Depressive Symptoms Before, During, and After Delirium: A Literature Review

The possible role of gut microbiota dysbiosis in the pathophysiology of delirium in older persons

Delirium is a clinical syndrome characterized by an acute change in attention, awareness and cognition with fluctuating course, frequently observed in older patients during hospitalization for acute medical illness or after surgery. Its pathogenesis is multifactorial and still not completely understood, but there is general consensus on the fact that it results from the interaction between an underlying predisposition, such as neurodegenerative diseases, and an acute stressor acting as a trigger, such as infection or anesthesia. Alterations in brain insulin sensitivity and metabolic function, increased blood-brain barrier permeability, neurotransmitter imbalances, abnormal microglial activation and neuroinflammation have all been involved in the pathophysiology of delirium. Interestingly, all these mechanisms can be regulated by the gut microbiota, as demonstrated in experimental studies investigating the microbiota-gut-brain axis in dementia. Aging is also associated with profound changes in gut microbiota composition and functions, which can influence several aspects of disease pathophysiology in the host. This review provides an overview of the emerging evidence linking age-related gut microbiota dysbiosis with delirium, opening new perspectives for the microbiota as a possible target of interventions aimed at delirium prevention and treatment.

Delirium-related psychiatric and neurocognitive impairment and the association with post-intensive care syndrome-A narrative review

INTRODUCTION

Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest. These new-onset or worsening conditions, together with physical alterations, are called post-intensive care syndrome (PICS). Our aim is to update on the latest screening and follow-up options for psychological and cognitive sequelae of PICS.

METHOD

This narrative review discusses the occurrence of delirium in ICU settings and the relatively new concept of PICS. Psychiatric and neurocognitive morbidities that may occur in survivors of critical illness following delirium are addressed. Future perspectives for practice and research are discussed.

RESULTS

There is no "gold standard" for diagnosing delirium in the ICU, but two extensively validated tools, the confusion assessment method for the ICU and the intensive care delirium screening checklist, are often used. PICS complaints are frequent in ICU survivors who have suffered delirium and have been recognized as an important public health and socio-economic problem worldwide. Depression, anxiety, post-traumatic stress disorder, and long-term cognitive impairment are recurrently exhibited. Screening tools for these deficits are discussed, as well as the suggestion of early assessment after discharge and at 3 and 12 months.

CONCLUSIONS

Delirium is a complex but common phenomenon in the ICU and a risk factor for PICS. Its diagnosis is challenging with potential long-term adverse outcomes, including psychiatric and cognitive difficulties. The implementation of screening and follow-up protocols for PICS sequelae is warranted to ensure early detection and appropriate management.

Delirium and Its Pharmacological Causes in Older People, Part 1

Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. This article will review the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people, with a focus on the pharmacological causes.

Risk factors for postoperative delirium after spinal surgery: a systematic review and meta-analysis

BACKGROUND

Postoperative delirium is common in older patients after spinal surgery. Many reports investigating the risk factors for delirium after spinal surgery have been published recently.

METHODS

A literature search was performed using the Cochrane Library, Web of Science, PubMed, Embase, and Springer databases from inception to February 2019. Relevant studies involving patients with delirium who underwent spinal surgery were included if the studies contained data about blood transfusion or other related factors, such as haemoglobin, haematocrit, and blood loss levels. The Newcastle-Ottawa Scale was used for the study-quality evaluation. The pooled odds ratios or (standard) mean differences of the individual risk factors were estimated using the Mantel-Haenszel or inverse-variance methods.

RESULTS

Fifteen observational studies met the inclusion criteria; the studies included a total of 583,290 patients (5431 patients with delirium and 577,859 patients without delirium). In addition to an advanced age, the results of the meta-analyses showed that living in an institution, diabetes, cerebral vascular diseases, pulmonary diseases, opioid use, length of surgery, intraoperative blood loss, blood transfusions, intraoperative infusion, preoperative albumin, postoperative albumin, preoperative haematocrit, postoperative haematocrit, preoperative haemoglobin, postoperative haemoglobin, preoperative sodium, postoperative sodium, Mini-Mental State Examination score, inability to ambulate, depression, number of medications, and treatment with multiple drugs (> three types) were significantly associated with delirium.

CONCLUSION

The above-mentioned risk factors can be used to identify high-risk patients, and the appropriate prophylaxis strategies should be implemented to prevent delirium after spinal surgery.

