognitive performance (GCP) between patients who developed post-operative delirium and those who did not. Surgical patients were evaluated pre-operatively and at 1, 2, 6, 12, and 18 months following surgery. Inferences from linear mixed effects models using four approaches were compared: 1) no retest correction, 2) mean-difference correction, 3) predicted-difference correction, and 4) model-based correction. RESULTS Using Approaches 1 or 4, which use uncorrected data, both surgical groups appeared to improve or remain stable after surgery. In contrast, Approaches 2 and 3, which dissociate retest and surgery effects by using retest-adjusted GCP scores, revealed an acute decline in performance in both surgical groups followed by a recovery to baseline. Relative differences between delirium groups were generally consistent across all approaches: the delirium group showed greater short- and longer-term decline compared to the group without delirium, although differences were attenuated after 2 months. Standard errors and model fit were also highly consistent across approaches. CONCLUSION All four approaches would lead to nearly identical inferences regarding relative mean differences between groups experiencing a key post-operative outcome (delirium) but produced qualitatively different impressions of absolute performance differences following surgery. Each of the four retest correction approaches analyzed in this study has strengths and weakness that should be evaluated in the context of future studies. Retest correction is critical for interpretation of absolute cognitive performance measured over time and, consequently, for advancing our understanding of the effects of exposures such as surgery, hospitalization, acute illness, and delirium.
Collapse
|
17
|
Abstract
Cognition is essential to all aspects of our everyday life. Although we take our cognitive function for granted, the perioperative period is prone to several aggressions that might impair it. Postoperative cognitive dysfunction, has been the aim of many studies recently, and was shown to be very common with an incidence that can reach 40%, yielding not only impairment in cognition, but also longer hospital stays, higher costs and greater mortality. While several studies have revealed some of the mechanisms contributing to postoperative cognitive dysfunction, the search for the perfect instrument to screen and measure cognitive (dys)function has proven more elusive. The present paper aims to review several cognitive evaluation methods, discussing their advantages and disadvantages as well as their potential clinical applications in evaluating the dynamics of the recovery of cognitive function after anesthesia and surgery. The current availability of easy to use computerized tests might provide the tools necessary to identify patients at risk, and promptly provide them with the adequate course of action.
Collapse
Affiliation(s)
- Sérgio Vide
- Hospital CLINIC de Barcelona, Anesthesiology Department, Systems Pharmacology Effect Control & Modeling (SPEC-M) Research Group, Barcelona, Spain; Hospital Pedro Hispano, Department of Anesthesia, Matosinhos, Portugal; Centro Hospitalar Universitário do Porto, Department of Anesthesiology, Center for Clinical Research in Anesthesia, Porto, Portugal
| | - Pedro L Gambús
- Hospital CLINIC de Barcelona, Anesthesiology Department, Systems Pharmacology Effect Control & Modeling (SPEC-M) Research Group, Barcelona, Spain; University of California San Francisco (UCSF), Department of Anesthesia and Perioperative Care, San Francisco, California, USA; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), NeuroImmunology Research Group, Barcelona, Spain.
| |
Collapse
|
18
|
Abstract
BACKGROUND Hospital procedures have been associated with cognitive change in older patients. This study aimed to document the prevalence of mild cognitive impairment in individuals undergoing left heart catheterization (LHC) before the procedure and the incidence of cognitive decline to 3 months afterwards. METHODS AND RESULTS We conducted a prospective, observational, clinical investigation of elderly participants undergoing elective LHC. Cognition was assessed using a battery of written tests and a computerized cognitive battery before the LHC and then at 3 months afterwards. The computerized tests were also administered at 24 hours (or discharge) and 7 days after LHC. A control group of 51 community participants was recruited to calculate cognitive decline using the Reliable Change Index. Of 437 participants, mild cognitive impairment was identified in 226 (51.7%) before the procedure. Computerized tests detected an incidence of cognitive decline of 10.0% at 24 hours and 7.5% at 7 days. At 3 months, written tests detected an incidence of cognitive decline of 13.1% and computerized tests detected an incidence of 8.5%. Cognitive decline at 3 months using written tests was associated with increasing age, whereas computerized tests showed cognitive decline was associated with baseline amnestic mild cognitive impairment, diabetes mellitus, and prior coronary stenting. CONCLUSIONS More than half the patients aged >60 years presenting for LHC have mild cognitive impairment. LHC is followed by cognitive decline in 8% to 13% of individuals at 3 months after the procedure. Subtle cognitive decline both before and after LHC is common and may have important clinical implications. CLINICAL TRIAL REGISTRATION INFORMATION URL: www.anzctr.org.au. Unique identifier: ACTRN12607000051448.
