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Gaba A, Li P, Zheng X, Gao C, Cai R, Hu K, Gao L. Associations Between Depression Symptom Burden and Delirium Risk: A Prospective Cohort Study. Innov Aging 2024; 8:igae029. [PMID: 38660114 PMCID: PMC11041407 DOI: 10.1093/geroni/igae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Indexed: 04/26/2024] Open
Abstract
Background and Objectives Delirium and depression are prevalent in aging. There is considerable clinical overlap, including shared symptoms and comorbid conditions, including Alzheimer's disease, functional decline, and mortality. Despite this, the long-term relationship between depression and delirium remains unclear. This study assessed the associations of depression symptom burden and its trajectory with delirium risk in a 12-year prospective study of older hospitalized individuals. Research Design and Methods A total of 319 141 UK Biobank participants between 2006 and 2010 (mean age 58 years [range 37-74, SD = 8], 54% women) reported frequency (0-3) of 4 depressive symptoms (mood, disinterest, tenseness, or lethargy) in the preceding 2 weeks prior to initial assessment visit and aggregated into a depressive symptom burden score (0-12). New-onset delirium was obtained from hospitalization records during 12 years of median follow-up. 40 451 (mean age 57 ± 8; range 40-74 years) had repeat assessment on average 8 years after their first visit. Cox proportional hazard models examined whether depression symptom burden and trajectory predicted incident delirium. Results A total of 5 753 (15 per 1 000) newly developed delirium during follow-up. Increased risk for delirium was seen for mild (aggregated scores 1-2, hazards ratio, HR = 1.16, [95% confidence interval (CI): 1.08-1.25], p < .001), modest (scores 3-5, 1.30 [CI: 1.19-1.43], p < .001), and severe (scores ≥ 5, 1.38 [CI: 1.24-1.55], p < .001) depressive symptoms, versus none in the fully adjusted model. These findings were independent of the number of hospitalizations and consistent across settings (eg, surgical, medical, or critical care) and specialty (eg, neuropsychiatric, cardiorespiratory, or other). Worsening depression symptoms (≥1 point increase), compared to no change/improved score, were associated with an additional 39% increased risk (1.39 [1.03-1.88], p = .03) independent of baseline depression burden. The association was strongest in those over 65 years at baseline (p for interaction <.001). Discussion and Implications Depression symptom burden and worsening trajectory predicted delirium risk during hospitalization. Increased awareness of subclinical depression symptoms may aid delirium prevention.
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Affiliation(s)
- Arlen Gaba
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Peng Li
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Xi Zheng
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Chenlu Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruixue Cai
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kun Hu
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Lei Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Mei X, Liu YH, Han YQ, Zheng CY. Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients. World J Psychiatry 2023; 13:973-984. [PMID: 38186721 PMCID: PMC10768493 DOI: 10.5498/wjp.v13.i12.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/14/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
Delirium is an acute reversible neuropsychiatric syndrome caused by multiple factors. It is associated with many adverse clinical outcomes including cognitive impairment, functional decline, prolonged hospitalization, and increased nursing service. The prevalence of delirium was high in department of cardiology, geriatric, and intensive care unit of hospital. With the increase in the aged population, further increases in delirium seem likely. However, it remains poorly recognized in the clinical practice. This article comprehensively discusses the latest research perspectives on the epidemiological data, risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium, including specific measures to manage delirium in clinical real-world situations. This article helps readers improve their knowledge and understanding of delirium and helps clinicians quickly identify and implement timely therapeutic measures to address various delirium subtypes that occur in the clinical settings to ensure patients are treated as aggressively as possible.
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Affiliation(s)
- Xi Mei
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Yue-Hong Liu
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Ya-Qing Han
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Cheng-Ying Zheng
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
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Fislage M, Feinkohl I, Borchers F, