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Mintz NB, Andrews N, Pan K, Bessette E, Asaad WF, Sherif M, Rubinos C, Mahta A, Girard TD, Reznik ME. Prevalence of clinical electroencephalography findings in stroke patients with delirium. Clin Neurophysiol 2024; 162:229-234. [PMID: 38548493 PMCID: PMC11185045 DOI: 10.1016/j.clinph.2024.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/15/2024] [Accepted: 03/06/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVE Delirium is an acute cognitive disorder associated with multiple electroencephalographic (EEG) abnormalities in non-neurological patients, though specific EEG characteristics in patients with stroke remain unclear. We aimed to compare the prevalence of EEG abnormalities in stroke patients during delirium episodes with periods that did not correspond to delirium. METHODS We retrospectively analyzed clinical EEG reports for stroke patients who received daily delirium assessments as part of a prospective study. We compared the prevalence of EEG features corresponding to patient-days with vs. without delirium, including focal and generalized slowing, and focal and generalized epileptiform abnormalities (EAs). RESULTS Among 58 patients who received EEGs, there were 192 days of both EEG and delirium monitoring (88% [n = 169] corresponding to delirium). Generalized slowing was significantly more prevalent on days with vs. without delirium (96% vs. 57%, p = 0.03), as were bilateral or generalized EAs (38% vs. 13%, p = 0.03). In contrast, focal slowing (53% vs. 74%, p = 0.11) and focal EAs were less prevalent on days with delirium (38% vs. 48%, p = 0.37), though these differences were not statistically significant. CONCLUSIONS We found a higher prevalence of generalized but not focal EEG abnormalities in stroke patients with delirium. SIGNIFICANCE These findings may reinforce the diffuse nature of delirium-associated encephalopathy, even in patients with discrete structural lesions.
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Affiliation(s)
- Noa B Mintz
- Department of Neurology, Brown University, Alpert Medical School, United States
| | - Nicholas Andrews
- Department of Neurology, Brown University, Alpert Medical School, United States
| | - Kelly Pan
- Department of Neurology, Brown University, Alpert Medical School, United States
| | - Eric Bessette
- Department of Neurology, Brown University, Alpert Medical School, United States
| | - Wael F Asaad
- Department of Neurosurgery, Brown University, Alpert Medical School, United States; Department of Neuroscience, Brown University, United States; Carney Institute for Brain Science, Brown University, United States; Norman Prince Neurosciences Institute, Rhode Island Hospital, United States
| | - Mohamed Sherif
- Carney Institute for Brain Science, Brown University, United States; Norman Prince Neurosciences Institute, Rhode Island Hospital, United States; Department of Psychiatry and Human Behavior, Brown University, Alpert Medical School, United States
| | - Clio Rubinos
- Department of Neurology, University of North Carolina School of Medicine, United States
| | - Ali Mahta
- Department of Neurology, Brown University, Alpert Medical School, United States; Department of Neurosurgery, Brown University, Alpert Medical School, United States; Norman Prince Neurosciences Institute, Rhode Island Hospital, United States
| | - Timothy D Girard
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, United States
| | - Michael E Reznik
- Department of Neurology, Brown University, Alpert Medical School, United States; Department of Neurosurgery, Brown University, Alpert Medical School, United States; Carney Institute for Brain Science, Brown University, United States; Norman Prince Neurosciences Institute, Rhode Island Hospital, United States; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, United States.
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2
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Chavez-Valdez R, Northington FJ, Sharp A, Burton VJ, Lammert DB, Jantzie LL, Robinson S, Stafstrom CE, Ferriero D, Gano D, Numis A, Gerner G, Scafidi J, Gilmore M, Allen MC, Hilberg M, Parkinson C. Correspondence on "Recognition and Management of Delirium in the Neonatal Intensive Care Unit: Case Series From a Single-Center Level IV Intensive Care Unit". J Child Neurol 2024:8830738241259054. [PMID: 38819375 DOI: 10.1177/08830738241259054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Affiliation(s)
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Neuroscience Intensive Care Nursery (NICN) Program, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Dawn B Lammert
- Neuroscience Intensive Care Nursery (NICN) Program, Johns Hopkins University, Baltimore, MD, USA
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lauren L Jantzie
- Division of Neonatology, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Neuroscience Intensive Care Nursery (NICN) Program, Johns Hopkins University, Baltimore, MD, USA
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Kennedy Krieger Institute, Baltimore, MD, USA
| | - Shenandoah Robinson
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Carl E Stafstrom
- Neuroscience Intensive Care Nursery (NICN) Program, Johns Hopkins University, Baltimore, MD, USA
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Adam Numis
- Department of Pediatrics and Neurology, University of California, San Francisco, CA, USA
| | - Gwendolyn Gerner
- Neuroscience Intensive Care Nursery (NICN) Program, Johns Hopkins University, Baltimore, MD, USA
- Kennedy Krieger Institute, Baltimore, MD, USA
| | - Joseph Scafidi
- Neuroscience Intensive Care Nursery (NICN) Program, Johns Hopkins University, Baltimore, MD, USA
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Kennedy Krieger Institute, Baltimore, MD, USA
| | | | - Marilee C Allen
- Division of Neonatology, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Neuroscience Intensive Care Nursery (NICN) Program, Johns Hopkins University, Baltimore, MD, USA
| | - Michelle Hilberg
- Neuroscience Intensive Care Nursery (NICN) Program, Johns Hopkins University, Baltimore, MD, USA
- Kennedy Krieger Institute, Baltimore, MD, USA
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Neuroscience Intensive Care Nursery (NICN) Program, Johns Hopkins University, Baltimore, MD, USA
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3
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Kurtz P, van den Boogaard M, Girard TD, Hermann B. Acute encephalopathy in the ICU: a practical approach. Curr Opin Crit Care 2024; 30:106-120. [PMID: 38441156 DOI: 10.1097/mcc.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury. RECENT FINDINGS Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes. SUMMARY Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute of Research and Education
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bertrand Hermann
- Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris - Centre (APHP-Centre)
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Université Paris Cité, Paris, France
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4
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Fislage M, Winzeck S, Woodrow R, Lammers‐Lietz F, Stamatakis EA, Correia MM, Preller J, Feinkohl I, Hendrikse J, Pischon T, Spies CD, Slooter AJC, Winterer G, Menon DK, Zacharias N. Structural disconnectivity in postoperative delirium: A perioperative two-center cohort study in older patients. Alzheimers Dement 2024; 20:2861-2872. [PMID: 38451782 PMCID: PMC11032567 DOI: 10.1002/alz.13749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/26/2023] [Accepted: 01/21/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Structural disconnectivity was found to precede dementia. Global white matter abnormalities might also be associated with postoperative delirium (POD). METHODS We recruited older patients (≥65 years) without dementia that were scheduled for major surgery. Diffusion kurtosis imaging metrics were obtained preoperatively, after 3 and 12 months postoperatively. We calculated fractional anisotropy (FA), mean diffusivity (MD), mean kurtosis (MK), and free water (FW). A structured and validated delirium assessment was performed twice daily. RESULTS Of 325 patients, 53 patients developed POD (16.3%). Preoperative global MD (standardized beta 0.27 [95% confidence interval [CI] 0.21-0.32] p < 0.001) was higher in patients with POD. Preoperative global MK (-0.07 [95% CI -0.11 to (-0.04)] p < 0.001) and FA (0.07 [95% CI -0.10 to (-0.04)] p < 0.001) were lower. When correcting for baseline diffusion, postoperative MD was lower after 3 months (0.05 [95% CI -0.08 to (-0.03)] p < 0.001; n = 183) and higher after 12 months (0.28 [95% CI 0.20-0.35] p < 0.001; n = 45) among patients with POD. DISCUSSION Preoperative structural disconnectivity was associated with POD. POD might lead to white matter depletion 3 and 12 months after surgery.
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Affiliation(s)
- Marinus Fislage
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Department of NeurologyNational Taiwan University HospitalTaipei CityTaiwan
| | - Stefan Winzeck
- Department of ComputingImperial College LondonBioMedIA GroupLondonUK
- University Division of Anaesthesia, Department of MedicineUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
| | - Rebecca Woodrow
- University Division of Anaesthesia, Department of MedicineUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
- Department of Clinical NeurosciencesUniversity of Cambridge; Addenbrooke's HospitalCambridgeUK
| | - Florian Lammers‐Lietz
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Emmanuel A. Stamatakis
- University Division of Anaesthesia, Department of MedicineUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
- Department of Clinical NeurosciencesUniversity of Cambridge; Addenbrooke's HospitalCambridgeUK
| | - Marta M. Correia
- MRC Cognition and Brain Sciences Unit, University of CambridgeCambridgeUK
| | - Jacobus Preller
- Addenbrooke's Cambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Insa Feinkohl
- Faculty of Health/School of MedicineWitten/Herdecke UniversityWittenGermany
- Max‐Delbrueck‐Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research GroupBerlinGermany
| | - Jeroen Hendrikse
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Tobias Pischon
- Max‐Delbrueck‐Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research GroupBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Max‐Delbrueck‐Center for Molecular Medicine in the Helmholtz Association (MDC), Biobank Technology PlatformBerlinGermany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Core Facility BiobankBerlinGermany
| | - Claudia D. Spies
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Arjen J. C. Slooter
- Departments of Psychiatry and Intensive Care Medicine, and UMC Utrecht Brain CenterUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Department of NeurologyUZ Brussel and Vrije Universiteit BrusselBrusselsBelgium
| | - Georg Winterer
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Pharmaimage Biomarker Solutions GmbHBerlinGermany
| | - David K. Menon
- University Division of Anaesthesia, Department of MedicineUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
| | - Norman Zacharias
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Pharmaimage Biomarker Solutions GmbHBerlinGermany
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5
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Hanna A, Jirsch J, Alain C, Corvinelli S, Lee JS. Electroencephalogram measured functional connectivity for delirium detection: a systematic review. Front Neurosci 2023; 17:1274837. [PMID: 38033553 PMCID: PMC10687158 DOI: 10.3389/fnins.2023.1274837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023] Open
Abstract
Objective Delirium is an acute alteration of consciousness marked by confusion, inattention, and changes in cognition. Some speculate that delirium may be a disorder of functional connectivity, but the requirement to lay still may limit measurement with existing functional imaging modalities in this population. Electroencephalography (EEG) may allow for a more feasible approach to the study of potential connectivity disturbances in delirium. We conducted a systematic review to investigate whether there are EEG-measurable differences in brain functional connectivity in the resting state associated with delirium. Methods Medline, PubMed, PsychInfo, Embase and CINAHL were searched for relevant articles containing original data studying EEG functional connectivity measures in delirium. Results The search yielded 1,516 records. Following strict inclusion criteria, four studies were included in the review. The studies used a variety of EEG measures including phase lag index, coherence, entropy, shortest path length, minimum spanning tree, and network clustering coefficients to study functional connectivity between scalp electrodes. Across connectivity measures, delirium was associated with decreased brain functional connectivity. All four studies found decreased alpha band connectivity for patients with delirium. None of the studies directly compared the different motor subtypes of delirium. Significance This systematic review provides converging evidence for disturbances in oscillatory-based functional connectivity in delirium.