Collapse
Affiliation(s)
- David A Scott
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia.,Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Australia
| | - Lisbeth Evered
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia.,Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Australia
| | - Paul Maruff
- Florey Institute for Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Andrew MacIsaac
- Department of Cardiology, St Vincent's Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Australia
| | - Sarah Maher
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Brendan S Silbert
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia .,Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Australia
| |
Collapse
|
19
|
Vasunilashorn SM, Fong TG, Albuquerque A, Marcantonio ER, Schmitt EM, Tommet D, Gou Y, Travison TG, Jones RN, Inouye SK. Delirium Severity Post-Surgery and its Relationship with Long-Term Cognitive Decline in a Cohort of Patients without Dementia. J Alzheimers Dis 2018; 61:347-358. [PMID: 29171992 PMCID: PMC5714669 DOI: 10.3233/jad-170288] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Delirium has been associated with more rapid cognitive decline. However, it is unknown whether increased delirium severity is associated with a higher rate of long-term cognitive decline. OBJECTIVE To evaluate delirium severity and the presence and rate of cognitive decline over 36 months following surgery. METHODS We examined patients from the Successful Aging after Elective Surgery Study, who were age ≥70 years undergoing major elective surgery (N = 560). Delirium severity was determined by the peak Confusion Assessment Method-Severity (CAM-S) score for each patient's hospitalization and grouped based on the sample distribution: scores of 0-2, 3-7, and 8-19. A neuropsychological composite, General Cognitive Performance (GCP), and proxy-reported Informant Questionnaire for Cognitive Decline (IQCODE) were used to examine cognitive outcomes following surgery at 0, 1, and 2 months, and then every 6 months for up to 3 years. RESULTS No significant cognitive decline was observed for patients with peak CAM-S scores 0-2 (-0.17 GCP units/year, 95% confidence interval [CI] -0.35, 0.01). GCP scores decreased significantly in the group with peak CAM-S scores 3-7 (-0.30 GCP units/year, 95% CI -0.51, -0.09), and decreased almost three times faster in the highest delirium severity group (peak CAM-S scores 8-19; -0.82 GCP units/year, 95% CI -1.28, -0.37). A similar association was found for delirium severity and the proportion of patients who developed IQCODE impairment over time. CONCLUSION Patients with the highest delirium severity experienced the greatest rate of cognitive decline, which exceeds the rate previously observed for patients with dementia, on serial neuropsychological testing administered over 3 years, with a dose-response relationship between delirium severity and long-term cognitive decline.
Collapse
Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center
- Harvard Medical School
| | - Tamara G. Fong
- Harvard Medical School
- Department of Neurology, Beth Israel Deaconess Medical Center
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife
| | - Edward R. Marcantonio
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center
- Harvard Medical School
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center
| | - Eva M. Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife
| | - Douglas Tommet
- Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University
| | - Yun Gou
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife
| | - Thomas G. Travison
- Harvard Medical School
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife
- Research Program on Men’s Health, Aging, and Metabolism, Brigham and Women’s Hospital
| | - Richard N. Jones
- Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University
| | - Sharon K. Inouye
- Harvard Medical School
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center
| |
Collapse
|
20
|
Devore EE, Fong TG, Marcantonio ER, Schmitt EM, Travison TG, Jones RN, Inouye SK. Prediction of Long-term Cognitive Decline Following Postoperative Delirium in Older Adults. J Gerontol A Biol Sci Med Sci 2017; 72:1697-1702. [PMID: 28329149 DOI: 10.1093/gerona/glx030] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/16/2017] [Indexed: 12/21/2022] Open
Abstract
Background Increasing evidence suggests that postoperative delirium may result in long-term cognitive decline among older adults. Risk factors for such cognitive decline are unknown. Methods We studied 126 older participants without delirium or dementia upon entering the Successful AGing After Elective Surgery (SAGES) study, who developed postoperative delirium and completed repeated cognitive assessments (up to 36 months of follow-up). Pre-surgical factors were assessed preoperatively and divided into nine groupings of related factors ("domains"). Delirium was evaluated at baseline and daily during hospitalization using the Confusion Assessment Method diagnostic algorithm, and cognitive function was assessed using a neuropsychological battery and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) at baseline and 6-month intervals over 3 years. Linear regression was used to examine associations between potential risk factors and rate of long-term cognitive decline over time. A domain-specific and then overall selection method based on adjusted R2 values was used to identify explanatory factors for the outcome. Results The General Cognitive Performance (GCP) score (combining all neuropsychological test scores), IQCODE score, and living alone were significantly associated with long-term cognitive decline. GCP score explained the most variation in rate of cognitive decline (13%), and six additional factors-IQCODE score, cognitive independent activities of daily living impairment, living alone, cerebrovascular disease, Charlson comorbidity index score, and exhaustion level-in combination explained 32% of variation in this outcome. Conclusions Global cognitive performance was most strongly associated with long-term cognitive decline following delirium. Pre-surgical factors may substantially predict this outcome.
Collapse
Affiliation(s)
- Elizabeth E Devore
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tamara G Fong
- Aging Brain Center, Institute of Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Neurology
| | - Edward R Marcantonio
- Aging Brain Center, Institute of Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Eva M Schmitt
- Aging Brain Center, Institute of Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Thomas G Travison
- Aging Brain Center, Institute of Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Richard N Jones
- Aging Brain Center, Institute of Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Departments of Psychiatry and Human Behavior and Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Sharon K Inouye
- Aging Brain Center, Institute of Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
21
|
The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients. Alzheimers Dement 2016; 12:766-75. [PMID: 27103261 DOI: 10.1016/j.jalz.2016.03.005] [Citation(s) in RCA: 271] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/24/2016] [Accepted: 03/01/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION As the relationship between delirium and long-term cognitive decline has not been well-explored, we evaluated this association in a prospective study. METHODS SAGES is an ongoing study involving 560 adults age 70 years or more without dementia scheduled for major surgery. Delirium was assessed daily in the postoperative period using the Confusion Assessment Method. General Cognitive Performance (GCP) and the Informant Questionnaire for Cognitive Decline in the Elderly were assessed preoperatively then repeatedly out to 36 months. RESULTS On average, patients with postoperative delirium had significantly lower preoperative cognitive performance, greater immediate (1 month) impairment, equivalent recovery at 2 months, and significantly greater long-term cognitive decline relative to the nondelirium group. Proxy reports corroborated the clinical significance of the long-term cognitive decline in delirious patients. DISCUSSION Cognitive decline after surgery is biphasic and accelerated among persons with delirium. The pace of long-term decline is similar to that seen with mild cognitive impairment.
Collapse
|
22
|
Preexisting Cognitive Impairment Is Associated with Postoperative Cognitive Dysfunction after Hip Joint Replacement Surgery. Anesthesiology 2015; 122:1224-34. [DOI: 10.1097/aln.0000000000000671] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Background:
This study investigated the prevalence of cognitive impairment in elderly noncardiac surgery patients and any association between preoperative cognitive impairment and postoperative cognitive dysfunction (POCD). Additionally, the incidence of cognitive decline at 12 months after surgery was identified.
Methods:
Three hundred patients for hip joint replacement and 51 nonsurgical controls aged 60 yr or older were studied in a prospective observational clinical trial. All study participants and controls completed a battery of eight neuropsychological tests before surgery and at 7 days, 3 months, and 12 months afterwards. Preoperative cognitive status was assessed using preexisting cognitive impairment (PreCI) defined as a decline of at least 2 SD on two or more of seven neuropsychological tests compared to population norms. POCD and cognitive decline were assessed using the reliable change index utilizing the results of the control group.
Results:
PreCI was classified in 96 of 300 (32%) patients (95% CI, 23 to 43%). After surgery, 49 of 286 (17%) patients (95% CI, 13 to 22%) and 27 of 284 (10%) patients (95% CI, 6 to 13%) demonstrated POCD at 7 days and 3 months, respectively, while 7 of 271 (3%) patients (95% CI, 1 to 4%) demonstrated cognitive decline at 12 months. Patients with PreCI had a significantly increased incidence of POCD at 7 days and 3 months and cognitive decline at 12 months.
Conclusions:
Patients with PreCI have an increased incidence of POCD and cognitive decline. PreCI is a good predictor of subsequent POCD and cognitive decline. The incidence of cognitive decline after 12 months in this group of patients is low.
Collapse
|
23
|
Silbert B, Evered L, Scott D. Incidence of postoperative cognitive dysfunction after general or spinal anaesthesia for extracorporeal shock wave lithotripsy. Br J Anaesth 2014; 113:784-91. [DOI: 10.1093/bja/aeu163] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
24
|
The temporal relationship between early postoperative delirium and postoperative cognitive dysfunction in older patients: a prospective cohort study. Can J Anaesth 2014; 61:1084-92. [PMID: 25287962 DOI: 10.1007/s12630-014-0242-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 09/17/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Postoperative delirium and cognitive dysfunction are frequent phenomena in older patients; however, few studies have examined the temporal relationship between these two conditions in the early postoperative period. Therefore, this study aimed to determine if postoperative delirium and postoperative cognitive dysfunction (POCD) coexist after major noncardiac surgery. METHODS This was a prospective cohort study of patients who were ≥ 65 yr of age undergoing noncardiac surgery. Patients were evaluated preoperatively and for two days postoperatively for delirium and POCD. Delirium was determined using the Confusion Assessment Method, and POCD was measured by three cognitive tests addressing changes in executive function, memory, attention, and concentration. For each postoperative day, patients' neurologic status was categorized into three mutually exclusive categories: delirium, POCD, or neither condition. RESULTS Four hundred sixty-one patients aged ≥ 65 yr of age were studied, and 421 patients with complete postoperative cognitive testing were reported. Eighty percent of patients experienced either delirium or POCD on the first day after surgery. Seventy percent of patients who had delirium on the first postoperative day also had delirium on the second postoperative day. Sixty-three percent of patients who had POCD on postoperative day one continued to have POCD on the next day. Sixteen percent of patients with delirium on day one were non-delirious on day two but met criteria for POCD on day two. Conversely, 15% of patients with POCD on day one became delirious on day two. Only 13% of patients did not experience delirium or POCD on either day after surgery. CONCLUSIONS Eighty percent of surgical patients experienced some form of cognitive dysfunction the day after surgery, and few recovered by the second day after surgery.
Collapse
|
25
|
Rossi A, Burkhart C, Dell-Kuster S, Pollock BG, Strebel SP, Monsch AU, Kern C, Steiner LA. Serum Anticholinergic Activity and Postoperative Cognitive Dysfunction in Elderly Patients. Anesth Analg 2014; 119:947-955. [DOI: 10.1213/ane.0000000000000390] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
26
|
Price CC, Tanner JJ, Schmalfuss I, Garvan CW, Gearen P, Dickey D, Heilman K, McDonagh DL, Libon DJ, Leonard C, Bowers D, Monk TG. A pilot study evaluating presurgery neuroanatomical biomarkers for postoperative cognitive decline after total knee arthroplasty in older adults. Anesthesiology 2014; 120:601-13. [PMID: 24534857 DOI: 10.1097/aln.0000000000000080] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Total knee arthroplasty improves quality of life but is associated with postoperative cognitive dysfunction in older adults. This prospective longitudinal pilot study with a parallel control group tested the hypotheses that (1) nondemented adults would exhibit primary memory and executive difficulties after total knee arthroplasty, and (2) reduced preoperative hippocampus/entorhinal volume would predict postoperative memory change, whereas preoperative leukoaraiosis and lacunae volumes would predict postoperative executive dysfunction. METHODS Surgery (n = 40) and age-education-matched controls with osteoarthritis (n = 15) completed pre- and postoperative (3 weeks, 3 months, and 1 yr) memory and cognitive testing. Hypothesized brain regions of interest were measured in patients completing preoperative magnetic resonance scans (surgery, n = 31; control, n = 12). Analyses used reliable change methods to identify the frequency of cognitive change at each time point. RESULTS The incidence of postoperative memory difficulties was shown with delay test indices (i.e., story memory test: 3 weeks = 17%, 3 months = 25%, 1 yr = 9%). Postoperative executive difficulty with measures of inhibitory function (i.e., Stroop Color Word: 3 weeks = 21%, 3 months = 22%, 1 yr = 9%). Hierarchical regression analysis assessing the predictive interaction of group (surgery, control) and preoperative neuroanatomical structures on decline showed that greater preoperative volumes of leukoaraiosis/lacunae were significantly contributed to postoperative executive (inhibitory) declines. CONCLUSIONS This pilot study suggests that executive and memory declines occur in nondemented adults undergoing orthopedic surgery. Severity of preoperative cerebrovascular disease may be relevant for understanding executive decline, in particular.
Collapse
Affiliation(s)
- Catherine C Price
- From the Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida (C.C.P., J.J.T., D.D., and D.B.); Joint Appointment, Department of Anesthesiology, University of Florida, Gainesville, Florida (C.C.P.); Department of Radiology, University of Florida, Gainesville, Florida (I.S.); Department of Radiology, North Florida South Georgia Veteran Association, Gainesville, Florida (I.S.); Health Science Center, University of Florida, Gainesville, Florida (C.W.G.); Department of Orthopedic Surgery, University of Florida, Gainesville, Florida (P.G. and D.B.); Department of Neurology, University of Florida, Gainesville, Florida (K.H. and T.G.M.); Department of Anesthesiology, Duke University, Durham, North Carolina (D.L.M.); Department of Neurology, Drexel University, Philadelphia, Pennsylvania (D.J.L.); and Department of Neuroscience, University of Florida, Gainesville, Florida (C.L.)
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Hogan KJ. Hereditary vulnerabilities to post-operative cognitive dysfunction and dementia. Prog Neuropsychopharmacol Biol Psychiatry 2013; 47:128-34. [PMID: 23562862 DOI: 10.1016/j.pnpbp.2013.02.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 02/26/2013] [Accepted: 02/27/2013] [Indexed: 11/18/2022]
Abstract
In view of multiple prospective investigations reporting an incidence of 10% or greater in elderly patients after cardiac and non-cardiac procedures, it is surprising that no families, twins or even individual cases have been reported with persistent post-operative cognitive dysfunction (POCD) or post-operative dementia (POD) that is otherwise unexplained. As POCD and POD research has shifted in recent years from surgical and anesthetic variables to predictors of intrinsic, patient-specific susceptibility, a number of markers based on DNA sequence variation have been investigated. Nevertheless, no heritable, genomic indices of persistent POCD or post-operative dementia lasting 3 months or longer after surgery have been identified to date. The present manuscript surveys challenges confronting the search for markers of heritable vulnerability to POCD and POD, and proposes steps forward to be taken now, including the addition of surgical and anesthetic descriptors to ongoing longitudinal dementia protocols and randomized clinical trials (RCTs) comprising serial psychometric testing, and a fresh focus on phenotypes and genotypes shared between outliers with "extreme" POCD and POD traits.