Delirium Post-Stroke: Short- and Long-Term Effect on Depression, Anxiety, Apathy and Aggression (Research Study-Part of PROPOLIS Study)

Background: Stroke patients are particularly vulnerable to delirium episodes, but very little is known about its subsequent adverse mental health outcomes. The author’s objective was to explore the association between in-hospital delirium and depression, anxiety, anger and apathy after stroke. Methods: A total of 750 consecutive patients with acute stroke or transient ischemic attack, were screened for delirium during hospitalization. Patients underwent mental health evaluation in hospital, 3 and 12 months post-stroke; depression, apathy, anxiety and anger were the outcomes measured at all evaluation check points. Results: Delirium was an independent risk factor for depression (OR = 2.28, 95%CI 1.15–4.51, p = 0.017) and aggression (OR = 3.39, 95%CI 1.48–7.73, p = 0.004) at the hospital, for anxiety 3 months post-stroke (OR = 2.83, 95%CI 1.25–6.39, p = 0.012), and for apathy at the hospital (OR = 4.82, 95%CI 2.25–10.47, p < 0.001), after 3 (OR = 3.84, 95%CI 1.31–11.21, p = 0.014) and 12 months (OR = 4.95, 95%CI 1.68–14.54, p = 0.004) post stroke. Conclusions: The results of this study confirm, that mental health problems are very frequent complications of stroke. Delirium in the acute phase of stroke influences mental health of patients. This effect is especially significant in the first months post-stroke and vanishes with time, which suggests that in-hospital delirium might not be a damaging occurrence in most measures of mental health problems from a long-term perspective.

Depression Predicts Delirium After Coronary Artery Bypass Graft Surgery Independent of Cognitive Impairment and Cerebrovascular Disease: An Analysis of the Neuropsychiatric Outcomes After Heart Surgery Study

OBJECTIVE

Although depression is a known risk factor for delirium after coronary artery bypass graft (CABG) surgery, it is unclear whether this risk is independent of delirium risk attributable to cognitive impairment or cerebrovascular disease. This study examines depression, mild cognitive impairment (MCI), and cerebrovascular disease as post-CABG delirium risk factors.

METHODS

This prospective observational cohort study was performed in a tertiary-care academic hospital. Subjects were without dementia and undergoing CABG surgery. Preoperative cognitive assessment included Clinical Dementia Rating and neuropsychological battery; depression was assessed using Depression Interview and Structured Hamilton. Baseline intracranial stenosis was evaluated by transcranial Doppler of bilateral middle cerebral arteries (MCAs). Study psychiatrists assessed delirium on postoperative days 2-5 using the Confusion Assessment Method.

RESULTS

Our analytic sample comprised 131 subjects (average age: 65.8 ± 9.2years, 27% women). MCI prevalence was 24%, preoperative depression 10%, lifetime depression 35%, and MCA stenosis (≥50%) 28%. Sixteen percent developed delirium. Multivariate analysis revealed that age, MCI (odds ratio [OR]: 5.1; 95% confidence interval [CI]: 1.3-20.1), and preoperative depression (OR: 9.9; 95% CI: 1.3-77.9)-but not lifetime depression-predicted delirium. MCA stenosis and severity predicted delirium in univariate but not multivariate analysis. Right MCA stenosis severity predicted delirium severity, but left-sided stenosis severity did not.

CONCLUSION

We established that the risk of delirium attributable to depression extends beyond the potential moderating influence of cognitive impairment and cerebrovascular disease alone. Even mild depression and cognitive impairment before CABG deserve recognition for their effect on post-CABG cognitive health.

Delirium post-stroke: short- to long-term effect on anxiety and depression compared to effect on cognition