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Affiliation(s)
- Angelica Hanna
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Jeffrey Jirsch
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Claude Alain
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Rotman Research Institute Baycrest, Toronto, ON, Canada
- Music and Health Research Collaboratory, Faculty of Music, University of Toronto, Toronto, ON, Canada
- Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Sara Corvinelli
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Jacques S. Lee
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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6
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Neuner B, Wolter S, McCarthy WJ, Spies C, Cunningham C, Radtke FM, Franck M, Koenig T. EEG microstate quantifiers and state space descriptors during anaesthesia in patients with postoperative delirium: a descriptive analysis. Brain Commun 2023; 5:fcad270. [PMID: 37942086 PMCID: PMC10629467 DOI: 10.1093/braincomms/fcad270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 08/21/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023] Open
Abstract
Postoperative delirium is a serious sequela of surgery and surgery-related anaesthesia. One recommended method to prevent postoperative delirium is using bi-frontal EEG recording. The single, processed index of depth of anaesthesia allows the anaesthetist to avoid episodes of suppression EEG and excessively deep anaesthesia. The study data presented here were based on multichannel (19 channels) EEG recordings during anaesthesia. This enabled the analysis of various parameters of global electrical brain activity. These parameters were used to compare microstate topographies under anaesthesia with those in healthy volunteers and to analyse changes in microstate quantifiers and EEG global state space descriptors with increasing exposure to anaesthesia. Seventy-three patients from the Surgery Depth of Anaesthesia and Cognitive Outcome study (SRCTN 36437985) received intraoperative multichannel EEG recordings. Altogether, 720 min of artefact-free EEG data, including 210 min (29.2%) of suppression EEG, were analysed. EEG microstate topographies, microstate quantifiers (duration, frequency of occurrence and global field power) and the state space descriptors sigma (overall EEG power), phi (generalized frequency) and omega (number of uncorrelated brain processes) were evaluated as a function of duration of exposure to anaesthesia, suppression EEG and subsequent development of postoperative delirium. The major analyses involved covariate-adjusted linear mixed-effects models. The older (71 ± 7 years), predominantly male (60%) patients received a median exposure of 210 (range: 75-675) min of anaesthesia. During seven postoperative days, 21 patients (29%) developed postoperative delirium. Microstate topographies under anaesthesia resembled topographies from healthy and much younger awake persons. With increasing duration of exposure to anaesthesia, single microstate quantifiers progressed differently in suppression or non-suppression EEG and in patients with or without subsequent postoperative delirium. The most pronounced changes occurred during enduring suppression EEG in patients with subsequent postoperative delirium: duration and frequency of occurrence of microstates C and D progressed in opposite directions, and the state space descriptors showed a pattern of declining uncorrelated brain processes (omega) combined with increasing EEG variance (sigma). With increasing exposure to general anaesthesia, multiple changes in the dynamics of microstates and global EEG parameters occurred. These changes varied partly between suppression and non-suppression EEG and between patients with or without subsequent postoperative delirium. Ongoing suppression EEG in patients with subsequent postoperative delirium was associated with reduced network complexity in combination with increased overall EEG power. Additionally, marked changes in quantifiers in microstate C and in microstate D occurred. These putatively adverse intraoperative trajectories in global electrical brain activity may be seen as preceding and ultimately predicting postoperative delirium.
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Affiliation(s)
- Bruno Neuner
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
| | - Simone Wolter
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
| | - William J McCarthy
- Centre for Cancer Prevention and Control Research, Fielding School of Public Health and Jonsson Comprehensive Cancer Centre, University of California Los Angeles (UCLA), Los Angeles, CA 90095-1781, USA
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, 2 D02 R590 Dublin, Ireland
| | - Finn M Radtke
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
- Department of Anaesthesia and Intensive Care, Hospital of Nykøbing Falster, Fjordvej 15, 4800 Nykøbing Falster, Denmark
- University of Southern Denmark (SDU), Campusvej 55, 5230 Odense, Denmark
| | - Martin Franck
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
- Department of Anaesthesia, Alexianer St.Hedwig Hospital, 10115 Berlin, Germany
| | - Thomas Koenig
- University Hospital of Psychiatry, Translational Research Centre, University of Bern, 3000 Bern, Switzerland
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7
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Wang Q, Zhang X, Guo YJ, Pang YY, Li JJ, Zhao YL, Wei JF, Zhu BT, Tang JX, Jiang YY, Meng J, Yue JR, Lei P. Scopolamine causes delirium-like brain network dysfunction and reversible cognitive impairment without neuronal loss. Zool Res 2023; 44:712-724. [PMID: 37313848 PMCID: PMC10415773 DOI: 10.24272/j.issn.2095-8137.2022.473] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/05/2023] [Indexed: 06/15/2023] Open
Abstract
Delirium is a severe acute neuropsychiatric syndrome that commonly occurs in the elderly and is considered an independent risk factor for later dementia. However, given its inherent complexity, few animal models of delirium have been established and the mechanism underlying the onset of delirium remains elusive. Here, we conducted a comparison of three mouse models of delirium induced by clinically relevant risk factors, including anesthesia with surgery (AS), systemic inflammation, and neurotransmission modulation. We found that both bacterial lipopolysaccharide (LPS) and cholinergic receptor antagonist scopolamine (Scop) induction reduced neuronal activities in the delirium-related brain network, with the latter presenting a similar pattern of reduction as found in delirium patients. Consistently, Scop injection resulted in reversible cognitive impairment with hyperactive behavior. No loss of cholinergic neurons was found with treatment, but hippocampal synaptic functions were affected. These findings provide further clues regarding the mechanism underlying delirium onset and demonstrate the successful application of the Scop injection model in mimicking delirium-like phenotypes in mice.
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Affiliation(s)
- Qing Wang
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xiang Zhang
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yu-Jie Guo
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ya-Yan Pang
- Pediatric Research Institute, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Jun-Jie Li
- Pediatric Research Institute, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Yan-Li Zhao
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jun-Fen Wei
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Bai-Ting Zhu
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jing-Xiang Tang
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yang-Yang Jiang
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jie Meng
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ji-Rong Yue
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China. E-mail:
| | - Peng Lei
- Department of Geriatrics and State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China. E-mail:
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8
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Friedman G, Turk KW, Budson AE. The Current of Consciousness: Neural Correlates and Clinical Aspects. Curr Neurol Neurosci Rep 2023; 23:345-352. [PMID: 37303019 PMCID: PMC10287796 DOI: 10.1007/s11910-023-01276-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE OF REVIEW In this review, we summarize the current understanding of consciousness including its neuroanatomic basis. We discuss major theories of consciousness, physical exam-based and electroencephalographic metrics used to stratify levels of consciousness, and tools used to shed light on the neural correlates of the conscious experience. Lastly, we review an expanded category of 'disorders of consciousness,' which includes disorders that impact either the level or experience of consciousness. RECENT FINDINGS Recent studies have revealed many of the requisite EEG, ERP, and fMRI signals to predict aspects of the conscious experience. Neurological disorders that disrupt the reticular activating system can affect the level of consciousness, whereas cortical disorders from seizures and migraines to strokes and dementia may disrupt phenomenal consciousness. The recently introduced memory theory of consciousness provides a new explanation of phenomenal consciousness that may explain better than prior theories both experimental studies and the neurologist's clinical experience. Although the complete neurobiological basis of consciousness remains a mystery, recent advances have improved our understanding of the physiology underlying level of consciousness and phenomenal consciousness.
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Affiliation(s)
- Garrett Friedman
- Center for Translational Cognitive Neuroscience, VA Boston Healthcare System, 150 S. Huntington Ave., Jamaica Plain, Boston, MA, 02130, USA
| | - Katherine W Turk
- Center for Translational Cognitive Neuroscience, VA Boston Healthcare System, 150 S. Huntington Ave., Jamaica Plain, Boston, MA, 02130, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Andrew E Budson
- Center for Translational Cognitive Neuroscience, VA Boston Healthcare System, 150 S. Huntington Ave., Jamaica Plain, Boston, MA, 02130, USA.
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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9
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Oldham MA, Slooter AJC, Ely EW, Crone C, Maldonado JR, Rosenthal LJ. An Interdisciplinary Reappraisal of Delirium and Proposed Subtypes. J Acad Consult Liaison Psychiatry 2023; 64:248-261. [PMID: 35840003 PMCID: PMC9839895 DOI: 10.1016/j.jaclp.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/10/2022] [Accepted: 07/04/2022] [Indexed: 01/17/2023]
Abstract
An interdisciplinary plenary session entitled "Rethinking and Rehashing Delirium" was held during the 2021 Annual Meeting of the Academy of Consultation-Liaison Psychiatry to facilitate dialog on the prevalent approach to delirium. Panel members included a psychiatrist, neurointensivist, and critical care specialist, and attendee comments were solicited with the goal of developing a statement. Discussion was focused on a reappraisal of delirium and, in particular, its disparate terminology and history in relation to acute encephalopathy. The authors endorse a recent joint position statement that describes acute encephalopathy as a rapidly evolving (<4 weeks) pathobiological brain process that presents as subsyndromal delirium, delirium, or coma and suggest the following points of refinement: (1) to suggest that "delirium disorder" describe the diagnostic construct including its syndrome, precipitant(s), and unique pathophysiology; (2) to restrict the term "delirium" to describing the clinical syndrome encountered at the bedside; (3) to clarify that the disfavored term "altered mental status" may occasionally be an appropriate preliminary designation where the diagnosis cannot yet be specified further; and (4) to provide rationale for rejecting the terms acute brain injury, failure, or dysfunction. The final common pathway of delirium appears to involve higher-level brain network dysfunction, but there are many insults that can disrupt functional connectivity. We propose that future delirium classification systems should seek to characterize the unique pathophysiological disturbances ("endotypes") that underlie delirium and delirium's individual neuropsychiatric symptoms. We provide provisional means of classification in hopes that novel subtypes might lead to specific intervention to improve patient experience and outcomes. This paper concludes by considering future directions for the field. Key areas of opportunity include interdisciplinary initiatives to harmonize efforts across specialties and settings, enhance underrepresented groups in research, integration of delirium and encephalopathy in coding, development of relevant quality and safety measures, and exploration of opportunities for translational science.
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Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, Department of Psychiatry, Rochester, NY.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research Education Clinical Center (GRECC), TN Valley Veterans Affairs Medical Center, Nashville, TN
| | - Cathy Crone
- Inova Health System, Behavioral Health, Falls Church, VA; George Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Washington, DC
| | - José R Maldonado
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, Stanford, CA
| | - Lisa J Rosenthal
- Northwestern University Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, Chicago, IL
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10
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Bommarito G, Garibotto V, Frisoni GB, Assal F, Lalive PH, Allali G. The Two-Way Route between Delirium Disorder and Dementia: Insights from COVID-19. NEURODEGENER DIS 2023; 22:91-103. [PMID: 37054684 DOI: 10.1159/000530566] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/23/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Delirium disorder is a frequent neurological complication of SARS-CoV-2 infection and associated with increased disease severity and mortality. Cognitive impairment is a major risk factor for developing delirium disorder during COVID-19, which, in turn, increases the risk of subsequent neurological complications and cognitive decline. SUMMARY The bidirectional connection between delirium disorder and dementia likely resides at multiple levels, and its pathophysiological mechanisms during COVID-19 include endothelial damage, blood-brain barrier dysfunction, and local inflammation, with activation of microglia and astrocytes. Here, we describe the putative pathogenic pathways underlying delirium disorder during COVID-19 and highlight how they cross with the ones leading to neurodegenerative dementia. KEY MESSAGES The analysis of the two-sided link can offer useful insights for confronting with long-term neurological consequences of COVID-19 and framing future prevention and early treatment strategies.
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Affiliation(s)
- Giulia Bommarito
- Department of Clinical Neurosciences, Lausanne University Hospitals and University of Lausanne, Lausanne, Switzerland
| | - Valentina Garibotto
- Division of Nuclear Medicine and Molecular Imaging, Geneva University Hospitals and NIMTlab, University of Geneva, Geneva, Switzerland
| | - Giovanni B Frisoni
- Memory Center and LANVIE-Laboratory of Neuroimaging of Aging, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Frédéric Assal
- Department of Clinical Neurosciences, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Patrice H Lalive
- Department of Clinical Neurosciences, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
| | - Gilles Allali
- Department of Clinical Neurosciences, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
- Division of Cognitive and Motor Aging, Department of Neurology, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York, USA
- Leenaards Memory Center, Lausanne University Hospitals and University of Lausanne, Lausanne, Switzerland
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11
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Renzi S, Gitti N, Piva S. Delirium in the intensive care unit: a narrative review. JOURNAL OF GERONTOLOGY AND GERIATRICS 2023. [DOI: 10.36150/2499-6564-n600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
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12
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Matar E, Sanders RD. ‘Where there's smoke’: longitudinal cognitive disintegration after postoperative delirium? Br J Anaesth 2023:S0007-0912(23)00102-2. [PMID: 36990826 DOI: 10.1016/j.bja.2023.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/25/2023] [Accepted: 02/14/2023] [Indexed: 03/29/2023] Open
Abstract
Postoperative delirium is an important complication of surgery and is associated with poor long-term cognitive outcomes, although the neural basis underlying this relationship is poorly understood. Neuroimaging studies and network-based approaches play an important role in our understanding of the mechanism by which delirium relates to longitudinal cognitive decline. A recent resting state functional MRI study is reviewed, which shows reduced global connectivity up to 3 months after delirium, supporting recent models of delirium and opening the door for applying this approach to understanding the complex inter-relationship between delirium and dementia.
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Affiliation(s)
- Elie Matar
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Forefront Research Team, Brain and Mind Centre, University of Sydney, Sydney, Australia.
| | - Robert D Sanders
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW, Australia.
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13
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Ditzel FL, van Montfort SJT, Vernooij LM, Kant IMJ, Aarts E, Spies CD, Hendrikse J, Slooter AJC, van Dellen E. Functional brain network and trail making test changes following major surgery and postoperative delirium: a prospective, multicentre, observational cohort study. Br J Anaesth 2023; 130:e281-e288. [PMID: 36261307 DOI: 10.1016/j.bja.2022.07.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/22/2022] [Accepted: 07/31/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Delirium is a frequent complication after surgery in older adults and is associated with an increased risk of long-term cognitive impairment and dementia. Disturbances in functional brain networks were previously reported during delirium. We hypothesised that alterations in functional brain networks persist after remission of postoperative delirium and that functional brain network alterations are associated with long-term cognitive impairment. METHODS In this prospective, multicentre, observational cohort study, we included older patients who underwent clinical assessments (including the Trail Making Test B [TMT-B]) and resting-state functional MRI (rs-fMRI) before and 3 months after elective surgery. Delirium was assessed on the first seven postoperative days. RESULTS Of the 554 enrolled patients, 246 remained after strict motion correction, of whom 38 (16%) developed postoperative delirium. The rs-fMRI functional connectivity strength increased 3 months after surgery in the total study population (β=0.006; 95% confidence interval [CI]: 0.001-0.011; P=0.013), but it decreased after postoperative delirium (β=-0.015; 95% CI: -0.028 to 0.002; P=0.023). No difference in TMT-B scores was found at follow-up between patients with and without postoperative delirium. Patients with decreased functional connectivity strength declined in TMT-B scores compared with those who did not (β=11.04; 95% CI: 0.85-21.2; P=0.034). CONCLUSIONS Postoperative delirium was associated with decreased brain functional connectivity strength after 3 months, suggesting that delirium has a long-lasting impact on brain networks. The decreased connectivity strength was associated with significant cognitive deterioration after major surgery. CLINICAL TRIAL REGISTRATION NCT02265263.
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Affiliation(s)
- Fienke L Ditzel
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - Simone J T van Montfort
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands
| | - Lisette M Vernooij
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ilse M J Kant
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands
| | - Ellen Aarts
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; Faculty of Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Claudia D Spies
- Department of Anaesthesiology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Edwin van Dellen
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; Department of Psychiatry and UMC University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands
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14
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Trzepacz PT, Franco JG, Meagher D, Kishi Y, Sepúlveda E, Gaviria AM, Chen CH, Huang MC, Furlanetto LM, Negreiros D, Lee Y, Kim JL, Kean J. Delusions and Hallucinations Are Associated With Greater Severity of Delirium. J Acad Consult Liaison Psychiatry 2022; 64:236-247. [PMID: 36539078 DOI: 10.1016/j.jaclp.2022.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The 3 core domains of delirium (cognitive, higher level thinking, circadian) do not include the less common noncore psychotic symptoms. However, psychosis might inform about perturbations of neural circuitry, outcomes, or suggest tailored clinical management. OBJECTIVE We assessed for the first time the relationships between psychosis and other characteristics of delirium in patients without confounders for delirium phenotype, such as dementia or antipsychotics treatment. METHODS Cross-sectional analysis of 366 adults with delirium per the Delirium Rating Scale Revised-98, whose items distinguish hallucinations and delusions from other types of misperceptions and abnormal thought content, assessed during the preceding 24 hours to capture symptom severity fluctuation. The relationship of psychosis with other delirium characteristics was assessed using bivariate comparisons and analysis of variance as appropriate for groups with no psychosis and any psychosis (hallucinations and/or delusions), and subgroups with only hallucinations, only delusions, or both. A discriminant logistic model assessed variables associated with presence of any psychotic features versus none. RESULTS Delirium with any psychotic features occurred in 44.5% (163 of 366). Of the 366, 119 (32.5%) had only hallucinations (Hall), 14 (3.8%) had only delusions (Del), and 30 (8.2%) had both (Both). In the psychotic group (n = 163), 73.0% were Hall, 8.6% Del, and 18.4% Both. All psychotic patient groupings had significantly greater delirium severity on the Delirium Rating Scale Revised-98. Delusions and hallucinations were discordant for occurring together. The discriminant model found increased odds of having psychosis as 3 symptom severities increased (visuospatial ability, thought process, and sleep-wake cycle) where these each represented a delirium core domain. The noncore symptom of lability of affect had high odds ratio for psychosis, while motor retardation reduced odds of psychosis in this model. CONCLUSIONS Consistent with prior reports, psychosis occurred in less than half of delirious patients with delusions being infrequent, and an association with affective lability was found. We are the first to report that psychotic features are a marker for more severe delirium affecting all core domains. Given that previous functional magnetic resonance imaging research found a correlation between neural network dysconnectivity with greater severity of delirium, psychotic symptoms might be a clinical marker for greater underlying cerebral cortical neural circuitry dysfunction.