Collapse
Affiliation(s)
- Kirk J Hogan
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, B6/319 Clinical Sciences Center, 600 Highland Avenue, Madison, WI 53792, USA.
| |
Collapse
|
28
|
Silbert BS, Evered LA, Scott DA, Rahardja S, Gerraty RP, Choong PF. Review of transcranial Doppler ultrasound to detect microemboli during orthopedic surgery. AJNR Am J Neuroradiol 2013; 35:1858-63. [PMID: 23969341 DOI: 10.3174/ajnr.a3688] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Transcranial Doppler ultrasonography has been used to detect microemboli in the middle cerebral artery during orthopedic surgery. We conducted a comprehensive systematic literature review of transcranial Doppler ultrasonography in orthopedic surgery to evaluate its status in this setting. Fourteen studies were selected for qualitative analysis. The highest number of patients studied was 45; emboli were detected in all studies, occurring in 20%-100% of patients. Most embolic counts were below 10, but some high counts were noted. No study reported all the technical parameters of the transcranial Doppler ultrasonography. All studies assessed neurologic status, and 6 studies evaluated cognitive function postoperatively. No study identified an association between postoperative cognitive function and embolic count. Six studies sought the presence of right-to-left shunts.
Collapse
Affiliation(s)
- B S Silbert
- From the Department of Anaesthesia (B.S.S., L.A.E., D.A.S., S.R.), Centre for Anaesthesia and Cognitive Function, St. Vincent's Hospital, Melbourne, Australia Department of Anaesthesia (B.S.S., L.A.E., D.A.S.), Perioperative and Pain Medicine Unit, Melbourne Medical School
| | - L A Evered
- From the Department of Anaesthesia (B.S.S., L.A.E., D.A.S., S.R.), Centre for Anaesthesia and Cognitive Function, St. Vincent's Hospital, Melbourne, Australia Department of Anaesthesia (B.S.S., L.A.E., D.A.S.), Perioperative and Pain Medicine Unit, Melbourne Medical School
| | - D A Scott
- From the Department of Anaesthesia (B.S.S., L.A.E., D.A.S., S.R.), Centre for Anaesthesia and Cognitive Function, St. Vincent's Hospital, Melbourne, Australia Department of Anaesthesia (B.S.S., L.A.E., D.A.S.), Perioperative and Pain Medicine Unit, Melbourne Medical School
| | - S Rahardja
- From the Department of Anaesthesia (B.S.S., L.A.E., D.A.S., S.R.), Centre for Anaesthesia and Cognitive Function, St. Vincent's Hospital, Melbourne, Australia
| | - R P Gerraty
- Epworth Healthcare (R.P.G.), Richmond, Victoria, Australia Department of Medicine (R.P.G.), Epworth HealthCare, Monash University, Melbourne, Australia
| | - P F Choong
- Department of Surgery (P.F.C.), University of Melbourne, Melbourne, Australia
| |
Collapse
|
29
|
Lopez O, Gollaher T, Riddle D. Cerebral oxygen desaturation monitored by intraoperative near-infrared spectroscopy, and incidence of post-operative cognitive dysfunction: a systematic review protocol. ACTA ACUST UNITED AC 2013. [DOI: 10.11124/jbisrir-2013-531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
30
|
Cormack F, Shipolini A, Awad WI, Richardson C, McCormack DJ, Colleoni L, Underwood M, Baldeweg T, Hogan AM. A meta-analysis of cognitive outcome following coronary artery bypass graft surgery. Neurosci Biobehav Rev 2012; 36:2118-29. [DOI: 10.1016/j.neubiorev.2012.06.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 05/16/2012] [Accepted: 06/12/2012] [Indexed: 10/28/2022]
|
31
|
Cognitive decline in the elderly: Is anaesthesia implicated? Best Pract Res Clin Anaesthesiol 2011; 25:379-93. [DOI: 10.1016/j.bpa.2011.05.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 05/11/2011] [Indexed: 11/19/2022]
|
32
|
Evered L, Scott DA, Silbert B, Maruff P. Postoperative Cognitive Dysfunction Is Independent of Type of Surgery and Anesthetic. Anesth Analg 2011; 112:1179-85. [DOI: 10.1213/ane.0b013e318215217e] [Citation(s) in RCA: 262] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
33
|
Devapalasundarum AN, Silbert BS, Evered LA, Scott DA, MacIsaac AI, Maruff PT. Cognitive function in patients undergoing coronary angiography. HEART ASIA 2010; 2:75-9. [PMID: 27325949 DOI: 10.1136/ha.2009.001230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/27/2009] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To measure cognition in patients before and after coronary angiography. DESIGN Prospective observational cohort study. SETTING University teaching hospital. PATIENTS 56 patients presenting for elective coronary angiography. MAIN OUTCOME MEASURES Computerised cognitive test battery administered before coronary angiography, before discharge from hospital and 7 days after discharge. A matched healthy control group was used as a comparator. RESULTS When analysed by group, coronary angiography patients performed worse than matched controls at each time point. When the cognitive change was examined for each individual, of the 48 patients tested at discharge, 19 (39.6%) were classified as having a new cognitive dysfunction, and of 49 patients tested at day 7, six (12.2%) were classified as having a new cognitive dysfunction. CONCLUSIONS The results confirm that cognitive function is decreased in patients who have cardiovascular disease. Furthermore, coronary angiography may exacerbate this impaired cognition in some patients.