Background Delirium is common after stroke and has significant negative impact on mortality, morbidity, cognitive function, and institutionalization. Despite these known effects, any impact of delirium on the emotional well-being of stroke survivors is unclear. Methods A post hoc analysis was performed on our prospective cohort study of 156 stroke patients. Hospital Anxiety and Depression (HAD) scale scores were compared between patients with delirium and patients without delirium at 1-month, 6-month, and 12-month post-stroke. Results Contrary to the negative impact of delirium on cognition and functional status, we did not discern any influence on HAD scale scores in the short to long term. The median scores of the HAD anxiety scale were 4 (interquartile range IQR 3) at 1 month, 5.5 (IQR 8.75) at 6 months, and 6 (IQR 5) at 12 months in the delirium group compared to 5 (IQR 7) at 1 month (p = 0.6), 4 (IQR 7) at 6 months (p = 0.4), and 6 (IQR 5.75) at 12 months (p = 0.9) in the non-delirium group, respectively. Similarly, the median scores of the HAD depression scale were 5 (IQR 4) at 1 month, 4 (IQR 6.5) at 6 months, and 3 (IQR 6) at 12 months in the delirium group compared to 6 (IQR 5.75) at 1 month (p = 0.9), 5 (IQR 7) at 6 months (p = 0.9), and 6 (IQR 5) at 12 months (p = 0.5) in the non-delirium group. Conclusion Delirium may not have a significant effect on the development of anxiety or depression after stroke which differs in its effect on cognitive function and functional status.

Psychiatric symptomatology after delirium: a systematic review

Delirium is an acute and usually transient severe neuropsychiatric syndrome associated with significant long-term physical morbidity. However, its chronic psychiatric sequelae remain poorly characterized. To investigate the prevalence of psychiatric symptoms, namely anxiety, depressive, and post-traumatic stress disorder (PTSD) symptoms after delirium, a systematic literature search of MEDLINE, EMBASE and PsycINFO databases was performed independently by two authors in March 2016. Bibliographies were hand-searched, and a forward- and backward-citation search using Web of Science was performed for all included studies. Of 6411 titles, we included eight prospective cohort studies, including 370 patients with delirium and 1073 without delirium. Studies were heterogeneous and mostly included older people from a range of clinical groups. Consideration of confounders was variable. The prevalence of depressive symptoms was almost three times higher in patients with delirium than in patients without delirium (22.2% vs 8.0%, risk ratio = 2.79; 95% confidence interval = 1.36-5.73). There was no statistically significant difference between the prevalence of anxiety symptoms between patients with and without delirium. The prevalence of PTSD symptoms after delirium was inconclusive: only one study investigated this and no association between PTSD symptoms after delirium was reported. There is limited published evidence of the prevalence of psychiatric symptoms after non-ICU delirium and the strongest evidence is for depressive symptoms. Further longitudinal studies are warranted to investigate the prevalence of anxiety and PTSD symptoms.

Pre-stroke apathy symptoms are associated with an increased risk of delirium in stroke patients

Neuropsychiatric symptoms can be interrelated to delirium. We aimed to investigate an association between pre-stroke neuropsychiatric symptoms and the risk of delirium in stroke patients. We included 606 patients (median age: 73, 53% female) with stroke or transient ischemic attack admitted within 48 hours from symptoms onset. We assessed delirium on a daily basis during the first 7 days of hospitalization. To make diagnosis of delirium we used DSM-5 criteria. We used Neuropsychiatric Inventory to assess neuropsychiatric symptoms occurring within 4 weeks prior to stroke. We diagnosed delirium in 28.2% of patients. On univariate analysis, higher score of pre-stroke depression (OR: 1.58, 95% CI: 1.04-2.40, P = 0.03), apathy (OR: 2.23, 95% CI: 1.44-3.45, P < 0.01), delusions (OR: 2.00, 95% CI: 1.09-3.68, P = 0.03), hallucinations (OR: 2.39, 95% CI: 1.19-4.81, P = 0.01) and disinhibition (OR: 2.10, 95% CI: 1.04-4.25, P = 0.04) was associated with the increased risk of delirium. On multivariate analysis adjusted for age, atrial fibrillation, diabetes mellitus, stroke severity, right hemisphere lesion, pre-stroke cognitive decline, pre-stroke disability and infections, higher apathy score (OR: 2.03, 95% CI: 1.17-3.50, P = 0.01), but no other neuropsychiatric symptoms, remained independent predictor of delirium. We conclude that pre-stroke apathy symptoms are associated with increased risk of delirium in stroke patients.

Meeting Its Mission: Does Psychosomatics Align With the Mission of Its Parent Organization, the Academy of Psychosomatic Medicine?

BACKGROUND

The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education.

OBJECTIVE

As the APM owns the journal, Psychosomatics, we sought to assess whether the APM's journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence.

METHODS

We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered.

RESULTS

In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often.

CONCLUSIONS

Psychosomatics appears to be successfully providing content relevant to the APM's vision and mission statements and to practitioners of psychosomatic medicine.