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Bruzzone MJ, Chapin B, Walker J, Santana M, Wang Y, Amini S, Kimmet F, Perera E, Rubinos C, Arias F, Price C. Electroencephalographic Measures of Delirium in the Perioperative Setting: A Systematic Review. Anesth Analg 2024:00000539-990000000-00887. [PMID: 39088366 DOI: 10.1213/ane.0000000000007079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
Postoperative delirium (POD) is frequent in older adults and is associated with adverse cognitive and functional outcomes. In the last several decades, there has been an increased interest in exploring tools that easily allow the early recognition of patients at risk of developing POD. The electroencephalogram (EEG) is a widely available tool used to understand delirium pathophysiology, and its use in the perioperative setting has grown exponentially, particularly to predict and detect POD. We performed a systematic review to investigate the use of EEG in the pre-, intra-, and postoperative settings. We identified 371 studies, and 56 met the inclusion criteria. A range of techniques was used to obtain EEG data, from limited 1-4 channel setups to complex 256-channel systems. Power spectra were often measured preoperatively, yet the outcomes were inconsistent. During surgery, the emphasis was primarily on burst suppression (BS) metrics and power spectra, with a link between the frequency and timing of BS, and POD. The EEG patterns observed in POD aligned with those noted in delirium in different contexts, suggesting a reduction in EEG activity. Further research is required to investigate preoperative EEG indicators that may predict susceptibility to delirium.
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Affiliation(s)
- Maria J Bruzzone
- From the Department of Neurology, University of Florida, Gainesville, Florida
| | - Benjamin Chapin
- Department of Anesthesia, University of Florida, Gainesville, Florida
| | - Jessie Walker
- From the Department of Neurology, University of Florida, Gainesville, Florida
| | - Marcos Santana
- From the Department of Neurology, University of Florida, Gainesville, Florida
| | - Yue Wang
- From the Department of Neurology, University of Florida, Gainesville, Florida
| | - Shawna Amini
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Faith Kimmet
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Estefania Perera
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Clio Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
| | - Franchesca Arias
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Catherine Price
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
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Wang W, Zhang Y, Yao W, Tang W, Li Y, Sun H, Ding W. Association between preoperative persistent hyperglycemia and postoperative delirium in geriatric hip fracture patients. BMC Geriatr 2024; 24:585. [PMID: 38977983 PMCID: PMC11232206 DOI: 10.1186/s12877-024-05192-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND The management of preoperative blood glucose levels in reducing the incidence of postoperative delirium (POD) remains controversial. This study aims to investigate the impact of preoperative persistent hyperglycemia on POD in geriatric patients with hip fractures. METHODS This retrospective cohort study analyzed medical records of patients who underwent hip fracture surgery at a tertiary medical institution between January 2013 and November 2023. Patients were categorized based on preoperative hyperglycemia (hyperglycemia defined as ≥ 6.1mmol/L), clinical classification of hyperglycemia, and percentile thresholds. Multivariate logistic regression and propensity score matching analysis (PSM) were employed to assess the association between different levels of preoperative glucose and POD. Subgroup analysis was conducted to explore potential interactions. RESULTS A total of 1440 patients were included in this study, with an incidence rate of POD at 19.1% (275/1440). Utilizing multiple logistic analysis, we found that patients with hyperglycemia had a 1.65-fold increased risk of experiencing POD compared to those with normal preoperative glucose levels (95% CI: 1.17-2.32). Moreover, a significant upward trend was discerned in both the strength of association and the predicted probability of POD with higher preoperative glucose levels. PSM did not alter this trend, even after meticulous adjustments for potential confounding factors. Additionally, when treating preoperative glucose levels as a continuous variable, we observed a 6% increase in the risk of POD (95% CI: 1-12%) with each 1mmol/L elevation in preoperative glucose levels. CONCLUSIONS There exists a clear linear dose-response relationship between preoperative blood glucose levels and the risk of POD. Higher preoperative hyperglycemia was associated with a greater risk of POD. CLINICAL TRIAL NUMBER NCT06473324.
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Affiliation(s)
- Wei Wang
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China
| | - Yingqi Zhang
- School of Clinical Medicine, Dalian Medical University, Dalian, China
| | - Wei Yao
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China
| | - Wanyun Tang
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China
| | - Yuhao Li
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China
| | - Hongbo Sun
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China.
- Dandong Central Hospital, China Medical University, No. 338 Jinshan Street, Zhenxing District, Dandong, Liaoning Province, 118002, P.R. China.
| | - Wenbo Ding
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China.
- Dandong Central Hospital, China Medical University, No. 338 Jinshan Street, Zhenxing District, Dandong, Liaoning Province, 118002, P.R. China.
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Titlestad I, Watne LO, Caplan GA, McCann A, Ueland PM, Neerland BE, Myrstad M, Halaas NB, Pollmann CT, Henjum K, Ranhoff AH, Solberg LB, Figved W, Cunningham C, Giil LM. Impaired glucose utilization in the brain of patients with delirium following hip fracture. Brain 2024; 147:215-223. [PMID: 37658825 PMCID: PMC10766236 DOI: 10.1093/brain/awad296] [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: 11/26/2022] [Revised: 07/08/2023] [Accepted: 08/08/2023] [Indexed: 09/05/2023] Open
Abstract
Alterations in brain energy metabolism have long been proposed as one of several neurobiological processes contributing to delirium. This is supported by previous findings of altered CSF lactate and neuron-specific enolase concentrations and decreased glucose uptake on brain-PET in patients with delirium. Despite this, there are limited data on metabolic alterations found in CSF samples, and targeted metabolic profiling of CSF metabolites involved in energy metabolism has not been performed. The aim of the study was to investigate whether metabolites related to energy metabolism in the serum and CSF of patients with hip fracture are associated with delirium. The study cohort included 406 patients with a mean age of 81 years (standard deviation 10 years), acutely admitted to hospital for surgical repair of a hip fracture. Delirium was assessed daily until the fifth postoperative day. CSF was collected from all 406 participants at the onset of spinal anaesthesia, and serum samples were drawn concurrently from 213 participants. Glucose and lactate in CSF were measured using amperometry, whereas plasma glucose was measured in the clinical laboratory using enzymatic photometry. Serum and CSF concentrations of the branched-chain amino acids, 3-hydroxyisobutyric acid, acetoacetate and β-hydroxybutyrate were measured using gas chromatography-tandem mass spectrometry (GC-MS/MS). In total, 224 (55%) patients developed delirium pre- or postoperatively. Ketone body concentrations (acetoacetate, β-hydroxybutyrate) and branched-chain amino acids were significantly elevated in the CSF but not in serum among patients with delirium, despite no group differences in glucose concentrations. The level of 3-hydroxyisobutyric acid was significantly elevated in both CSF and serum. An elevation of CSF lactate during delirium was explained by age and comorbidity. Our data suggest that altered glucose utilization and a shift to ketone body metabolism occurs in the brain during delirium.
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Affiliation(s)
- Irit Titlestad
- Department of Clinical Medicine, University of Bergen, 5020 Bergen, Norway
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, 5009 Bergen, Norway
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
- Department of Geriatric Medicine, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, 2031 Sydney, Australia
- Prince of Wales Clinical School, University of New South Wales, 2031 Sydney, Australia
| | | | | | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Marius Myrstad
- Department of Internal Medicine, Bærum Hospital Vestre Viken Hospital Trust, 1346 Gjettum, Norway
| | - Nathalie Bodd Halaas
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | | | - Kristi Henjum
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | - Anette Hylen Ranhoff
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway
- Geriatric Unit, Clinic of Medicine, Diakonhjemmet Hospital, 0319 Oslo, Norway
| | - Lene B Solberg
- Division of Orthopaedic Surgery, Oslo University Hospital, 0424 Oslo, Norway
| | - Wender Figved
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
- Orthopaedic Department, Bærum Hospital, Vestre Viken Hospital Trust, 1349 Gjettum, Norway
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute and Trinity College Institute of Neuroscience, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Lasse M Giil
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, 5009 Bergen, Norway
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway
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Shpakov AO, Zorina II, Derkach KV. Hot Spots for the Use of Intranasal Insulin: Cerebral Ischemia, Brain Injury, Diabetes Mellitus, Endocrine Disorders and Postoperative Delirium. Int J Mol Sci 2023; 24:3278. [PMID: 36834685 PMCID: PMC9962062 DOI: 10.3390/ijms24043278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
A decrease in the activity of the insulin signaling system of the brain, due to both central insulin resistance and insulin deficiency, leads to neurodegeneration and impaired regulation of appetite, metabolism, endocrine functions. This is due to the neuroprotective properties of brain insulin and its leading role in maintaining glucose homeostasis in the brain, as well as in the regulation of the brain signaling network responsible for the functioning of the nervous, endocrine, and other systems. One of the approaches to restore the activity of the insulin system of the brain is the use of intranasally administered insulin (INI). Currently, INI is being considered as a promising drug to treat Alzheimer's disease and mild cognitive impairment. The clinical application of INI is being developed for the treatment of other neurodegenerative diseases and improve cognitive abilities in stress, overwork, and depression. At the same time, much attention has recently been paid to the prospects of using INI for the treatment of cerebral ischemia, traumatic brain injuries, and postoperative delirium (after anesthesia), as well as diabetes mellitus and its complications, including dysfunctions in the gonadal and thyroid axes. This review is devoted to the prospects and current trends in the use of INI for the treatment of these diseases, which, although differing in etiology and pathogenesis, are characterized by impaired insulin signaling in the brain.
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Affiliation(s)
- Alexander O. Shpakov
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, 194223 St. Petersburg, Russia
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Nitchingham A, Pereira JVB, Wegner EA, Oxenham V, Close J, Caplan GA. Regional cerebral hypometabolism on 18F-FDG PET/CT scan in delirium is independent of acute illness and dementia. Alzheimers Dement 2023; 19:97-106. [PMID: 35289980 PMCID: PMC10078760 DOI: 10.1002/alz.12604] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 12/24/2021] [Accepted: 12/27/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Delirium is associated with new onset dementia and accelerated cognitive decline; however, its pathophysiology remains unknown. Cerebral glucose metabolism previously seen in delirium may have been attributable to acute illness and/or dementia. We aimed to statistically map cerebral glucose metabolism attributable to delirium. METHODS We assessed cerebral glucose metabolism using 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET) in sick, older patients with and without delirium, all without clinical dementia (N = 20). Strict exclusion criteria were adopted to minimize the effect of established confounders on FDG-PET. RESULTS Patients with delirium demonstrated hypometabolism in the bilateral thalami and right superior frontal, right posterior cingulate, right infero-lateral anterior temporal, and left superior parietal cortices. Regional hypometabolism correlated with delirium severity and performance on neuropsychological testing. DISCUSSION In patients with acute illness but without clinical dementia, delirium is accompanied by regional cerebral hypometabolism. While some hypometabolic regions may represent preclinical Alzheimer's disease (AD), thalamic hypometabolism is atypical of AD and consistent with the clinical features that are unique to delirium.
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Affiliation(s)
- Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | | | - Eva A Wegner
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.,Department of Nuclear Medicine and PET, Prince of Wales Hospital, Sydney, Australia
| | - Vincent Oxenham
- Department of Psychology, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Neurology, Royal North Shore Hospital, Sydney, Australia
| | - Jacqueline Close
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.,Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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Alexander SK, Needham E. Diagnosis of delirium: a practical approach. Pract Neurol 2022; 23:192-199. [PMID: 36581459 DOI: 10.1136/pn-2022-003373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/31/2022]
Abstract
Delirium is an acute disorder of fluctuating attention and awareness with cardinal features that allow it to be positively distinguished from other causes of an acute confusional state. These features include fluctuations, prominent inattentiveness with other cognitive deficits, a change in awareness and visual hallucinations. We describe a framework for diagnosing delirium, noting the need to consider certain caveats and differential diagnoses. Delirium is a clinical diagnosis where a thorough history and clinical examination are much more helpful diagnostically than any single test or combination of tests.
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Affiliation(s)
- Sian K Alexander
- Department of Neurology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Edward Needham
- Department of Neurology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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7
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Denk A, Müller K, Schlosser S, Heissner K, Gülow K, Müller M, Schmid S. Liver diseases as a novel risk factor for delirium in the ICU-Delirium and hepatic encephalopathy are two distinct entities. PLoS One 2022; 17:e0276914. [PMID: 36413529 PMCID: PMC9681112 DOI: 10.1371/journal.pone.0276914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Delirium prevalence is high in critical care settings. We examined the incidence, risk factors, and outcome of delirium in a medical intensive care unit (MICU) with a particular focus on liver diseases. We analyzed this patient population in terms of delirium risk prediction and differentiation between delirium and hepatic encephalopathy. METHODS We conducted an observational study and included 164 consecutive patients admitted to an MICU of a university hospital. Patients were assessed for delirium using the Confusion Assessment Method for ICUs and the Richmond Agitation-Sedation Scale (RASS). On admission and at the onset of delirium Sequential Organ Failure Assessment (SOFA) score was determined. A population of patients with liver disease was compared to a population with gastrointestinal diseases. In the population with liver diseases, hepatic encephalopathy was graded according to the West Haven classification. We analyzed the incidence, subtype, predisposing, precipitating, and health-care setting-related factors, treatment, outcome of delirium and the association between delirium and hepatic encephalopathy in patients with liver diseases. RESULTS The incidence of delirium was 32.5% (n = 53). Univariable binary regression analyses adjusted by the Holm-Bonferroni method showed that the development of delirium was significantly determined by 10 risk factors: Alcohol abuse (p = 0.016), severity of disease (Simplified Acute Physiology Score (SAPS) II, p = 0.016), liver diseases (p = 0.030) and sepsis (p = 0.016) compared to the control group (gastrointestinal (GI) diseases and others), increased sodium (p = 0.016), creatinine (p = 0.030), urea (p = 0.032) or bilirubin (p = 0.042), decreased hemoglobin (p = 0.016), and mechanical ventilation (p = 0.016). Of note, we identified liver diseases as a novel and relevant risk factor for delirium. Hepatic encephalopathy was not a risk factor for delirium. Delirium and hepatic encephalopathy are both life-threatening but clearly distinct conditions. The median SOFA score for patients with delirium at delirium onset was significantly higher than the SOFA score of all patients at admission (p = 0.008). Patients with delirium had five times longer ICU stays (p = 0.004) and three times higher in-hospital mortality (p = 0.036). Patients with delirium were five times more likely to be transferred to an intensive medical rehabilitation unit for post-intensive care (p = 0.020). Treatment costs per case were more than five times higher in patients with delirium than in patients without delirium (p = 0.004). CONCLUSIONS The 10 risk factors identified in this study should be assessed upon admission to ICU for effective detection, prevention, and treatment of delirium. Liver diseases are a novel risk factor for delirium with a level of significance comparable to sepsis as an established risk factor. Of note, in patients with liver diseases delirium and hepatic encephalopathy should be recognized as distinct entities to initiate appropriate treatment. Therefore, we propose a new algorithm for efficient diagnosis, characterization, and treatment of altered mental status in the ICU. This algorithm integrates the 10 risk factor prediction-model for delirium and prompts grading of the severity of hepatic encephalopathy using the West Haven classification if liver disease is present or newly diagnosed.
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Affiliation(s)
- Alexander Denk
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karolina Müller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Sophie Schlosser
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Klaus Heissner
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Karsten Gülow
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious diseases, University Hospital Regensburg, Regensburg, Germany
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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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Whitby J, Nitchingham A, Caplan G, Davis D, Tsui A. Persistent delirium in older hospital patients: an updated systematic review and meta-analysis. DELIRIUM (BIELEFELD, GERMANY) 2022; 1:36822. [PMID: 36936539 PMCID: PMC7614331 DOI: 10.56392/001c.36822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Introduction Delirium is associated with future dementia progression. Yet whether this occurs subclinically over months and years, or persistent delirium merges into worsened dementia is not understood. Our objective was to estimate the prevalence of persistent delirium and understand variation in its duration. Methods We adopted an identical search strategy to a previous systematic review, only including studies using a recognised diagnostic framework for ascertaining delirium at follow-up (persistent delirium). Studies included hospitalised older patients outside critical and palliative care settings. We searched MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews on 11th January 2022. We applied risk of bias assessments based on Standards of Reporting of Neurological Disorders criteria and assessed strength of recommendations using the grading of recommendation, assessment, development and evaluation (GRADE) approach. Estimates were pooled across studies using random-effects meta-analysis, and we estimated associations with follow-up duration using robust error meta-regression. Results We identified 13 new cohorts, which we added to 10 from the previous systematic review (23 relevant studies, with 39 reports of persistent delirium at 7 time-points in 3186 individuals admitted to hospital care (mean age 82 years and 41% dementia prevalence). Studies were mainly at moderate risk of bias. Pooled delirium prevalence estimates at discharge were 36% (95% CI 22% to 51%, 13 studies). Robust error meta-regression did not show variation in prevalence of persistent delirium over time (-1.6% per month, 95% CI -4.8 to 1.6, p=0.08). Margins estimates for this model indicate a prevalence of persistent delirium of 16% (95% CI 6% to 25%) at 12 months. Conclusions This systematic review emphasises the importance of delirium as a persistent and extensive problem (GRADE certainty = moderate), raising questions on chronic delirium as a clinical entity and how it might evolve into dementia. Addressing persistent delirium will require a whole-system, integrated approach to detect, follow-up and implement opportunities for recovery across all healthcare settings.
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Affiliation(s)
- Jonathan Whitby
- MRC Unit for Lifelong Health and Ageing, University College London
| | | | - Gideon Caplan
- The Prince of Wales Clinical School, University of New South Wales
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London
| | - Alex Tsui
- MRC Unit for Lifelong Health and Ageing, University College London
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Song Q, Dai M, Zhao Y, Lin T, Huang L, Yue J. Association between stress hyperglycemia ratio and delirium in older hospitalized patients: a cohort study. BMC Geriatr 2022; 22:277. [PMID: 35369877 PMCID: PMC8978391 DOI: 10.1186/s12877-022-02935-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/10/2022] [Indexed: 02/08/2023] Open
Abstract
Background It remains unclear whether stress hyperglycemia is associated with delirium. We performed this cohort study to determine the association between stress hyperglycemia and delirium. Methods We consecutively enrolled patients aged ≥70 years who were admitted to the Geriatric Department of West China Hospital between March 2016 and July 2017. Stress hyperglycemia ratio (SHR) was calculated as fasting blood glucose divided by estimated average glucose derived from glycosylated hemoglobin (HbA1c) and was classified into three tertiles. Delirium was screened within 24 h of admission and three times daily thereafter, using the confusion assessment method. The Cox proportional hazards models were used to assess the association of SHR with delirium. Results Among 487 included patients (mean age 83.0 years, 72.0% male), 50 (10.3%) patients experienced delirium during hospitalization. Compared to the second tertile, both the lowest and the highest SHR tertiles were independently associated with delirium (hazard ratio [HR] 3.71, 95% confidence interval [CI] 1.45-9.51; and HR 2.97, 95% CI 1.29-6.81, respectively). Similar results were found after further adjusting for statin comedication. Multiple-adjusted restricted cubic splines revealed a nonlinear relationship between SHR and delirium (Pnonlinearity=0.04). Adding SHR to conventional risk factors improved the risk prediction of delirium (net reclassification index 0.39, P=0.01; integrated discrimination improvement 0.07, P=0.03). Subgroup analyses indicated that the relationship between SHR and delirium was more apparent in patients with HbA1c <6.5%, with significantly higher HR in the first (3.65, 95% CI 1.11-11.97) and third (3.13, 95% CI 1.13-8.72) SHR tertiles compared to the second tertile, while there was no significant association between SHR and delirium in those with HbA1c ≥6.5%. Conclusions Both lower and higher SHR were associated with increased risk of delirium but only in patients with HbA1c <6.5%. Admission SHR may serve as a promising predictor of delirium, and incorporating this biomarker into prediction algorithms might have potential clinical utility in aiding delirium risk stratification, especially in those with HbA1c <6.5%. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-02935-6.
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Affiliation(s)
- Quhong Song
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Miao Dai
- Jiujiang First People's Hospital, Jiujiang, China
| | - Yanli Zhao
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Taiping Lin
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Li Huang
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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11
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Taylor J, Parker M, Casey CP, Tanabe S, Kunkel D, Rivera C, Zetterberg H, Blennow K, Pearce RA, Lennertz RC, Sanders RD. Postoperative delirium and changes in the blood-brain barrier, neuroinflammation, and cerebrospinal fluid lactate: a prospective cohort study. Br J Anaesth 2022; 129:219-230. [PMID: 35144802 PMCID: PMC9465948 DOI: 10.1016/j.bja.2022.01.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/28/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Case-control studies have associated delirium with blood-brain barrier (BBB) permeability. However, this approach cannot determine whether delirium is attributable to high pre-existing permeability or to perioperative changes. We tested whether perioperative changes in cerebrospinal fluid/plasma albumin ratio (CPAR) and plasma S100B were associated with delirium severity. METHODS Participants were recruited to two prospective cohort studies of non-intracranial surgery (NCT01980511, NCT03124303, and NCT02926417). Delirium severity was assessed using the Delirium Rating Scale-98. Delirium incidence was diagnosed with the 3D-Confusion Assessment Method (3D-CAM) or CAM-ICU (CAM for the ICU). CSF samples from 25 patients and plasma from 78 patients were analysed for albumin and S100B. We tested associations between change in CPAR (n=11) and S100B (n=61) and delirium, blood loss, CSF interleukin-6 (IL-6), and CSF lactate. RESULTS The perioperative increase in CPAR and S100B correlated with delirium severity (CPAR ρ=0.78, P=0.01; S100B ρ=0.41, P<0.001), delirium incidence (CPAR P=0.012; S100B P<0.001) and CSF IL-6 (CPAR ρ=0.66 P=0.04; S100B ρ=0.75, P=0.025). Linear mixed-effect analysis also showed that decreased levels of S100B predicted recovery from delirium symptoms (P=0.001). Linear regression demonstrated that change in plasma S100B was independently associated with surgical risk, cardiovascular surgery, blood loss, and hypotension. Blood loss also correlated with CPAR (ρ=0.64, P=0.04), S100B (ρ=0.70, P<0.001), CSF lactate (R=0.81, P=0.01), and peak delirium severity (ρ=0.36, P=0.01). CONCLUSION Postoperative delirium is associated with a breakdown in the BBB. This increased permeability is dynamic and associated with a neuroinflammatory and lactate response. Strategies to mitigate blood loss may protect the BBB.
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Affiliation(s)
- Jennifer Taylor
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Margaret Parker
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Cameron P Casey
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sean Tanabe
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - David Kunkel
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Cameron Rivera
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK; UK Dementia Research Institute at UCL, London, UK; Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Robert A Pearce
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Richard C Lennertz
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Robert D Sanders
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia.
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12
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Nitchingham A, Milne A, Toson B, Tuch B, Agar M, Close J, Caplan G. Intranasal insulin for treatment of delirium in older hospitalised patients: study protocol for a randomised controlled trial. BMJ Open 2021; 11:e050765. [PMID: 34667006 PMCID: PMC8527126 DOI: 10.1136/bmjopen-2021-050765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Delirium is one of the most common conditions diagnosed in hospitalised older people and is associated with numerous adverse outcomes, yet there are no proven pharmacological treatments. Recent research has identified cerebral glucose hypometabolism as a pathophysiological mechanism offering a therapeutic target in delirium. Insulin, delivered via the intranasal route, acts directly on the central nervous system and has been shown to enhance cerebral metabolism and improve cognition in patients with mild cognitive impairment and dementia. This trial will determine whether intranasal insulin can reduce the duration of delirium in older hospitalised patients. METHODS AND ANALYSIS This is a prospective randomised, placebo-controlled, double-blind study with 6 months follow-up. One hundred patients aged 65 years or older presenting to hospital with delirium admitted under geriatric medicine will be recruited. Participants will be randomised to intranasal insulin detemir or placebo administered twice daily until delirium resolves, defined as Confusion Assessment Method (CAM) negative for 2 days, or discharge from hospital. The primary outcome measure will be duration of delirium using the CAM. Secondary outcome measures will include length of hospital stay, severity of delirium, adherence to treatment, hospital complications, new admission to nursing home, mortality, use of antipsychotic medications during hospital stay and cognitive and physical function at 6 months postdischarge. ETHICS AND DISSEMINATION This trial has been approved by the South Eastern Sydney Human Research and Ethics Committee. Dissemination plans include submission to a peer-reviewed journal for publication and presentation at scientific conferences. TRIAL REGISTRATION NUMBER ACTRN12618000318280.
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Affiliation(s)
- Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Milne
- Rural Clinical School, Coffs Harbour Health Campus, University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - Barbara Toson
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, South Australia, Australia
| | - Bernard Tuch
- Department of Molecular & Translational Science, Hudson Institute, Monash University, Melbourne, Victoria, Australia
| | - Meera Agar
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jacqueline Close
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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13
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Katayama T, Sawada J, Takahashi K, Yahara O, Hasebe N. Meta-analysis of cerebrospinal fluid neuron-specific enolase levels in Alzheimer's disease, Parkinson's disease, dementia with Lewy bodies, and multiple system atrophy. Alzheimers Res Ther 2021; 13:163. [PMID: 34610837 PMCID: PMC8493707 DOI: 10.1186/s13195-021-00907-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 09/23/2021] [Indexed: 12/29/2022]
Abstract
Background This study examined the usefulness of cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels as a candidate biomarker of neurodegeneration in Alzheimer’s disease (AD), Parkinson’s disease (PD), PD with dementia (PDD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). Methods We performed a systematic search of PubMed, the Cochrane Library, Scopus, and Google Scholar to find studies that measured CSF NSE levels in AD, PD, DLB, and/or MSA. For each disease, we pooled all available data and performed a meta-analysis, and meta-regression analyses of age and sex were conducted if the main analysis found a significant association. Results Twenty studies were included (13 for AD, 8 for PD/PDD/DLB, and 4 for MSA). Significantly elevated CSF NSE levels were detected in AD (Hedges’ g = 0.822, 95% confidence interval [95% CI] 0.332 to 1.311, p = 0.0010), but the data exhibited high heterogeneity (I2 = 88.43%, p < 0.001). The meta-regression analysis of AD showed that age (p < 0.001), but not sex, had a significant effect on CSF NSE levels. A meta-analysis of the pooled data for PD/PDD/DLB did not show any significant changes in the CSF NSE level, but a sub-group analysis of PDD/DLB revealed significantly elevated CSF NSE levels (Hedges’ g = 0.507, 95% CI 0.020 to 0.993, p = 0.0412). No significant changes in CSF NSE levels were detected in MSA. Conclusions The CSF NSE level may be a useful biomarker of neurodegeneration in AD and PDD/DLB. Age was found to affect the CSF NSE levels of AD patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13195-021-00907-3.
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Affiliation(s)
- Takayuki Katayama
- Department of Neurology, Asahikawa City Hospital, 1-1-65 Kinseicho, Asahikawa, 070-8610, Japan.
| | - Jun Sawada
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Kae Takahashi
- Department of Neurology, Asahikawa City Hospital, 1-1-65 Kinseicho, Asahikawa, 070-8610, Japan
| | - Osamu Yahara
- Department of Neurology, Asahikawa City Hospital, 1-1-65 Kinseicho, Asahikawa, 070-8610, Japan
| | - Naoyuki Hasebe
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
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Shirvani F, Sedighi M, Shahzamani M. Metabolic disturbance affects postoperative cognitive function in patients undergoing cardiopulmonary bypass. Neurol Sci 2021; 43:667-672. [PMID: 33973078 DOI: 10.1007/s10072-021-05308-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/05/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Postoperative delirium is a common neuropsychiatric syndrome after coronary artery bypass grafting (CABG). We aimed to assess and compare clinical outcomes of CABG patients with delirium with a specific focus on the blood biochemical parameters. METHODS This investigation was carried out on the 90 eligible patients undergoing CABG. Delirium was measured using the Neecham confusion scale and assessed patients were divided into two groups of delirium (n = 43) and non-delirium (n = 47). Preoperative variables and intraoperative and postoperative outcomes were compared. RESULTS Delirium patients were older (p = 0.003) and had longer intubation time (p = 0.003). Non-delirium patients obtained a significantly higher Neecham confusion score (p = 0.001), and delirium patients experienced a hyperglycemic state at intraoperative (p = 0.004), intubation (p = 0.03), and extubation time (p = 0.02). Lower value of pH was seen at intubation (p = 0.03) and extubation periods (p = 0.001) in delirium group. A significant difference in base excess was observed between two groups at intubation (p = 0.04) and extubation periods (p = 0.004). Potassium level showed a significant decrease in delirium group at intubation (p = 0.01) and extubation periods (p = 0.001). Multivariate regression indicated that aging (OR = 1.08, p = 0.01), narcotic consumption (OR = 3.27, p = 0.05), DM (OR = 3.03, p=0.03), and prolonged intubation (OR = 1.18, p = 0.03) are predictors of delirium. Postoperative hyperglycemia (OR = 1.01, p = 0.002), low pH value (OR = 2.62, p = 0.02), and low potassium level (OR = 3.25, p = 0.03) are associated with development of delirium. CONCLUSIONS Postoperative metabolic disturbance and electrolyte imbalances are closely related to the development of delirium after CABG and need to be considered more carefully. Aging, DM, and preoperative use of narcotics are strong predictors of delirium following CABG.
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Affiliation(s)
- Fahimeh Shirvani
- Cardiac Intensive Care Unit, Shahid Chamran Heart Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Sedighi
- Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Mehran Shahzamani
- Department of Cardiovascular Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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15
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Bellelli G, Brathwaite JS, Mazzola P. Delirium: A Marker of Vulnerability in Older People. Front Aging Neurosci 2021; 13:626127. [PMID: 33994990 PMCID: PMC8119654 DOI: 10.3389/fnagi.2021.626127] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/06/2021] [Indexed: 12/11/2022] Open
Abstract
Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge - especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | | | - Paolo Mazzola
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
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16
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Caplan GA. Delirium Superimposed Upon Dementia. J Am Med Dir Assoc 2021; 20:1382-1383. [PMID: 31676026 DOI: 10.1016/j.jamda.2019.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Gideon A Caplan
- Prince of Wales Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia.
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17
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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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18
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Wang S, Lindroth H, Chan C, Greene R, Serrano-Andrews P, Khan S, Rios G, Jabbari S, Lim J, Saykin AJ, Khan B. A Systematic Review of Delirium Biomarkers and Their Alignment with the NIA-AA Research Framework. J Am Geriatr Soc 2020; 69:255-263. [PMID: 32975827 DOI: 10.1111/jgs.16836] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/23/2020] [Accepted: 08/24/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To identify whether delirium biomarkers aligned with the National Institute on Aging-Alzheimer's Association (NIA-AA) research framework, a conceptual model that describes the use of diagnostic biomarkers for Alzheimer's disease and other related dementias (ADRD). DESIGN Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. SETTING Acute care and outpatient settings. PARTICIPANTS Adults diagnosed with delirium. METHODS AND MEASUREMENTS MEDLINE, PsycInfo, Embase, and the Cochrane Library were searched for English-language studies published from January 2010 to February 2020. Studies included adults older than 18 years, identified delirium with a standardized assessment tool, and measured an ADRD biomarker. Independent reviewers determined whether an association between delirium and ADRD biomarker was found, the quality of biomarker data based on the REMARK (REporting recommendations for tumor MARKer prognostic studies) checklist, and the study bias based on the Newcastle-Ottawa Scale. RESULTS A total of 61,256 citations were identified; 113 studies were included. Most studies did not examine amyloid, tau, or neurodegeneration biomarkers. Delirium may be associated with neurodegeneration biomarkers, but few to no studies found an association with amyloid and tau biomarkers. Delirium was not consistently associated with inflammatory biomarkers. The quality of biomarker data was moderate, and the risk of bias was moderate to high. Studies often did not collect prehospital and posthospital cognitive data. CONCLUSION Most delirium diagnostic biomarker studies did not measure amyloid, tau, and/or neurodegenerative biomarkers, making characterization of the relationship between delirium and ADRD difficult. Future delirium biomarker diagnostic studies could improve the understanding of pathophysiologic links between delirium with other conditions affecting cognition.
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Affiliation(s)
- Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana.,Indiana Alzheimer's Disease Research Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Heidi Lindroth
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,IU Center of Aging Research, Regenstrief Institute, Indianapolis, Indiana.,Center for Health Innovation and Implementation Science, Indianapolis, Indiana
| | - Carol Chan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ryan Greene
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
| | - Patricia Serrano-Andrews
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sikandar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,IU Center of Aging Research, Regenstrief Institute, Indianapolis, Indiana.,Center for Health Innovation and Implementation Science, Indianapolis, Indiana
| | - Gabriel Rios
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shiva Jabbari
- Department of Pathology, Washington University, St. Louis, Missouri
| | | | - Andrew J Saykin
- Indiana Alzheimer's Disease Research Center, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Babar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,IU Center of Aging Research, Regenstrief Institute, Indianapolis, Indiana.,Center for Health Innovation and Implementation Science, Indianapolis, Indiana
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Fong TG, Vasunilashorn SM, Ngo L, Libermann TA, Dillon ST, Schmitt EM, Pascual-Leone A, Arnold SE, Jones RN, Marcantonio ER, Inouye SK. Association of Plasma Neurofilament Light with Postoperative Delirium. Ann Neurol 2020; 88:984-994. [PMID: 32881052 DOI: 10.1002/ana.25889] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To examine the association of the plasma neuroaxonal injury markers neurofilament light (NfL), total tau, glial fibrillary acid protein, and ubiquitin carboxyl-terminal hydrolase L1 with delirium, delirium severity, and cognitive performance. METHODS Delirium case-no delirium control (n = 108) pairs were matched by age, sex, surgery type, cognition, and vascular comorbidities. Biomarkers were measured in plasma collected preoperatively (PREOP), and 2 days (POD2) and 30 days postoperatively (PO1MO) using Simoa technology (Quanterix, Lexington, MA). The Confusion Assessment Method (CAM) and CAM-S (Severity) were used to measure delirium and delirium severity, respectively. Cognitive function was measured with General Cognitive Performance (GCP) scores. RESULTS Delirium cases had higher NfL on POD2 and PO1MO (median matched pair difference = 16.2pg/ml and 13.6pg/ml, respectively; p < 0.05). Patients with PREOP and POD2 NfL in the highest quartile (Q4) had increased risk for incident delirium (adjusted odds ratio [OR] = 3.7 [95% confidence interval (CI) = 1.1-12.6] and 4.6 [95% CI = 1.2-18.2], respectively) and experienced more severe delirium, with sum CAM-S scores 7.8 points (95% CI = 1.6-14.0) and 9.3 points higher (95% CI = 3.2-15.5). At PO1MO, delirium cases had continued high NfL (adjusted OR = 9.7, 95% CI = 2.3-41.4), and those with Q4 NfL values showed a -2.3 point decline in GCP score (-2.3 points, 95% CI = -4.7 to -0.9). INTERPRETATION Patients with the highest PREOP or POD2 NfL levels were more likely to develop delirium. Elevated NfL at PO1MO was associated with delirium and greater cognitive decline. These findings suggest NfL may be useful as a predictive biomarker for delirium risk and long-term cognitive decline, and once confirmed would provide pathophysiological evidence for neuroaxonal injury following delirium. ANN NEUROL 2020;88:984-994.
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Affiliation(s)
- Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Sarinnapha M Vasunilashorn
- Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Long Ngo
- Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Towia A Libermann
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics, and Systems Biology Center, Boston, Massachusetts, USA
| | - Simon T Dillon
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics, and Systems Biology Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA.,Guttmann Brain Health Institute, Guttmann Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Steven E Arnold
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Richard N Jones
- Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Acute Inflammation Alters Brain Energy Metabolism in Mice and Humans: Role in Suppressed Spontaneous Activity, Impaired Cognition, and Delirium. J Neurosci 2020; 40:5681-5696. [PMID: 32513828 PMCID: PMC7363463 DOI: 10.1523/jneurosci.2876-19.2020] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 01/09/2023] Open
Abstract
Systemic infection triggers a spectrum of metabolic and behavioral changes, collectively termed sickness behavior, which while adaptive, can affect mood and cognition. In vulnerable individuals, acute illness can also produce profound, maladaptive, cognitive dysfunction including delirium, but our understanding of delirium pathophysiology remains limited. Here, we used bacterial lipopolysaccharide (LPS) in female C57BL/6J mice and acute hip fracture in humans to address whether disrupted energy metabolism contributes to inflammation-induced behavioral and cognitive changes. LPS (250 µg/kg) induced hypoglycemia, which was mimicked by interleukin (IL)-1β (25 µg/kg) but not prevented in IL-1RI−/− mice, nor by IL-1 receptor antagonist (IL-1RA; 10 mg/kg). LPS suppression of locomotor activity correlated with blood glucose concentrations, was mitigated by exogenous glucose (2 g/kg), and was exacerbated by 2-deoxyglucose (2-DG) glycolytic inhibition, despite preventing IL-1β synthesis. Using the ME7 model of chronic neurodegeneration in female mice, to examine vulnerability of the diseased brain to acute stressors, we showed that LPS (100 µg/kg) produced acute cognitive dysfunction, selectively in those animals. These acute cognitive impairments were mimicked by insulin (11.5 IU/kg) and mitigated by glucose, demonstrating that acutely reduced glucose metabolism impairs cognition selectively in the vulnerable brain. To test whether these acute changes might predict altered carbohydrate metabolism during delirium, we assessed glycolytic metabolite levels in CSF in humans during inflammatory trauma-induced delirium. Hip fracture patients showed elevated CSF lactate and pyruvate during delirium, consistent with acutely altered brain energy metabolism. Collectively, the data suggest that disruption of energy metabolism drives behavioral and cognitive consequences of acute systemic inflammation. SIGNIFICANCE STATEMENT Acute systemic inflammation alters behavior and produces disproportionate effects, such as delirium, in vulnerable individuals. Delirium has serious short and long-term sequelae but mechanisms remain unclear. Here, we show that both LPS and interleukin (IL)-1β trigger hypoglycemia, reduce CSF glucose, and suppress spontaneous activity. Exogenous glucose mitigates these outcomes. Equivalent hypoglycemia, induced by lipopolysaccharide (LPS) or insulin, was sufficient to trigger cognitive impairment selectively in animals with existing neurodegeneration and glucose also mitigated those impairments. Patient CSF from inflammatory trauma-induced delirium also shows altered brain carbohydrate metabolism. The data suggest that the degenerating brain is exquisitely sensitive to acute behavioral and cognitive consequences of disrupted energy metabolism. Thus “bioenergetic stress” drives systemic inflammation-induced dysfunction. Elucidating this may offer routes to mitigating delirium.
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Amgarth-Duff I, Hosie A, Caplan G, Agar M. A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes. BMC Psychiatry 2020; 20:182. [PMID: 32321448 PMCID: PMC7178636 DOI: 10.1186/s12888-020-02584-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 04/05/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis. METHODS A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others. RESULTS The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting. CONCLUSION There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness.
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Affiliation(s)
- Ingrid Amgarth-Duff
- University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW, Australia.
| | - Annmarie Hosie
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia
| | - Gideon Caplan
- grid.1005.40000 0004 4902 0432Prince of Wales Clinical School, University of New South Wales, Sydney, NSW Australia ,grid.415193.bDepartment of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW Australia
| | - Meera Agar
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia ,grid.1005.40000 0004 4902 0432South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales Australia ,grid.429098.eClinical Trials, Ingham Institute of Applied Medical Research, Liverpool, New South Wales Australia
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22
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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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23
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Preoperative transcranial Doppler and cerebral oximetry as predictors of delirium following valvular heart surgery: a case–control study. J Clin Monit Comput 2019; 34:715-723. [DOI: 10.1007/s10877-019-00385-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/29/2019] [Indexed: 12/25/2022]
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24
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Fong TG, Vasunilashorn SM, Libermann T, Marcantonio ER, Inouye SK. Delirium and Alzheimer disease: A proposed model for shared pathophysiology. Int J Geriatr Psychiatry 2019; 34:781-789. [PMID: 30773695 PMCID: PMC6830540 DOI: 10.1002/gps.5088] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 02/07/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Tamara G. Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA,Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA,Harvard Medical School, Boston, MA
| | | | - Towia Libermann
- Harvard Medical School, Boston, MA,Division of Interdisciplinary Medicine and Biotechnology, BIDMC, Boston, MA.,BIDMC Genomics, Proteomics, Bioinformatics and Systems Biology Center, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sharon K. Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA,Harvard Medical School, Boston, MA,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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25
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Hall RJ, Watne LO, Cunningham E, Zetterberg H, Shenkin SD, Wyller TB, MacLullich AMJ. CSF biomarkers in delirium: a systematic review. Int J Geriatr Psychiatry 2018; 33:1479-1500. [PMID: 28585290 DOI: 10.1002/gps.4720] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/16/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In recent years, there has been a blossoming of studies examining cerebrospinal fluid (CSF) as a method of studying the pathophysiology of delirium. We systematically reviewed the literature for CSF studies in delirium and provide here a summary of the implications for our understanding of delirium pathophysiology. We also summarise the methods used for CSF analysis and discuss challenges and implications for future studies. METHODS In this systematic review, we screened MEDLINE, EMBASE, PsycINFO, Web of Science, PubMed and the Cochrane Library for articles on CSF biomarkers in delirium, published on 3 September 2016. Studies were required to use Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria for delirium or a validated tool. We excluded case reports. There were no other restrictions on study type. RESULTS We identified 3280 articles from our initial search, and 22 articles were included in this review. All studies were prospective, including over 400 patients with delirium and 700 controls. More than 70 different biomarkers were studied. Studies could not be compared with each other for meta-analysis because of their heterogeneity and varied widely in their risk of bias and quality assessments. CONCLUSIONS The 22 studies identified in this review reveal a small but growing literature, in which many of the important hypotheses in delirium pathogenesis have been examined, but from which few firm conclusions can currently be drawn. Nevertheless, the overall interpretation of the literature supports the vulnerable brain concept, that is, that biomarker evidence of, for example, Alzheimer's disease pathology and/or neuroinflammation, is associated with delirium.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Emma Cunningham
- Centre for Public Health, Queen's University of Belfast, Belfast, Ireland
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Susan D Shenkin
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
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26
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27
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Hov KR, Bolstad N, Idland AV, Zetterberg H, Blennow K, Chaudhry FA, Frihagen F, Ræder J, Wyller TB, Watne LO. Cerebrospinal Fluid S100B and Alzheimer's Disease Biomarkers in Hip Fracture Patients with Delirium. Dement Geriatr Cogn Dis Extra 2017; 7:374-385. [PMID: 29282410 PMCID: PMC5731172 DOI: 10.1159/000481853] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/19/2017] [Indexed: 01/23/2023] Open
Abstract
Objectives This study aimed to investigate the relationship between cerebrospinal fluid (CSF) S100B astrocyte-derived protein and delirium and to perform stratified analyses according to clinical and CSF markers of dementia. Methods We performed a prospective cohort study in a university hospital setting. The participants were patients admitted for hip fracture (n = 98) or for elective surgery (n = 50). Delirium was assessed daily perioperatively in hip fracture patients using the Confusion Assessment Method. A consensus-based diagnosis of prefracture dementia was made using all available information. CSF was drawn at the onset of spinal anesthesia. S100B and phosphorylated tau (P-tau) concentrations were measured using electrochemiluminescence immunoassay and enzyme-linked immunosorbent assays, respectively. Results In the hip fracture population (n = 98) there was no significant difference in CSF S100B concentrations between patients with ongoing preoperative (i.e., prevalent) delirium (n = 36, median [interquartile range] 1.11 μg/L [0.91–1.29]) and patients who never developed delirium (n = 46, 1.08 μg/L [0.92–1.28], p = 0.92). In patients without preoperative delirium, those who developed delirium postoperatively (i.e., incident delirium) (n = 16, 1.38 μg/L [1.08–1.62]) had higher concentrations of S100B than the 46 who never did (p = 0.013). This difference was confined to patients with pathological concentrations of P-tau (≥60 ng/L, n = 38). We also found that P-tau and S100B were correlated in CSF in the elective surgery patients. Conclusions CSF S100B was elevated in patients with incident delirium who also had pathological levels of the Alzheimer disease biomarker P-tau, suggesting vulnerability caused by a preexisting process of astrocytic activation and tau pathology.
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Affiliation(s)
- Karen Roksund Hov
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nils Bolstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Ane-Victoria Idland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Group for Lifespan Changes in Brain and Cognition, Department of Psychology, University of Oslo, Oslo, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, United Kingdom
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Farrukh A Chaudhry
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Frede Frihagen
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Johan Ræder
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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28
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Haggstrom LR, Nelson JA, Wegner EA, Caplan GA. 2- 18F-fluoro-2-deoxyglucose positron emission tomography in delirium. J Cereb Blood Flow Metab 2017; 37:3556-3567. [PMID: 28350285 PMCID: PMC5669345 DOI: 10.1177/0271678x17701764] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Delirium is a common, serious, yet poorly understood syndrome. Growing evidence suggests cerebral metabolism is fundamentally disturbed; however, it has not been investigated using 2-18F-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) in delirium. This prospective study thus explored FDG PET patterns of cerebral glucose metabolism in older inpatients with delirium. A particular emphasis was on the posterior cingulate cortex (PCC), a key region for attention, which is a central feature of delirium. Delirium scans were compared with post-delirium scans using visual analysis and semi-quantitative analysis with NeuroQ; 13 participants (8 female, median 84 y) were scanned during delirium, and 6 scanned again after resolution. On visual analysis, cortical hypometabolism was evident in all participants during delirium (13/13), and improved with delirium resolution (6/6). Using NeuroQ, glucose metabolism was higher post-delirium in the whole brain and bilateral PCC compared to during delirium ( p < 0.05). Greater metabolism in both PCCs correlated with better performance on a neuropsychological test of attention, the WAIS-IV Digit Span Test forwards, and with shorter delirium duration. This research found widespread, reversible cortical hypometabolism during delirium and PCC hypometabolism was associated with inattention during delirium.
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Affiliation(s)
- Lucy R Haggstrom
- 1 Faculty of Medicine, University of New South Wales, Sydney, Australia
| | | | - Eva A Wegner
- 2 Prince of Wales Hospital, Randwick, NSW, Australia
| | - Gideon A Caplan
- 1 Faculty of Medicine, University of New South Wales, Sydney, Australia.,2 Prince of Wales Hospital, Randwick, NSW, Australia
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29
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Idland AV, Wyller TB, Støen R, Dahl GT, Frihagen F, Brækhus A, Hassel B, Watne LO. Cerebrospinal Fluid Phosphate in Delirium after Hip Fracture. Dement Geriatr Cogn Dis Extra 2017; 7:309-317. [PMID: 29118783 PMCID: PMC5662974 DOI: 10.1159/000478723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 05/22/2017] [Indexed: 01/16/2023] Open
Abstract
Aims Phosphate is essential for neuronal activity. We aimed to investigate whether delirium is associated with altered phosphate concentrations in cerebrospinal fluid (CSF) and serum. Methods Seventy-seven patients with hip fracture were assessed for delirium before and after acute surgery. Prefracture dementia was diagnosed by an expert panel. Phosphate was measured in CSF obtained immediately before spinal anesthesia (n = 77) and in serum (n = 47). CSF from 23 cognitively healthy elderly patients undergoing spinal anesthesia was also analyzed. Results Hip fracture patients with prevalent delirium had higher CSF phosphate concentrations than those without delirium (median 0.63 vs. 0.55 mmol/L, p = 0.001). In analyses stratified on dementia status, this difference was only significant in patients with dementia. Serum phosphate was ∼1 mmol/L; there was no association between serum phosphate concentration and delirium status. CSF phosphate did not correlate with serum levels. Conclusion Patients with delirium superimposed on dementia have elevated phosphate levels.
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Affiliation(s)
- Ane-Victoria Idland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Group for Lifespan Changes in Brain and Cognition, Department of Psychology, University of Oslo, Oslo, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Randi Støen
- Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | | | - Frede Frihagen
- Department of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Anne Brækhus
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Bjørnar Hassel
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Norwegian Defense Research Establishment (FFI), Kjeller, Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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30
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Caplan GA, Tai JI, Mohd Hanizan F, McVeigh CL, Hill MA, Poljak A. Cerebrospinal Fluid Apolipoprotein E Levels in Delirium. Dement Geriatr Cogn Dis Extra 2017; 7:240-248. [PMID: 28868067 PMCID: PMC5567000 DOI: 10.1159/000477847] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/29/2017] [Indexed: 12/23/2022] Open
Abstract
Background/Aims Delirium and the apolipoprotein E ε4 allele are risk factors for late-onset Alzheimer disease (LOAD), but the connection is unclear. We looked for an association. Methods Inpatients with delirium (n = 18) were compared with LOAD outpatients (n = 19), assaying blood and cerebrospinal fluid (CSF) using multiplex ELISA. Results The patients with delirium had a higher Confusion Assessment Method (CAM) score (5.6 ± 1.2 vs. 0.0 ± 0.0; p < 0.001) and Delirium Index (13.1 ± 4.0 vs. 2.9 ± 1.2; p = 0.001) but a lower Mini-Mental State Examination (MMSE) score (14.3 ± 6.8 vs. 20.8 ± 4.6; p = 0.003). There was a reduction in absolute CSF apolipoprotein E level during delirium (median [interquartile range]: 9.55 μg/mL [5.65–15.05] vs. 16.86 μg/mL [14.82–20.88]; p = 0.016) but no differences in apolipoprotein A1, B, C3, H, and J. There were no differences in blood apolipoprotein levels, and no correlations between blood and CSF apolipoprotein levels. CSF apolipoprotein E correlated negatively with the CAM score (r = −0.354; p = 0.034) and Delirium Index (r = −0.341; p = 0.042) but not with the Acute Physiology and Chronic Health Evaluation (APACHE) index, or the MMSE or Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Conclusion Reduced CSF apolipoprotein E levels during delirium may be a mechanistic link between two important risk factors for LOAD.
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Affiliation(s)
- Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - JIan Tai
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Fazrul Mohd Hanizan
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Catherine L McVeigh
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark A Hill
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Anne Poljak
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia.,Bioanalytical Mass Spectrometry Facility, University of New South Wales, Sydney, New South Wales, Australia.,Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
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31
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Haggstrom L, Welschinger R, Caplan GA. Functional neuroimaging offers insights into delirium pathophysiology: A systematic review. Australas J Ageing 2017; 36:186-192. [DOI: 10.1111/ajag.12417] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Lucy Haggstrom
- University of New South Wales; Sydney New South Wales Australia
| | - Robert Welschinger
- Department of Geriatric Medicine; Prince of Wales Hospital; Sydney New South Wales Australia
| | - Gideon A Caplan
- Department of Geriatric Medicine; Prince of Wales Hospital; Sydney New South Wales Australia
- Prince of Wales Clinical School; University of New South Wales; Sydney New South Wales Australia
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32
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Caplan GA, Kurrle SE, Cumming A. Appropriate care for older people with cognitive impairment in hospital. Med J Aust 2017; 205:S12-S15. [PMID: 27852196 DOI: 10.5694/mja15.00898] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 04/29/2016] [Indexed: 12/20/2022]
Abstract
More than half of the patients in adult hospitals are over 65 years of age. Although not a normal part of ageing, many older people will present to hospital with cognitive impairment (dementia or delirium) along with other complex comorbidities. Older people, and particularly those with dementia, are also at increased risk of developing delirium during their hospital stay. Delirium has serious short and long term consequences, such as increased mortality, falls, accelerated functional and cognitive decline, and earlier entry to residential care. Appropriate delirium care consists of introducing evidence-based prevention strategies for all patients at risk. For patients with delirium, it is crucial that delirium is not missed and that the underlying causes are identified and treated. Screening, assessment and a systematic workup is vital. As well as treating the underlying medical and surgical causes, the involvement of family members and a calm, safe environment are important. Patients with cognitive impairment should receive person-centred, goal-directed care so that their particular risks of harm are identified and minimised, and their care is aligned with their preferences and is medically appropriate for their circumstances. Three de-identified, composite case scenarios illustrate, respectively, the role of medicines in causing delirium, how family members can assist in evaluation, and the importance of the appropriate management of post-operative delirium.
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Affiliation(s)
| | | | - Anne Cumming
- Australian Commission on Safety and Quality in Health Care, Sydney, NSW
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Beishuizen SJE, Scholtens RM, Munster BC, Rooij SE. Unraveling the Relationship Between Delirium, Brain Damage, and Subsequent Cognitive Decline in a Cohort of Individuals Undergoing Surgery for Hip Fracture. J Am Geriatr Soc 2016; 65:130-136. [DOI: 10.1111/jgs.14470] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sara J. E. Beishuizen
- Geriatrics Section Department of Internal Medicine Academic Medical Center University of Amsterdam Amsterdam the Netherlands
| | - Rikie M. Scholtens
- Geriatrics Section Department of Internal Medicine Academic Medical Center University of Amsterdam Amsterdam the Netherlands
| | - Barbara C. Munster
- Department of Geriatrics Gelre Hospitals Apeldoorn the Netherlands
- Department of Internal Medicine University Center of Geriatric Medicine University Medical Center Groningen Groningen the Netherlands
| | - Sophia E. Rooij
- Geriatrics Section Department of Internal Medicine Academic Medical Center University of Amsterdam Amsterdam the Netherlands
- Department of Internal Medicine University Center of Geriatric Medicine University Medical Center Groningen Groningen the Netherlands
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Beishuizen SJ, Scholtens RM, Vellekoop AE, Vrouenraets BC, Westhoff D, van de Beek D, de Rooij SE, van Munster BC. Timing Is Critical in Determining the Association Between Delirium and S100 Calcium-Binding Protein B. J Am Geriatr Soc 2015; 63:2212-4. [DOI: 10.1111/jgs.13696] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Sara J. Beishuizen
- Department of Internal Medicine; University of Amsterdam; Academic Medical Center; Amsterdam the Netherlands
| | - Rikie M. Scholtens
- Department of Internal Medicine; University of Amsterdam; Academic Medical Center; Amsterdam the Netherlands
| | | | - Bart C. Vrouenraets
- Department of Surgery; Sint Lucas Andreas Hospital; Amsterdam the Netherlands
| | - Dunja Westhoff
- Department of Neurology; University of Amsterdam; Academic Medical Center; Amsterdam the Netherlands
| | - Diederik van de Beek
- Department of Neurology; University of Amsterdam; Academic Medical Center; Amsterdam the Netherlands
| | - Sophia E. de Rooij
- Department of Internal Medicine; University of Amsterdam; Academic Medical Center; Amsterdam the Netherlands
- Department of Internal Medicine; University Center of Geriatric Medicine; University Medical Center Groningen; Groningen the Netherlands
| | - Barbara C. van Munster
- Geriatrics Section; Department of Internal Medicine; University of Amsterdam; Academic Medical Center; Amsterdam the Netherlands
- Department of Geriatrics; Gelre Hospitals; Apeldoorn the Netherlands
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Poljak A, Hill M, Hall RJ, MacLullich AM, Raftery MJ, Tai J, Yan S, Caplan GA. Quantitative proteomics of delirium cerebrospinal fluid. Transl Psychiatry 2014; 4:e477. [PMID: 25369144 PMCID: PMC4259987 DOI: 10.1038/tp.2014.114] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 09/05/2014] [Accepted: 09/11/2014] [Indexed: 12/12/2022] Open
Abstract
Delirium is a common cause and complication of hospitalization in older people, being associated with higher risk of future dementia and progression of existing dementia. However relatively little data are available on which biochemical pathways are dysregulated in the brain during delirium episodes, whether there are protein expression changes common among delirium subjects and whether there are any changes which correlate with the severity of delirium. We now present the first proteomic analysis of delirium cerebrospinal fluid (CSF), and one of few studies exploring protein expression changes in delirium. More than 270 proteins were identified in two delirium cohorts, 16 of which were dysregulated in at least 8 of 17 delirium subjects compared with a mild Alzheimer's disease neurological control group, and 31 proteins were significantly correlated with cognitive scores (mini-mental state exam and acute physiology and chronic health evaluation III). Bioinformatics analyses revealed expression changes in several protein family groups, including apolipoproteins, secretogranins/chromogranins, clotting/fibrinolysis factors, serine protease inhibitors and acute-phase response elements. These data not only provide confirmatory evidence that the inflammatory response is a component of delirium, but also reveal dysregulation of protein expression in a number of novel and unexpected clusters of proteins, in particular the granins. Another surprising outcome of this work is the level of similarity of CSF protein profiles in delirium patients, given the diversity of causes of this syndrome. These data provide additional elements for consideration in the pathophysiology of delirium as well as potential biomarker candidates for delirium diagnosis.