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Affiliation(s)
- Paula T Trzepacz
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - José G Franco
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - David Meagher
- Cognitive Impairment Research Group (CIRG), Graduate-Entry Medical School, University of Limerick, Limerick, Ireland
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Esteban Sepúlveda
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Hospital Psiquiàtric Universitari Institut Pere Mata, IISPV, Reus, Spain; Universitat Rovira i Virgili, Tarragona, Spain
| | - Ana M Gaviria
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Hospital Psiquiàtric Universitari Institut Pere Mata, IISPV, Reus, Spain; Facultad de Ciencias de la Salud, Fundación Universitaria María Cano, Medellín, Colombia
| | - Chun-Hsin Chen
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Psychiatry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Chyi Huang
- Department of Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Leticia M Furlanetto
- Department of Internal Medicine, Federal University of Santa Catarina, Florianopolis, Brazil
| | - Daniel Negreiros
- Department of Internal Medicine, Federal University of Santa Catarina, Florianopolis, Brazil
| | - Yanghyun Lee
- Chilgok Yeonhap Mental Health Clinic, Daegu, South Korea
| | - Jeong-Lan Kim
- Department of Psychiatry, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Jacob Kean
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT
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15
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Fong TG, Inouye SK. The inter-relationship between delirium and dementia: the importance of delirium prevention. Nat Rev Neurol 2022; 18:579-596. [PMID: 36028563 PMCID: PMC9415264 DOI: 10.1038/s41582-022-00698-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/30/2022]
Abstract
Delirium and dementia are two frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium is an acute confusional state characterized by inattention, cognitive dysfunction and an altered level of consciousness, whereas dementia is an insidious, chronic and progressive loss of a previously acquired cognitive ability. People with dementia have a higher risk of developing delirium than the general population, and the occurrence of delirium is an independent risk factor for subsequent development of dementia. Furthermore, delirium in individuals with dementia can accelerate the trajectory of the underlying cognitive decline. Delirium prevention strategies can reduce the incidence of delirium and associated adverse outcomes, including falls and functional decline. Therefore, delirium might represent a modifiable risk factor for dementia, and interventions that prevent or minimize delirium might also reduce or prevent long-term cognitive impairment. Additionally, understanding the pathophysiology of delirium and the connection between delirium and dementia might ultimately lead to additional treatments for both conditions. In this Review, we explore mechanisms that might be common to both delirium and dementia by reviewing evidence on shared biomarkers, and we discuss the importance of delirium recognition and prevention in people with dementia. In this Review, Fong and Inouye explore mechanisms that might be common to both delirium and dementia. They present delirium as a possible modifiable risk factor for dementia and discuss the importance of delirium prevention strategies in reducing this risk. Delirium and dementia are frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium prevention strategies have been shown to reduce not only the incidence of delirium but also the incidence of adverse outcomes associated with delirium such as falls and functional decline. Adverse outcomes associated with delirium, such as the onset of dementia symptoms in individuals with preclinical dementia, and/or the acceleration of cognitive decline in individuals with dementia might also be delayed by the implementation of delirium prevention strategies. Evidence regarding the association of systemic inflammatory and neuroinflammatory biomarkers with delirium is variable, possibly as a result of co-occurring dementia pathology or disruption of the blood–brain barrier. Alzheimer disease pathology, even prior to the onset of symptoms, might have an effect on delirium risk, with potential mechanisms including neuroinflammation and gene–protein interactions with the APOE ε4 allele. Novel strategies, including proteomics, multi-omics, neuroimaging, transcranial magnetic stimulation and EEG, are beginning to reveal how changes in cerebral blood flow, spectral power and connectivity can be associated with delirium; further work is needed to expand these findings to patients with delirium superimposed upon dementia.
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Affiliation(s)
- Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA. .,Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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16
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What is It Like to be Delirious? Neurocrit Care 2022; 37:1-5. [PMID: 35614296 DOI: 10.1007/s12028-022-01520-4] [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: 03/01/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
Abstract
The current terminology of delirium and encephalopathy is open to debate. As with any poorly understood disorder with an unknown mechanism, there is a range of opinions. Attention must be paid to a proliferation of new terms and the ease with which they were introduced. In this viewpoint article, the authors invite the readers to return to the patient and rethink linguistic usage. The meaning of terms will be determined by their use rather than by authoritative description. We conclude that the suggested terminology of delirium is subjective, unsatisfactory, and may seriously hamper scholarly work. Rather than expand the definitions of types of delirium and separate them from encephalopathy, we advocate a definition-encephalopathy with or without characteristics of delirium-with the understanding that agitated patients in a delirium are innately encephalopathic. We subscribe to the prevailing neurologic description of delirium. This would allow sufficient granularity for bedside use and prospective studies.
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17
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Ramirez-Bermudez J, Medina-Gutierrez A, Gomez-Cianca H, Arias P, Pérez-Gonzalez A, Lebrija-Reyes PA, Espinola-Nadurille M, Aguilar-Venegas LC, Ojeda-López C, Restrepo-Martínez M, Bayliss L, Juárez-Jaramillo CA, Peñaloza G, Rivas-Alonso V, Flores-Rivera J, Gómez-Amador JL, Rios C, Sachdev PS. Clinical Significance of Delirium With Catatonic Signs in Patients With Neurological Disorders. J Neuropsychiatry Clin Neurosci 2022; 34:132-140. [PMID: 35040665 DOI: 10.1176/appi.neuropsych.18120364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE According to DSM-5, catatonia and delirium are mutually exclusive clinical syndromes. The investigators explored the co-occurrence of delirium and catatonia (i.e., catatonic delirium) and the clinical significance of this syndrome with a sample of neurological patients. METHODS This prospective study with consecutive sampling included patients diagnosed with delirium at the National Institute of Neurology and Neurosurgery of Mexico. DSM-5 criteria for delirium, the Confusion Assessment Method, and the Delirium Rating Scale-Revised-98 were used to select and characterize patients. Catatonia was assessed using the Bush-Francis Catatonia Rating Scale and DSM-5 diagnostic criteria. Logistic regression analysis was performed to identify etiological factors associated with catatonic delirium. RESULTS A total of 264 patients with delirium were included, 61 (23%) of whom fulfilled the criteria for catatonia and delirium simultaneously. Brain tumors, subarachnoid hemorrhage, acute hydrocephalus, and ischemic stroke were associated with delirium without catatonic signs. Catatonic delirium was observed among patients with encephalitis, epilepsy, brain neoplasms, and brain tuberculosis. After multivariate analysis, the association between catatonic delirium and encephalitis (both viral and anti-N-methyl-d-aspartate receptor [NMDAR]) was confirmed. CONCLUSIONS Delirium is a common complication of neurological diseases, and it can coexist with catatonia. The recognition of catatonic delirium has clinical significance in terms of etiology, as it was significantly associated with viral and anti-NMDAR encephalitis.
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Affiliation(s)
- Jesus Ramirez-Bermudez
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Angela Medina-Gutierrez
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Heraclides Gomez-Cianca
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Patricia Arias
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Andres Pérez-Gonzalez
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Paulina Angélica Lebrija-Reyes
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Mariana Espinola-Nadurille
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Luis Carlos Aguilar-Venegas
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Carmen Ojeda-López
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Miguel Restrepo-Martínez
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Leo Bayliss
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Cynthia Areli Juárez-Jaramillo
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Guillermo Peñaloza
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Verónica Rivas-Alonso
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - José Flores-Rivera
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Juan Luis Gómez-Amador
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Camilo Rios
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
| | - Perminder S Sachdev
- Neuropsychiatry Department (Ramirez-Bermudez, Medina-Gutierrez, Gomez-Cianca, Arias, Pérez-Gonzalez, Lebrija-Reyes, Espinola-Nadurille, Restrepo-Martinez, Juárez-Jaramillo, Peñaloza), Neurology Department (Aguilar-Venegas, Ojeda-López, Bayliss, Rivas-Alonso, Flores-Rivera), Neurosurgery Department (Gómez-Amador), and Neurochemistry Department (Rios),the National Institute of Neurology and Neurosurgery of Mexico; and the Prince of Wales Hospital and Center for Healthy Brain Ageing, University of New South Wales, Sydney, Australia (Sachdev)
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18
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Blomsma N, de Rooy B, Gerritse F, van der Spek R, Tewarie P, Hillebrand A, Otte WM, Stam CJ, van Dellen E. Minimum spanning tree analysis of brain networks: A systematic review
of network size effects, sensitivity for neuropsychiatric pathology and disorder
specificity. Netw Neurosci 2022; 6:301-319. [PMID: 35733422 PMCID: PMC9207994 DOI: 10.1162/netn_a_00245] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/10/2022] [Indexed: 11/05/2022] Open
Abstract
Brain network characteristics’ potential to serve as a neurological and psychiatric pathology biomarker has been hampered by the so-called thresholding problem. The minimum spanning tree (MST) is increasingly applied to overcome this problem. It is yet unknown whether this approach leads to more consistent findings across studies and converging outcomes of either disease-specific biomarkers or transdiagnostic effects. We performed a systematic review on MST analysis in neurophysiological and neuroimaging studies (N = 43) to study consistency of MST metrics between different network sizes and assessed disease specificity and transdiagnostic sensitivity of MST metrics for neurological and psychiatric conditions. Analysis of data from control groups (12 studies) showed that MST leaf fraction but not diameter decreased with increasing network size. Studies showed a broad range in metric values, suggesting that specific processing pipelines affect MST topology. Contradicting findings remain in the inconclusive literature of MST brain network studies, but some trends were seen: (1) a more linelike organization characterizes neurodegenerative disorders across pathologies, and is associated with symptom severity and disease progression; (2) neurophysiological studies in epilepsy show frequency band specific MST alterations that normalize after successful treatment; and (3) less efficient MST topology in alpha band is found across disorders associated with attention impairments. The potential of brain network characteristics to serve as biomarker of neurological and psychiatric pathology has been hampered by the so-called thresholding problem. The minimum spanning tree (MST) is increasingly applied to overcome this problem. We performed a systematic review on MST analysis in neurophysiological and neuroimaging studies and assessed disease specificity and transdiagnostic sensitivity of MST metrics for neurological and psychiatric conditions. MST leaf fraction but not diameter decreased with increasing network size. Contradicting findings remain in the literature on MST brain network studies, but some trends were seen: (1) a more linelike organization characterizes neurodegenerative disorders; (2) in epilepsy there are frequency band specific MST alterations that normalize after successful treatment; and (3) less efficient MST topology is found across disorders associated with attention impairments.