Collapse
Affiliation(s)
- A N Devapalasundarum
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia
| | - B S Silbert
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia; Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - L A Evered
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia
| | - D A Scott
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia; Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - A I MacIsaac
- Department of Cardiology, St Vincent's Hospital, Melbourne, Australia
| | - P T Maruff
- Centre for Neuroscience, University of Melbourne, Melbourne, Australia
| |
Collapse
|
34
|
Vogel AP, Morgan AT. Assessment of impairment or monitoring change in Friedreich ataxia. Mov Disord 2010; 25:1753-4. [DOI: 10.1002/mds.23103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
35
|
Fodale V, Santamaria LB, Schifilliti D, Mandal PK. Anaesthetics and postoperative cognitive dysfunction: a pathological mechanism mimicking Alzheimer’s disease. Anaesthesia 2010; 65:388-95. [DOI: 10.1111/j.1365-2044.2010.06244.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
36
|
|
37
|
Affiliation(s)
- Tiffany L Tsai
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, 94143-0648 (Tsai & Leung), and School of Nursing, Purdue University, West Lafayette, IN 47907-2069 (Sands)
| | | | | |
Collapse
|
38
|
Plasma Amyloid β42 and Amyloid β40 Levels Are Associated With Early Cognitive Dysfunction After Cardiac Surgery. Ann Thorac Surg 2009; 88:1426-32. [DOI: 10.1016/j.athoracsur.2009.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 06/25/2009] [Accepted: 07/01/2009] [Indexed: 11/19/2022]
|
39
|
Attix DK, Story TJ, Chelune GJ, Ball JD, Stutts ML, Hart RP, Barth JT. The prediction of Change: Normative neuropsychological trajectories. Clin Neuropsychol 2009; 23:21-38. [DOI: 10.1080/13854040801945078] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
40
|
van der Rijken R, Hulstijn-Dirkmaat G, Kraaimaat F, Nabuurs-Kohrman L, Nijveld A, Maassen B, Daniëls O. Open-heart surgery at school age does not affect neurocognitive functioning. Eur Heart J 2008; 29:2681-8. [PMID: 18820321 DOI: 10.1093/eurheartj/ehn432] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Although neurocognitive problems after open-heart surgery for congenital heart disease are frequent, due to a shortage of prospective studies assessing neurocognitive functioning both before and after the procedure, the exact nature of the deficits usually remains unknown. The present study aims at assessing the neurocognitive effects of, in particular, cardiopulmonary bypass at school age. In addition, surgery-related risk factors for reduced neurocognitive outcome are explored. METHODS AND RESULTS Participants were aged between 6 and 16 years. Forty-three children indicated for open-heart surgery and a comparison group of 19 children scheduled for interventional cardiac catheterization completed a neurocognitive assessment battery before and 1 year after their procedures. Forty healthy matched controls did so at a 1 year interval. The baseline-to-follow-up outcomes were similar in all three groups. The observed improvements most likely resulted from increased age and the repeated neurocognitive assessment. No risk factors for postsurgical neurocognitive deficits were identified. CONCLUSION The present study demonstrates that at school age cardiac surgery using full-flow cardiopulmonary bypass does not affect neurocognitive functioning.
Collapse
Affiliation(s)
- Rachel van der Rijken
- Department of Medical Psychology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
41
|
Soinne L, Helenius J, Tikkala I, Saimanen E, Salonen O, Hietanen M, Lindsberg PJ, Kaste M, Tatlisumak T. The effect of severe carotid occlusive disease and its surgical treatment on cognitive functions of the brain. Brain Cogn 2008; 69:353-9. [PMID: 18823689 DOI: 10.1016/j.bandc.2008.08.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Revised: 08/08/2008] [Accepted: 08/14/2008] [Indexed: 11/28/2022]
Abstract
Surgery of a high-grade carotid stenosis is evidence-based stroke prevention. Also cognitive effects are reported after carotid endarterectomy (CEA): both deterioration and improvement, the former attributed to perioperative complications and the latter often to learning effect. By imaging, brain perfusion and diffusion changes were shown in subjects with a high-grade stenosis undergoing CEA. We wanted to find out if the cognition of patients undergoing CEA display postoperative worsening or true improvement in association with findings in serial MR imaging. The patients had a poorer overall cognition than healthy matched controls. The cerebral hemisphere ipsilateral to the stenosis had higher diffusion and more sluggish perfusion leading to perfusion deficits. These asymmetries were abolished by CEA. Postoperatively, the patients showed a trend for cognitive worsening, most often attentional, but over months, the group performance improved similarly to the controls. Still, lower baseline perfusion was associated with a greater cognitive improvement, most clearly in executive functions. Consequently, despite the risk for transient decline, true cognitive benefit by CEA seems possible.