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Affiliation(s)
- A Poljak
- Bioanalytical Mass Spectrometry Facility, University of New South Wales, Sydney, NSW, Australia,School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia,Center for Healthy Brain Ageing, University of New South Wales, Sydney, NSW, Australia,Bioanalytical Mass Spectrometry Facility, University of New South Wales, Anzac Pde, Kensington, Sydney, NSW 2052, Australia. E-mail:
| | - M Hill
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - R J Hall
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, UK
| | - A M MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, UK
| | - M J Raftery
- Bioanalytical Mass Spectrometry Facility, University of New South Wales, Sydney, NSW, Australia
| | - J Tai
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - S Yan
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - G A Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia,Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
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Caplan GA, Lan Z, Newton L, Kvelde T, McVeigh C, Hill MA. Transcranial Doppler to Measure Cerebral Blood Flow in Delirium Superimposed on Dementia. A Cohort Study. J Am Med Dir Assoc 2014; 15:355-60. [DOI: 10.1016/j.jamda.2013.12.079] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 12/16/2013] [Accepted: 12/23/2013] [Indexed: 01/14/2023]
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Abstract
Delirium is an acute disorder of attention and cognition in elderly people (ie, those aged 65 years or older) that is common, serious, costly, under-recognised, and often fatal. A formal cognitive assessment and history of acute onset of symptoms are necessary for diagnosis. In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological risk factor approaches are the most effective strategy for prevention. No convincing evidence shows that pharmacological prevention or treatment is effective. Drug reduction for sedation and analgesia and non-pharmacological approaches are recommended. Delirium offers opportunities to elucidate brain pathophysiology--it serves both as a marker of brain vulnerability with decreased reserve and as a potential mechanism for permanent cognitive damage. As a potent indicator of patients' safety, delirium provides a target for system-wide process improvements. Public health priorities include improvements in coding, reimbursement from insurers, and research funding, and widespread education for clinicians and the public about the importance of delirium.
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Affiliation(s)
- Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
| | - Rudi G J Westendorp
- Leiden University Medical Center, Leiden, Netherlands; Leyden Academy on Vitality and Ageing, Leiden, Netherlands
| | - Jane S Saczynski
- Division of Geriatric Medicine and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
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Hall RJ, Ferguson KJ, Andrews M, Green AJE, White TO, Armstrong IR, MacLullich AMJ. Delirium and cerebrospinal fluid S100B in hip fracture patients: a preliminary study. Am J Geriatr Psychiatry 2013; 21:1239-43. [PMID: 23602305 DOI: 10.1016/j.jagp.2012.12.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 11/28/2012] [Accepted: 12/17/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Delirium is associated with an increased risk of long-term cognitive decline, suggesting the possibility of concurrent central nervous system (CNS) injury. S100B is a putative biomarker of CNS injury and elevated serum levels in delirium have been reported. Here we hypothesize that delirium is associated with raised concentrations of cerebrospinal fluid (CSF) S100B. METHODS Forty-five patients with hip fracture aged over 60 and awaiting surgery under spinal anesthesia were assessed for delirium pre- and post-operatively. CSF S100B levels were measured in samples collected at the onset of surgery. RESULTS Participants with pre-operative delirium (N = 8) had elevated Log10 CSF S100B (mean: -0.156; SD: 0.238) compared with those without delirium (mean: -0.306; SD: 0.162), Student's t-test t = 2.18, df = 43, p = 0.035. CONCLUSIONS This study provides preliminary evidence of elevated CSF S100B in current delirium, consistent with findings in serum and with other studies showing elevated S100B in the presence of diverse forms of CNS injury.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, Midlothian, Scotland; Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Midlothian, Scotland.
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Wijnia JW, Oudman E. Biomarkers of delirium as a clue to diagnosis and pathogenesis of Wernicke-Korsakoff syndrome. Eur J Neurol 2013; 20:1531-8. [PMID: 23790077 DOI: 10.1111/ene.12217] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 05/16/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Wernicke's encephalopathy (WE) and Korsakoff's syndrome are considered to be different stages of the same disorder due to thiamine deficiency, which is called Wernicke-Korsakoff syndrome (WKS). The earliest biochemical change is the decrease of α-ketoglutarate-dehydrogenase activity in astrocytes. According to autopsy-based series, mental status changes are present in 82% of WE cases. The objective of the present review is to identify possible underlying mechanisms relating the occurrence of delirium to WKS. METHODS Studies involving delirium in WKS, however, are rare. Therefore, first, a search was done for candidate biomarkers of delirium irrespective of the clinical setting. Secondly, the results were focused on identification of these biomarkers in reports on WKS. RESULTS In various settings, 10 biochemical and/or genetic biomarkers showed strong associations with the occurrence of delirium. For WKS three of these candidate biomarkers were identified, namely brain tissue cell counts of CD68 positive cells as a marker of microglial activation, high cerebrospinal fluid lactate levels, and MHPG, a metabolite of norepinephrine. Based on current literature, markers of microglial activation may present an interesting patho-etiological relationship between thiamine deficiency and delirium in WKS. CONCLUSIONS In WKS cases, changes in astroglia and microglial proliferation were reported. The possible loss-of-function mechanisms following thiamine deficiency in WKS are proposed to come from microglial activation, resulting in a delirium in the initial phase of WKS.
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Affiliation(s)
- J W Wijnia
- Lelie Care Group, Slingedael Korsakoff Centre, Rotterdam, The Netherlands
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Current world literature. Curr Opin Psychiatry 2012; 25:251-9. [PMID: 22456191 DOI: 10.1097/yco.0b013e328352dd8d] [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: 11/25/2022]
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Hall RJ, Shenkin SD, Maclullich AMJ. A systematic literature review of cerebrospinal fluid biomarkers in delirium. Dement Geriatr Cogn Disord 2012; 32:79-93. [PMID: 21876357 DOI: 10.1159/000330757] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2011] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) analysis has great potential to advance understanding of delirium pathophysiology. METHODS A systematic literature review of CSF studies of DSM or ICD delirium was performed. RESULTS In 8 studies of 235 patients, delirium was associated with: elevated serotonin metabolites, interleukin-8, cortisol, lactate and protein, and reduced somatostatin, β-endorphin and neuron-specific enolase. Elevated acetylcholinesterase predicted poor outcome after delirium and higher dopamine metabolites were associated with psychotic features. CONCLUSIONS No clear conclusions emerged, but the current literature suggests multiple areas for further investigation with more detailed studies.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences and Community Health, UK. roanna.hall @ ed.ac.uk
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Current World Literature. Curr Opin Anaesthesiol 2012; 25:111-20. [DOI: 10.1097/aco.0b013e32834fd93c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Current World Literature. Curr Opin Anaesthesiol 2011; 24:705-12. [DOI: 10.1097/aco.0b013e32834e25f9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr 2011; 11:45. [PMID: 21851627 PMCID: PMC3171714 DOI: 10.1186/1471-2318-11-45] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 08/18/2011] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Community-dwelling older people aged 65+ years sustain falls frequently; these can result in physical injuries necessitating medical attention including emergency department care and hospitalisation. Certain health conditions and impairments have been shown to contribute independently to the risk of falling or experiencing a fall injury, suggesting that individuals with these conditions or impairments should be the focus of falls prevention. Since older people commonly have multiple conditions/impairments, knowledge about which conditions/impairments coexist in at-risk individuals would be valuable in the implementation of a targeted prevention approach. The objective of this study was therefore to examine the prevalence and patterns of comorbidity in this population group. METHODS We analysed hospitalisation data from Victoria, Australia's second most populous state, to estimate the prevalence of comorbidity in patients hospitalised at least once between 2005-6 and 2007-8 for treatment of acute fall-related injuries. In patients with two or more comorbid conditions (multicomorbidity) we used an agglomerative hierarchical clustering method to cluster comorbidity variables and identify constellations of conditions. RESULTS More than one in four patients had at least one comorbid condition and among patients with comorbidity one in three had multicomorbidity (range 2-7). The prevalence of comorbidity varied by gender, age group, ethnicity and injury type; it was also associated with a significant increase in the average cumulative length of stay per patient. The cluster analysis identified five distinct, biologically plausible clusters of comorbidity: cardiopulmonary/metabolic, neurological, sensory, stroke and cancer. The cardiopulmonary/metabolic cluster was the largest cluster among the clusters identified. CONCLUSIONS The consequences of comorbidity clustering in terms of falls and/or injury outcomes of hospitalised patients should be investigated by future studies. Our findings have particular relevance for falls prevention strategies, clinical practice and planning of follow-up services for these patients.
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Affiliation(s)
- Trang Vu
- Monash Injury Research Institute, Monash University, Victoria 3800, Australia.
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