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Affiliation(s)
- Nicky Blomsma
- University Medical Center Utrecht, Department of Psychiatry, Brain Center, Heidelberglaan 100, Utrecht, the Netherlands
| | - Bart de Rooy
- University Medical Center Utrecht, Department of Psychiatry, Brain Center, Heidelberglaan 100, Utrecht, the Netherlands
| | - Frank Gerritse
- University Medical Center Utrecht, Department of Psychiatry, Brain Center, Heidelberglaan 100, Utrecht, the Netherlands
| | - Rick van der Spek
- University Medical Center Utrecht, Department of Psychiatry, Brain Center, Heidelberglaan 100, Utrecht, the Netherlands
| | - Prejaas Tewarie
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Neurology and Department of Clinical Neurophysiology and MEG center, Amsterdam Neuroscience, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Arjan Hillebrand
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Neurology and Department of Clinical Neurophysiology and MEG center, Amsterdam Neuroscience, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Wim M. Otte
- University Medical Center Utrecht, Department of Child Neurology, Brain Center, Heidelberglaan 100, Utrecht, the Netherlands
| | - Cornelis Jan Stam
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Neurology and Department of Clinical Neurophysiology and MEG center, Amsterdam Neuroscience, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Edwin van Dellen
- University Medical Center Utrecht, Department of Psychiatry, Brain Center, Heidelberglaan 100, Utrecht, the Netherlands
- University Medical Center Utrecht, Department of Intensive Care Medicine, Brain Center, Heidelberglaan 100, Utrecht, the Netherlands
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19
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Boukrina O, Kowalczyk M, Koush Y, Kong Y, Barrett A. Brain Network Dysfunction in Poststroke Delirium and Spatial Neglect: An fMRI Study. Stroke 2022; 53:930-938. [PMID: 34619987 PMCID: PMC8885764 DOI: 10.1161/strokeaha.121.035733] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/16/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Delirium, an acute reduction in cognitive functioning, hinders stroke recovery and contributes to cognitive decline. Right-hemisphere stroke is linked with higher delirium incidence, likely, due to the prevalence of spatial neglect (SN), a right-brain disorder of spatial processing. This study tested if symptoms of delirium and SN after right-hemisphere stroke are associated with abnormal function of the right-dominant neural networks specialized for maintaining attention, orientation, and arousal. METHODS Twenty-nine participants with right-hemisphere ischemic stroke undergoing acute rehabilitation completed delirium and SN assessments and functional neuroimaging scans. Whole-brain functional connectivity of 4 right-hemisphere seed regions in the cortical-subcortical arousal and attention networks was assessed for its relationship to validated SN and delirium severity measures. RESULTS Of 29 patients, 6 (21%) met the diagnostic criteria for delirium and 16 (55%) for SN. Decreased connectivity of the right basal forebrain to brain stem and basal ganglia predicted more severe SN. Increased connectivity of the arousal and attention network regions with the parietal, frontal, and temporal structures in the unaffected hemisphere was also found in more severe delirium and SN. CONCLUSIONS Delirium and SN are associated with decreased arousal network activity and an imbalance of cortico-subcortical hemispheric connectivity. Better understanding of neural correlates of poststroke delirium and SN will lead to improved neuroscience-based treatment development for these disorders. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03349411.
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Affiliation(s)
- Olga Boukrina
- Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, NJ, 07052, USA
- Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ, 07103, USA
| | - Mateusz Kowalczyk
- Rocco Ortenzio Neuroimaging Center, Kessler Foundation, West Orange, NJ, 07052, USA
| | - Yury Koush
- Magnetic Resonance Research Center, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Yekyung Kong
- Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ, 07103, USA
- Kessler Institute for Rehabilitation, West Orange, NJ, 07052, USA
| | - A.M. Barrett
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Medical Center, Decatur, 30033 GA, USA
- Neurology, Emory University School of Medicine, Atlanta, 30322, GA
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20
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Brefka S, Eschweiler GW, Dallmeier D, Denkinger M, Leinert C. Comparison of delirium detection tools in acute care : A rapid review. Z Gerontol Geriatr 2022; 55:105-115. [PMID: 35029755 PMCID: PMC8921069 DOI: 10.1007/s00391-021-02003-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/06/2021] [Indexed: 11/28/2022]
Abstract
Background Delirium is a frequent psychopathological syndrome in geriatric patients. It is sometimes the only symptom of acute illness and bears a high risk for complications. Therefore, feasible assessments are needed for delirium detection. Objective and methods Rapid review of available delirium assessments based on a current Medline search and cross-reference check with a special focus on those implemented in acute care hospital settings. Results A total of 75 delirium detection tools were identified. Many focused on inattention as well as acute onset and/or fluctuating course of cognitive changes as key features for delirium. A range of assessments are based on the confusion assessment method (CAM) that has been adapted for various clinical settings. The need for a collateral history, time resources and staff training are major challenges in delirium assessment. Latest tests address these through a two-step approach, such as the ultrabrief (UB) CAM or by optional assessment of temporal aspects of cognitive changes (4 As test, 4AT). Most delirium screening assessments are validated for patient interviews, some are suitable for monitoring delirium symptoms over time or diagnosing delirium based on collateral history only. Conclusion Besides the CAM the 4AT has become well-established in acute care because of its good psychometric properties and practicability. There are several other instruments extending and improving the possibilities of delirium detection in different clinical settings. Supplementary Information The online version of this article (10.1007/s00391-021-02003-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Simone Brefka
- Institute for Geriatric Research, Ulm University, Ulm, Germany. .,Geriatric Center Ulm/Alb Donau, Ulm, Germany. .,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany.
| | - Gerhard Wilhelm Eschweiler
- Geriatric Center, University Hospital Tuebingen, Tuebingen, Germany.,University Hospital for Psychiatry and Psychotherapy Tuebingen, Tuebingen, Germany
| | - Dhayana Dallmeier
- Geriatric Center Ulm/Alb Donau, Ulm, Germany.,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany.,Dept. of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Michael Denkinger
- Institute for Geriatric Research, Ulm University, Ulm, Germany.,Geriatric Center Ulm/Alb Donau, Ulm, Germany.,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany
| | - Christoph Leinert
- Institute for Geriatric Research, Ulm University, Ulm, Germany.,Geriatric Center Ulm/Alb Donau, Ulm, Germany.,Agaplesion Bethesda Hospital Ulm, Zollernring 26, 89073, Ulm, Germany
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21
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Abstract
Delirium, an acute disturbance in mental status due to another medical condition, is common and morbid in the intensive care unit. Despite its clear association with multiple common risk factors and important outcomes, including mortality and long-term cognitive impairment, both the ultimate causes of and ideal treatments for delirium remain unclear. Studies suggest that neuroinflammation, hypoxia, alterations in energy metabolism, and imbalances in multiple neurotransmitter pathways contribute to delirium, but commonly used treatments (e.g., antipsychotic medications) target only one or a few of these potential mechanisms and are not supported by evidence of efficacy. At this time, the optimal treatment for delirium during critical illness remains avoidance of risk factors, though ongoing trials may expand on the promise shown by agents such as melatonin and dexmedetomidine. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
| | - Perry J Tiberio
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
| | - Timothy D Girard
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA;
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22
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Abstract
An aging-related reduction in the brain's functional reserve may explain why delirium is more frequent in the elderly than in younger people insofar as the reserve becomes inadequate to cover the metabolic requirements that are critically increased by stressors. The aim of this paper is to review the normal aging-related changes that theoretically compromise complex mental activities, neuronal and synaptic densities, and the neurocomputational flexibility of the functional reserve. A pivotal factor is diminished connectivity, which is substantially due to the loss of synapses and should specifically affect association systems and cholinergic fibres in delirious patients. However, micro-angiopathy with impaired blood flow autoregulation, increased blood/brain barrier permeability, changes in cerebrospinal fluid dynamics, weakened mitochondrial performance, and a pro-inflammatory involution of the immune system may also jointly affect neurons and their synaptic assets, and even cause the progression of delirium to dementia regardless of the presence of co-existing plaques, tangles, or other pathological markers. On the other hand, the developmental growth in functional reserve during childhood and adolescence makes the brain increasingly resistant to delirium, and residual reserve can allow the elderly to recover. These data support the view that functional reserve is the variable that confronts stressors and governs the risk and intensity of and recovery from delirium. Although people of any age are at risk of delirium, the elderly are at greater risk because aging and age-dependent structural changes inevitably affect the brain's functional reserve.