Collapse
Affiliation(s)
- Lauri Soinne
- Department of Neurology, Helsinki University Central Hospital, Haartmaninkatu 4, 00029 Helsinki, Finland.
| | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Shapira-Lichter I, Beilin B, Ofek K, Bessler H, Gruberger M, Shavit Y, Seror D, Grinevich G, Posner E, Reichenberg A, Soreq H, Yirmiya R. Cytokines and cholinergic signals co-modulate surgical stress-induced changes in mood and memory. Brain Behav Immun 2008; 22:388-98. [PMID: 17959355 DOI: 10.1016/j.bbi.2007.09.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Revised: 09/11/2007] [Accepted: 09/13/2007] [Indexed: 11/30/2022] Open
Abstract
Inflammatory cytokines and the cholinergic system have been implicated in the effects of stressors on mood and memory; however, the underlying mechanisms involved and the potential interrelationships between these pathways remain unclear. To address these questions, we administered neuropsychological tests to 33 generally healthy surgery patients who donated blood samples several days prior to undergoing moderate surgery (baseline), on the morning of the surgery (i.e., a psychological stressor), and one day after surgery. Eighteen control subjects were similarly tested. Serum levels of inflammatory cytokines, acetylcholinesterase (AChE) activity, and the stressor-inducible AChE-R variant were measured. An elevation in anxiety levels, an increase in depressed mood, and a decline in declarative memory were observed on the morning of the surgery, prior to any medical intervention, and were exacerbated one day after surgery. The surgical stressor-induced elevated IL-1 beta levels, which contributed to the increased depressed mood and to the post-surgery increase in AChE-R expression. The latter increase, which was also predicted by pre-surgery AChE-R and post-surgery mood disturbances, was associated with exacerbated memory impairments induced by surgery. In addition, elevated levels of AChE-R on the morning of the surgery predicted the post-surgery elevation in IL-6 levels, which was associated with amelioration of the memory impairments induced by surgery. Taken together, these findings suggest that exposure to a surgical stressor induces a reciprocal up-regulation of AChE-R and pro-inflammatory cytokines, which are involved in regulating the surgery-induced mood and memory disturbances.
Collapse
|
43
|
Silbert BS, Scott DA, Evered LA, Lewis MS, Maruff PT. Preexisting Cognitive Impairment in Patients Scheduled for Elective Coronary Artery Bypass Graft Surgery. Anesth Analg 2007; 104:1023-8, tables of contents. [PMID: 17456647 DOI: 10.1213/01.ane.0000263285.03361.3a] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND An accurate assessment of the prevalence of cognitive impairment in patients scheduled for coronary artery bypass graft (CABG) surgery is necessary if valid assumptions regarding cognitive change are to be made. Such an assessment requires the use of a healthy control group free of cardiovascular disease. METHODS In a retrospective observational study, 349 patients scheduled for CABG surgery underwent neuropsychological testing. We compared the results with those from a group of 170 healthy controls without cardiovascular disease and containing more female patients who were matched for age and IQ score. Cognitive impairment was defined as test scores > or =2 sd less than the controls on two or more of the seven tests. RESULTS The CABG surgery patients performed significantly worse than the control group on all tests except the Grooved Pegboard test (nondominant). When analyzed by group, performance on the verbal learning test was the most impaired. Cognitive impairment was present in 122 (35%) of CABG surgery patients before their procedure. Prior myocardial infarction, age, and IQ were independent predictors of cognitive impairment. CONCLUSIONS Cognitive impairment is prevalent in patients presenting for CABG surgery. Impaired cognition before surgery must be considered when assessing the effects of CABG surgery on cognitive performance.
Collapse
Affiliation(s)
- Brendan S Silbert
- Department of Anaesthesia, Centre for Anaesthesia and Cognitive Function, St. Vincent's Hospital, Melbourne, Australia.
| | | | | | | | | |
Collapse
|
44
|
Lewis MS, Maruff P, Silbert BS, Evered LA, Scott DA. Detection of Postoperative Cognitive Decline After Coronary Artery Bypass Graft Surgery is Affected by the Number of Neuropsychological Tests in the Assessment Battery. Ann Thorac Surg 2006; 81:2097-104. [PMID: 16731137 DOI: 10.1016/j.athoracsur.2006.01.044] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Revised: 01/07/2006] [Accepted: 01/10/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND The assessment of postoperative cognitive dysfunction after coronary artery bypass graft surgery is made with the repeated administration of cognitive tests. This classification is vulnerable to error, and it has been suggested that increasing the number of tests in a battery while maintaining constant inclusion criteria for postoperative cognitive dysfunction increases the rate of false positive classification of deterioration. The current study tested this by applying a constant rule for cognitive dysfunction using combinations of two to seven cognitive tests. METHODS Two hundred and four coronary artery bypass graft patients (surgical) and 90 healthy nonsurgical controls aged 55 years or older completed a battery of cognitive tests at baseline (preoperative) and 1 week later (postoperative). In both groups, postoperative cognitive dysfunction was classified using all unique combinations of two to seven cognitive tests when performance deteriorated on two or more tests by at least the value of the baseline standard deviation. RESULTS The average incidence of cognitive dysfunction progressively increased in both groups as the number of cognitive tests increased from two (surgical: 13.3%; control: 3.1%) to seven tests (surgical: 49.4%; control: 41.1%). CONCLUSIONS Increasing the number of tests used to classify postoperative cognitive dysfunction appears to increase the sensitivity to change in the coronary artery bypass graft group. However, accompanying false positive classifications suggest that this improved sensitivity reflected increased error. Future rules for postoperative cognitive dysfunction need to account for this error and include a control group.