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23
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Liu X, Yang H, Becker B, Huang X, Luo C, Meng C, Biswal B. Disentangling age- and disease-related alterations in schizophrenia brain network using structural equation modeling: A graph theoretical study based on minimum spanning tree. Hum Brain Mapp 2021; 42:3023-3041. [PMID: 33960579 PMCID: PMC8193510 DOI: 10.1002/hbm.25403] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 02/05/2023] Open
Abstract
Functional brain networks have been shown to undergo fundamental changes associated with aging or schizophrenia. However, the mechanism of how these factors exert influences jointly or interactively on brain networks remains elusive. A unified recognition of connectomic alteration patterns was also hampered by heterogeneities in network construction and thresholding methods. Recently, an unbiased network representation method regardless of network thresholding, so called minimal spanning tree algorithm, has been applied to study the critical skeleton of the brain network. In this study, we aimed to use minimum spanning tree (MST) as an unbiased network reconstruction and employed structural equation modeling (SEM) to unravel intertwined relationships among multiple phenotypic and connectomic variables in schizophrenia. First, we examined global and local brain network properties in 40 healthy subjects and 40 schizophrenic patients aged 21–55 using resting‐state functional magnetic resonance imaging (rs‐fMRI). Global network alterations are measured by graph theoretical metrics of MSTs and a connectivity‐transitivity two‐dimensional approach was proposed to characterize nodal roles. We found that networks of schizophrenic patients exhibited a more star‐like global structure compared to controls, indicating excessive integration, and a loss of regional transitivity in the dorsal frontal cortex (corrected p <.05). Regional analysis of MST network topology revealed that schizophrenia patients had more network hubs in frontal regions, which may be linked to the “overloading” hypothesis. Furthermore, using SEM, we found that the level of MST integration mediated the influence of age on negative symptom severity (indirect effect 95% CI [0.026, 0.449]). These findings highlighted an altered network skeleton in schizophrenia and suggested that aging‐related enhancement of network integration may undermine functional specialization of distinct neural systems and result in aggravated schizophrenic symptoms.
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Affiliation(s)
- Xinyu Liu
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Laboratory for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China.,Center for Information in Medicine, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China.,Glasgow College, University of Electronic Science and Technology of China, Chengdu, China
| | - Hang Yang
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Laboratory for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China.,Center for Information in Medicine, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Benjamin Becker
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Laboratory for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China.,Center for Information in Medicine, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoqi Huang
- Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Cheng Luo
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Laboratory for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China.,Center for Information in Medicine, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Chun Meng
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Laboratory for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China.,Center for Information in Medicine, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Bharat Biswal
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Laboratory for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China.,Center for Information in Medicine, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China.,Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, New Jersey, USA
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24
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Winterer JM, Ofosu K, Borchers F, Hadzidiakos D, Lammers-Lietz F, Spies C, Winterer G, Zacharias N. Neurocognitive disorders in the elderly: altered functional resting-state hyperconnectivities in postoperative delirium patients. Transl Psychiatry 2021; 11:213. [PMID: 33846284 PMCID: PMC8041755 DOI: 10.1038/s41398-021-01304-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 02/03/2021] [Accepted: 03/02/2021] [Indexed: 01/11/2023] Open
Abstract
Postoperative delirium (POD) represents a confusional state during days/weeks after surgery and is particularly frequent in elderly patients. Hardly any fMRI studies were conducted to understand the underlying pathophysiology of POD patients. This prospective observational cohort study aims to examine changes of specific resting-state functional connectivity networks across different time points (pre- and 3-5 months postoperatively) in delirious patients compared to no-POD patients. Two-hundred eighty-three elderly surgical patients underwent preoperative resting-state fMRI (46 POD). One-hundred seventy-eight patients completed postoperative scans (19 POD). For functional connectivity analyses, three functional connectivity networks with seeds located in the orbitofrontal cortex (OFC), nucleus accumbens (NAcc), and hippocampus were investigated. The relationship of POD and connectivity changes between both time points (course connectivity) were examined (ANOVA). Preoperatively, delirious patients displayed hyperconnectivities across the examined functional connectivity networks. In POD patients, connectivities within NAcc and OFC networks demonstrated a decrease in course connectivity [max. F = 9.03, p = 0.003; F = 4.47, p = 0.036, resp.]. The preoperative hyperconnectivity in the three networks in the patients at risk for developing POD could possibly indicate existing compensation mechanisms for subtle brain dysfunction. The observed pathophysiology of network function in POD patients at least partially involves dopaminergic pathways.
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Affiliation(s)
- Jeanne M. Winterer
- grid.6363.00000 0001 2218 4662Department of Psychiatry and Psychotherapy (CCM), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany ,grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany ,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
| | - Kwaku Ofosu
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Friedrich Borchers
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Daniel Hadzidiakos
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Florian Lammers-Lietz
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Georg Winterer
- Department of Anesthesiology, Charité (CVK, CCM)-Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany. .,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany.
| | - Norman Zacharias
- grid.484013.aDepartment of Anesthesiology, Charité (CVK, CCM)–Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany ,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
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25
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 414] [Impact Index Per Article: 103.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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van Montfort SJT, Slooter AJC, Kant IMJ, van der Leur RR, Spies C, de Bresser J, Witkamp TD, Hendrikse J, van Dellen E. fMRI network correlates of predisposing risk factors for delirium: A cross-sectional study. NEUROIMAGE-CLINICAL 2020; 27:102347. [PMID: 32738752 PMCID: PMC7394743 DOI: 10.1016/j.nicl.2020.102347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 12/14/2022]
Abstract
Predisposing risk is not associated with delirium-related fMRI characteristics. Older age within an elderly cohort is related to higher functional connectivity strength. This relation is in opposite direction than hypothesized. The onset of delirium may reflect new functional network impairments.
Delirium, the clinical expression of acute encephalopathy, is a common neuropsychiatric syndrome that is related to poor outcomes, such as long-term cognitive impairment. Disturbances of functional brain networks are hypothesized to predispose for delirium. The aim of this study in non-delirious elderly individuals was to investigate whether predisposing risk factors for delirium are associated with fMRI network characteristics that have been observed during delirium. As predisposing risk factors, we studied age, alcohol misuse, cognitive impairment, depression, functional impairment, history of transient ischemic attack or stroke, and physical status. In this multicenter study, we included 554 subjects and analyzed resting-state fMRI data from 222 elderly subjects (63% male, age range: 65–85 year) after rigorous motion correction. Functional network characteristics were analyzed and based on the minimum spanning tree (MST). Global functional connectivity strength, network efficiency (MST diameter) and network integration (MST leaf fraction) were analyzed, as these measures were altered during delirium in previous studies. Linear regression analyses were used to investigate the relation between predisposing delirium risk factors and delirium-related fMRI characteristics, adjusted for confounding and multiple testing. Predisposing risk factors for delirium were not associated with delirium-related fMRI network characteristics. Older age within our elderly cohort was related to global functional connectivity strength (β = 0.182, p < 0.05), but in the opposite direction than hypothesized. Delirium-related functional network impairments can therefore not be considered as the common mechanism for predisposition for delirium.
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Affiliation(s)
- S J T van Montfort
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands.
| | - A J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - I M J Kant
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - R R van der Leur
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands; Faculty of Medicine, University of Utrecht, The Netherlands
| | - C Spies
- Department of Anaesthesiology, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - J de Bresser
- Department of Radiology, Leiden University Medical Center, The Netherlands
| | - T D Witkamp
- Department of Radiology and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - J Hendrikse
- Department of Radiology and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - E van Dellen
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands; Department of Psychiatry and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
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Franco JG, Trzepacz PT, Velásquez-Tirado JD, Ocampo MV, Serna PA, Giraldo AM, López C, Zuluaga A, Zaraza-Morales D. Discriminant Performance of Dysexecutive and Frontal Release Signs for Delirium in Patients With High Dementia Prevalence: Implications for Neural Network Impairment. J Acad Consult Liaison Psychiatry 2020; 62:56-69. [PMID: 32444154 DOI: 10.1016/j.psym.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prevalence of signs of abnormal executive function (EF) and primitive reflexes (PR) with delirium in older hospitalized patients with or without comorbid dementia has not been reported. OBJECTIVE To describe prevalence of signs of EF deficits and PR in older inpatients and their discriminant value for delirium while accounting for dementia. METHODS Participants were evaluated for delirium using the Diagnostic and Statistical Manual of Mental Disorders 5th edition and the Delirium Rating Scale Revised-98, dementia using Informant Questionnaire on Cognitive Decline in the Elderly, and signs of PR (n = 5) and EF deficits (n = 3) using bedside neuropsychiatric examination. Three indices (PR, EF, and Combined) and 4 diagnostic groups were created for correlational and discriminant analyses. RESULTS Correlations of indices were higher with the Delirium Rating Scale Revised-98 than with the Informant Questionnaire on Cognitive Decline in the Elderly and even higher in those with dementia, especially the Combined index (Delirium Frontal Index). Among individual signs, glabellar and Simple Luria Hand Sequence were most common in delirium and the best for delirium discrimination irrespective of dementia status. The Combined index had about 80% sensitivity and specificity at the ≥2 cutoff in the whole cohort (positive and negative predictive values and likelihood ratios: PPV 50.0%, NPV 93.8%, +LR 3.82, -LR 0.25). The Combined index also had the best performance on discriminating delirium in dementia patients at the ≥3 cutoff, with about 80% for both sensitivity and specificity. CONCLUSIONS PR and EF deficit signs are consistent with reduced neural network integration during delirium, even worse in those with dementia whose baseline structural injury impairs network connectivity with frontal regions. We recommend simple bedside assessment of PR and EF signs to help assess for delirium as an indicator of cerebral cortical neural network impairment in older persons.
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Affiliation(s)
- José G Franco
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Paula T Trzepacz
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Juan D Velásquez-Tirado
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - María V Ocampo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Paola A Serna
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Alejandra M Giraldo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Carolina López
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Adolfo Zuluaga
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Daniel Zaraza-Morales
- Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia
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van Montfort SJT, van Dellen E, Wattel LL, Kant IMJ, Numan T, Stam CJ, Slooter AJC. Predisposition for delirium and EEG characteristics. Clin Neurophysiol 2020; 131:1051-1058. [PMID: 32199395 DOI: 10.1016/j.clinph.2020.01.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 12/19/2019] [Accepted: 01/27/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Delirium is associated with increased electroencephalography (EEG) delta activity, decreased connectivity strength and decreased network integration. To improve our understanding of development of delirium, we studied whether non-delirious individuals with a predisposition for delirium also show these EEG abnormalities. METHODS Elderly subjects (N = 206) underwent resting-state EEG measurements and were assessed on predisposing delirium risk factors, i.e. older age, alcohol misuse, cognitive impairment, depression, functional impairment, history of stroke and physical status. Delirium-related EEG characteristics of interest were relative delta power, alpha connectivity strength (phase lag index) and network integration (minimum spanning tree leaf fraction). Linear regression analyses were used to investigate the relation between predisposing delirium risk factors and EEG characteristics that are associated with delirium, adjusting for confounding and multiple testing. RESULTS Functional impairment was related to a decrease in connectivity strength (adjusted R2 = 0.071, β = 0.201, p < 0.05). None of the other risk factors had significant influence on EEG delta power, connectivity strength or network integration. CONCLUSIONS Functional impairment seems to be associated with decreased alpha connectivity strength. Other predisposing risk factors for delirium had no effect on the studied EEG characteristics. SIGNIFICANCE Predisposition for delirium is not consistently related to EEG characteristics that can be found during delirium.
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Affiliation(s)
- S J T van Montfort
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - E van Dellen
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Psychiatry and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - L L Wattel
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Faculty of Science, University of Amsterdam, the Netherlands
| | - I M J Kant
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - T Numan
- Department of Anatomy and Neurosciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - C J Stam
- Department of Clinical Neurophysiology and MEG Center, Neuroscience Campus Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - A J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands
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Müller J, Nowak S, Vogelgesang A, von Sarnowski B, Rathmann E, Schmidt S, Rehberg S, Usichenko T, Kertscho H, Hahnenkamp K, Flöel A, Schroeder HW, Müller JU, Fleischmann R. Evaluating Mechanisms of Postoperative Delirium and Cognitive Dysfunction Following Elective Spine Surgery in Elderly Patients (CONFESS): Protocol for a Prospective Observational Trial. JMIR Res Protoc 2020; 9:e15488. [PMID: 32053113 PMCID: PMC7048391 DOI: 10.2196/15488] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 10/12/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022] Open
Abstract
Background Elderly people are at particular high risk for postoperative delirium (POD) following spine surgery, which is associated with longer hospital stays, higher costs, risk for delayed complications, long-term care dependency, and cognitive dysfunction (POCD). It is insufficiently understood which mechanisms and risk factors contribute to the development of POD and POCD following these major but plannable surgeries. Objective This study aims to identify modifiable risk factors in spine surgery. A better understanding thereof would help adapt medical management and surgical strategies to individual risk profiles. Methods This is a single-center observational study jointly conducted by the departments of neurosurgery, neurology, and anesthesiology at a tertiary care hospital in Germany. All patients aged 60 years and older presenting to the neurosurgery outpatient clinic or ward for elective spine surgery are screened for eligibility. Exclusion criteria include presence of neurodegenerative or history of psychiatric disease and medication with significant central nervous system activity (eg, antidepressants, antipsychotics, sedatives). Surgical and anesthetic procedures including duration of surgery as primary end point of this study are thoroughly documented. All patients are furthermore evaluated for their preoperative cognitive abilities by a number of tests, including the Consortium to Establish a Registry for Alzheimer's Disease Plus test battery. Physical, mental, and social health and well-being are assessed using the Patient-Reported Outcome Measurement Information System Profile 29 and Hospital Anxiety and Depression Scale. Patients additionally receive preoperative cerebrovascular ultrasound and structural and functional brain imaging. The immediate postoperative period includes screening for POD using the Nursing Delirium Screening Scale and validation through Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria. We furthermore investigate markers of (neuro)inflammation (eg, interleukins, C-reactive protein, tumor necrosis factor alpha). Preoperative examinations are repeated 3 months postoperatively to investigate the presence of POCD and its mechanisms. Statistical analyses will compare delirious and nondelirious patients for predictors of immediate (POD) and delayed (POCD) cognitive dysfunction. Results This is the first study to prospectively evaluate risk factors for POD and POCD in spine surgery. Recruitment is ongoing, and data collection is estimated to be finished with the inclusion of 200 patients by mid-2020. Conclusions The identification of mechanisms, possibly common, underlying POD and POCD would be a major step toward defining effective interventional strategies early in or even before the postoperative period, including the adaptation of surgical strategies to individual risk profiles. Trial Registration ClinicalTrials.gov NCT03486288; https://clinicaltrials.gov/ct2/show/NCT03486288
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Affiliation(s)
- Jonas Müller
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Stephan Nowak
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Antje Vogelgesang
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | | | - Eiko Rathmann
- Department of Radiology, University Medicine Greifswald, Greifswald, Germany
| | - Sein Schmidt
- Clinical Research Unit, Charité Campus Mitte, Berlin Institute of Health, Berlin, Germany
| | - Sebastian Rehberg
- Department of Anesthesiology, Protestant Hospital of the Bethel Foundation, Bielefeld, Germany
| | - Taras Usichenko
- Department of Anesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Harry Kertscho
- Department of Anesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Klaus Hahnenkamp
- Department of Anesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Agnes Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,Center for Neurodegenerative Diseases, Greifswald/Rostock, Germany
| | - Henry Ws Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Jan-Uwe Müller
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Robert Fleischmann
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
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Oh J, Shin JE, Yang KH, Kyeong S, Lee WS, Chung TS, Kim JJ. Cortical and subcortical changes in resting-state functional connectivity before and during an episode of postoperative delirium. Aust N Z J Psychiatry 2019; 53:794-806. [PMID: 31094211 DOI: 10.1177/0004867419848826] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Delirium is an acute brain failure related to uncertain problems in neural connectivity, including aberrant functional interactions between remote cortical regions. This study aimed to elucidate the underlying neural mechanisms of delirium by clarifying the changes in resting-state functional connectivity induced by postoperative delirium using imaging data scanned before and after surgery. METHOD Fifty-eight patients with a femoral neck fracture were preoperatively scanned using resting-state functional magnetic resonance imaging. Twenty-five patients developed postoperative delirium, and 14 of those had follow-up scans during delirium. Eighteen patients without delirium completed follow-up scans 5 or 6 days after surgery. We assessed group differences in voxel-based connectivity, in which the seeds were the posterior cingulate cortex, medial prefrontal cortex and 11 subcortical regions. Connections between the subcortical regions were also examined. RESULTS The results showed four major findings during delirium. Both the posterior cingulate cortex and medial prefrontal cortex were strongly connected to the dorsolateral prefrontal cortex. The posterior cingulate cortex had hyperconnectivity with the inferior parietal lobule, whereas the medial prefrontal cortex had hyperconnectivity with the frontopolar cortex and hypoconnectivity with the superior frontal gyrus. Connectivity of the striatum with the anterior cingulate cortex and insula was increased. Disconnections were found between the lower subcortical regions including the neurotransmitter origins and the striatum/thalamus in the upper level. CONCLUSIONS Our findings suggest that cortical dysfunction during delirium is characterized by a diminution of the anticorrelation between the default mode network and task-positive regions, excessive internal connections in the posterior default mode network and a complex imbalance of internal connectivity in the anterior default mode network. These dysfunctions can be attributed to the loss of reciprocity between the default mode network and central executive network associated with defective function in the salience network, which might be closely linked to aberrant subcortical neurotransmission-related connectivity and striato-cortical connectivity.
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Affiliation(s)
- Jooyoung Oh
- 1 Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.,2 Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Eun Shin
- 2 Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Hyun Yang
- 3 Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sunghyon Kyeong
- 2 Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Suk Lee
- 3 Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Sub Chung
- 4 Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Jin Kim
- 1 Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.,2 Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Oh J, Ham J, Cho D, Park JY, Kim JJ, Lee B. The Effects of Transcranial Direct Current Stimulation on the Cognitive and Behavioral Changes After Electrode Implantation Surgery in Rats. Front Psychiatry 2019; 10:291. [PMID: 31156472 PMCID: PMC6531794 DOI: 10.3389/fpsyt.2019.00291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/15/2019] [Indexed: 11/22/2022] Open
Abstract
Postoperative delirium can lead to increased morbidity and mortality, and may even be a potentially life-threatening clinical syndrome. However, the neural mechanism underlying this condition has not been fully understood and there is little knowledge regarding potential preventive strategies. To date, investigation of transcranial direct current stimulation (tDCS) for the relief of symptoms caused by neuropsychiatric disorders and the enhancement of cognitive performance has led to promising results. In this study, we demonstrated that tDCS has a possible effect on the fast recovery from delirium in rats after microelectrode implant surgery, as demonstrated by postoperative behavior and neurophysiology compared with sham stimulation. This is the first study to describe the possible effects of tDCS for the fast recovery from delirium based on the study of both electroencephalography and behavioral changes. Postoperative rats showed decreased attention, which is the core symptom of delirium. However, anodal tDCS over the right frontal area immediately after surgery exhibited positive effects on acute attentional deficit. It was found that relative power of theta was lower in the tDCS group than in the sham group after surgery, suggesting that the decrease might be the underlying reason for the positive effects of tDCS. Connectivity analysis revealed that tDCS could modulate effective connectivity and synchronization of brain activity among different brain areas, including the frontal cortex, parietal cortex, and thalamus. It was concluded that anodal tDCS on the right frontal regions may have the potential to help patients recover quickly from delirium.