Collapse
Affiliation(s)
- Matthew S Lewis
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia, St. Vincent's Hospital, Victoria Parade, Melbourne, Australia.
| | | | | | | | | |
Collapse
|
45
|
Phillips-Bute B, Mathew JP, Blumenthal JA, Grocott HP, Laskowitz DT, Jones RH, Mark DB, Newman MF. Association of neurocognitive function and quality of life 1 year after coronary artery bypass graft (CABG) surgery. Psychosom Med 2006; 68:369-75. [PMID: 16738066 DOI: 10.1097/01.psy.0000221272.77984.e2] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Although coronary artery bypass grafting (CABG) has been shown to improve quality of life and functional capacity for many patients, recent studies have demonstrated that a significant number of patients exhibit impairment in cognitive function immediately following surgery and beyond. We sought to determine the impact of this postoperative cognitive dysfunction on quality of life (QOL) and to characterize the dysfunction from the patient's perspective. METHODS With Institutional Review Board (IRB) approval and written informed consent, 732 patients at Duke University Hospital undergoing CABG were enrolled. Five hundred fifty-one (75%) completed baseline, 6-week, and 1-year neurocognitive tests and psychometric measures designed to assess QOL. Neurocognitive status was assessed by a composite cognitive index score representing the mean of the scores in four cognitive domains. Change in QOL was assessed by subtracting baseline from 1-year scores for each of 10 QOL measures. The association between QOL and cognitive dysfunction was investigated using multivariable linear regression analysis. RESULTS Cognitive decline limited improvement in QOL, with substantial correlation between change in cognition and change in QOL. One-year QOL measures are associated with both 6-week and 1-year change in cognition (Instrumental Activities of Daily Living, p < .0001; Duke Activity Status Index, p < .02; Cognitive Difficulties, p < .0001; Symptom Limitations, p = .0001; Center for Epidemiologic Study Depression, p < .0001; General Health Perception, p = .0001). CONCLUSIONS Postoperative cognitive decline may diminish improvements in QOL. Strategies to reduce cognitive decline may allow patients to achieve the maximum improvement in QOL afforded by CABG, as even short-term cognitive dysfunction has implications for QOL 1 year later.
Collapse
Affiliation(s)
- Barbara Phillips-Bute
- Department of Anesthesiology, Box 3094, DUMC, Duke University Medical Center, Durham, North Carolina 27710, USA.
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Lewis MS, Maruff P, Silbert BS, Evered LA, Scott DA. The sensitivity and specificity of three common statistical rules for the classification of post-operative cognitive dysfunction following coronary artery bypass graft surgery. Acta Anaesthesiol Scand 2006; 50:50-7. [PMID: 16451151 DOI: 10.1111/j.1399-6576.2006.00893.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The application of statistical rules to determine post-operative cognitive dysfunction (POCD) has varied, and partially explains the wide range of reported incidences of POCD in the literature. The current study assessed the sensitivity and specificity of three commonly used statistical rules in a sample of coronary artery bypass graft (CABG) patients and healthy non-surgical controls. METHODS Two hundred and four CABG patients [mean age, 68.8 years; standard deviation (SD), 7.0 years] completed neuropsychological assessment pre-operatively (baseline) and 1 week and 3 months post-operatively. Ninety age- and gender-matched non-surgical controls (mean age, 67.8 years; SD, 7.9 years) completed the same tasks at the same time points. POCD was determined in each group using three rules: the 1SD decline on two or more tasks; the 20% decline on 20% of tasks rule; and a modified reliable change index. RESULTS The modified reliable change index demonstrated the greatest combination of sensitivity and specificity. The 20% decline on 20% of tasks rule detected the largest incidence of impairment in the CABG group, but showed large incidences of false positive classifications in the control group. The 1SD rule detected the lowest incidence of POCD in the CABG group, but detected a larger incidence of impairment in the control group. CONCLUSIONS The use of the modified reliable change index is recommended, given the sensitivity to change it displayed and the low rates of false positive classification in the control sample. The use of control groups in future research is also recommended.
Collapse
Affiliation(s)
- M S Lewis
- Centre for Anaesthesia and Cognitive Function, Department of Anaesthesia, St. Vincent's Hospital, and School of Psychological Science, La Trobe University, Melbourne, Vic., Australia.
| | | | | | | | | |
Collapse
|
47
|
Stollery B. Delayed recovery of working memory following day-case surgery. APPLIED COGNITIVE PSYCHOLOGY 2006. [DOI: 10.1002/acp.1274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|