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Affiliation(s)
- Jooyoung Oh
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jinsil Ham
- Department of Biomedical Science and Engineering (BMSE), Institute of Integrated Technology (IIT), Gwangju Institute of Science and Technology (GIST), Gwangju, South Korea
| | - Dongrae Cho
- Department of Biomedical Science and Engineering (BMSE), Institute of Integrated Technology (IIT), Gwangju Institute of Science and Technology (GIST), Gwangju, South Korea
| | - Jin Young Park
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Jin Kim
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Boreom Lee
- Department of Biomedical Science and Engineering (BMSE), Institute of Integrated Technology (IIT), Gwangju Institute of Science and Technology (GIST), Gwangju, South Korea
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32
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van Montfort SJT, van Dellen E, Stam CJ, Ahmad AH, Mentink LJ, Kraan CW, Zalesky A, Slooter AJC. Brain network disintegration as a final common pathway for delirium: a systematic review and qualitative meta-analysis. NEUROIMAGE-CLINICAL 2019; 23:101809. [PMID: 30981940 PMCID: PMC6461601 DOI: 10.1016/j.nicl.2019.101809] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/25/2019] [Accepted: 03/31/2019] [Indexed: 01/05/2023]
Abstract
Delirium is an acute neuropsychiatric syndrome characterized by altered levels of attention and awareness with cognitive deficits. It is most prevalent in elderly hospitalized patients and related to poor outcomes. Predisposing risk factors, such as older age, determine the baseline vulnerability for delirium, while precipitating factors, such as use of sedatives, trigger the syndrome. Risk factors are heterogeneous and the underlying biological mechanisms leading to vulnerability for delirium are poorly understood. We tested the hypothesis that delirium and its risk factors are associated with consistent brain network changes. We performed a systematic review and qualitative meta-analysis and included 126 brain network publications on delirium and its risk factors. Findings were evaluated after an assessment of methodological quality, providing N=99 studies of good or excellent quality on predisposing risk factors, N=10 on precipitation risk factors and N=7 on delirium. Delirium was consistently associated with functional network disruptions, including lower EEG connectivity strength and decreased fMRI network integration. Risk factors for delirium were associated with lower structural connectivity strength and less efficient structural network organization. Decreased connectivity strength and efficiency appear to characterize structural brain networks of patients at risk for delirium, possibly impairing the functional network, while functional network disintegration seems to be a final common pathway for the syndrome. Delirium is consistently associated with functional network impairments. Risk factors are associated with lower structural connectivity strength. Risk factors are associated with a less efficient structural network organization. Structural impairments make the functional network more vulnerable to deterioration. Functional network disintegration seems to be a final common pathway for delirium.
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Affiliation(s)
- S J T van Montfort
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
| | - E van Dellen
- Department of Psychiatry and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Melbourne Neuropsychiatry Center, Department of Psychiatry, Level 3, Alan Gilbert Building, 161 Barry Street, Carlton South, 3053 Victoria, University of Melbourne and Melbourne Health, Australia
| | - C J Stam
- Department of Clinical Neurophysiology and MEG Center, Neuroscience Campus Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - A H Ahmad
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Faculty of Psychology, Utrecht University, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands
| | - L J Mentink
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - C W Kraan
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - A Zalesky
- Melbourne Neuropsychiatry Center, Department of Psychiatry, Level 3, Alan Gilbert Building, 161 Barry Street, Carlton South, 3053 Victoria, University of Melbourne and Melbourne Health, Australia
| | - A J C Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Sambin S, Gaspard N, Legros B, Depondt C, De Breucker S, Naeije G. Role of Epileptic Activity in Older Adults With Delirium, a Prospective Continuous EEG Study. Front Neurol 2019; 10:263. [PMID: 30941098 PMCID: PMC6434717 DOI: 10.3389/fneur.2019.00263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/27/2019] [Indexed: 12/29/2022] Open
Abstract
Background/Objectives: Delirium occurs in up to 50 % of hospitalized old patients and is associated with increased morbidity and mortality. Acute medical conditions favor delirium, but the pathophysiology is unclear. Preliminary evidence from retrospective and prospective studies suggests that a substantial minority of old patients with unexplained delirium have non-convulsive seizures or status epilepticus (NCSE). Yet, seeking epileptic activity only in unexplained cases of delirium might result in misinterpretation of its actual prevalence. We aimed to systematically investigate the role of epileptic activity in all older patients with delirium regardless of the underlying etiology. Design, Setting: Prospective observational study in a tertiary medical center. Adults >65 years with delirium underwent at least 24 h of continuous electro-encephalographic monitoring (cEEG). Background patterns and ictal and interictal epileptic discharges were identified, as well as clinical and biological characteristics. Participants: Fifty patients were included in the study. Results: NCSE was found in 6 (12%) patients and interictal discharges in 15 (30%). There was no difference in the prevalence of epileptic activity rates between delirium associated with an acute medical condition and delirium of unknown etiology. Conclusion: Epileptic activity may play a substantial role in the pathophysiology of delirium by altering brain functioning and neuronal metabolism. No clinical or biological marker was found to distinguish delirious patients with or without epileptic activity, underlining the importance of cEEG in this context.
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Affiliation(s)
- Sara Sambin
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Nicolas Gaspard
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Benjamin Legros
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Chantal Depondt
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sandra De Breucker
- Geriatrics Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gilles Naeije
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Fleischmann R, Traenkner S, Kraft A, Schmidt S, Schreiber SJ, Brandt SA. Delirium is associated with frequency band specific dysconnectivity in intrinsic connectivity networks: preliminary evidence from a large retrospective pilot case-control study. Pilot Feasibility Stud 2019; 5:2. [PMID: 30631448 PMCID: PMC6322230 DOI: 10.1186/s40814-018-0388-z] [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: 09/04/2018] [Accepted: 12/17/2018] [Indexed: 12/25/2022] Open
Abstract
Background Pathophysiological concepts in delirium are not sufficient to define objective biomarkers suited to improve clinical approaches. Advances in neuroimaging have revalued electroencephalography (EEG) as a tool to assess oscillatory network activity in neuropsychiatric disease. Yet, research in the field is limited to small populations and largely confined to postoperative delirium, which impedes generalizability of findings and planning of prospective studies in other populations. This study aimed to assess effect sizes of connectivity measures in a large mixed population to demonstrate that there are measurable EEG differences between delirium and control patients. Methods This retrospective pilot study investigated EEG measures as biomarkers in delirium using a case-control design including patients diagnosed with delirium (DSM-5 criteria) and age-/gender-matched controls drawn from a database of 9980 patients (n = 129 and 414, respectively). Assessors were not blinded for groups. Power spectra and connectivity estimates, using the weighted phase log index, of continuous EEG data were compared between conditions. Alterations of information flow through nodes of intrinsic connectivity networks (ICN; default mode, salience, and executive control network) were evaluated in source space using betweenness centrality. This was done frequency specific and network nodes were defined by the multimodal human cerebral cortex parcellation based on human connectome project data. Results Delirium and control patients exhibited distinct EEG power, connectivity, and network characteristics (F(72,540) = 70.3, p < .001; F(493,1079) = 2.69, p < .001; and F(718,2159) = 1.14, p = .007, respectively). Connectivity analyses revealed global alpha and regional beta band disconnectivity that was accompanied by theta band hyperconnectivity in delirious patients. Source and network analyses yielded that these changes are not specific to single intrinsic connectivity networks but affect multiple nodes of networks engaged in level of consciousness, attention, working memory, executive control, and salience detection. Effect sizes were medium to strong in this mixed population of delirious patients. Conclusions We quantified effect sizes for EEG connectivity and network analyses to be expected in delirium. This study implicates that theta band hyperconnectivity and alpha band disconnectivity may be essential mechanisms in the pathophysiology of delirium. Upcoming prospective studies will build upon these results and evaluate the clinical utility of identified EEG measures as therapeutic and prognostic biomarkers. Electronic supplementary material The online version of this article (10.1186/s40814-018-0388-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert Fleischmann
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany.,2Department of Neurology, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Steffi Traenkner
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Antje Kraft
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Sein Schmidt
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Stephan J Schreiber
- 3Department of Neurology, Asklepios Fachklinikum Brandenburg, 14772 Brandenburg an der Havel, Brandenburg Germany
| | - Stephan A Brandt
- 1Vision and Motor System Research Group, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
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Sleigh J, Sanders RW. Slow waves, cognitive disintegration, and delirium. Br J Anaesth 2018; 122:9-11. [PMID: 30579412 DOI: 10.1016/j.bja.2018.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- J Sleigh
- Department of Anaesthesia, Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand.
| | - R W Sanders
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
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van Montfort SJT, Numan T, van Dellen E, Kyeong S, Douw L, Kim JJ. Delirium is not associated with altered hub flexibility of the posterior cingulate cortex. Clin Neurophysiol 2018; 129:2541-2543. [PMID: 30384024 DOI: 10.1016/j.clinph.2018.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 11/15/2022]
Affiliation(s)
- S J T van Montfort
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, HP F.06.149, Postbus 85500, 3508 GA Utrecht, The Netherlands.
| | - T Numan
- Department of Anatomy and Neurosciences, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - E van Dellen
- Department of Psychiatry and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands; Melbourne Neuropsychiatry Center, Department of Psychiatry, University of Melbourne, Australia
| | - S Kyeong
- Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - L Douw
- Department of Anatomy and Neurosciences, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - J J Kim
- Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 135-720, Republic of Korea.
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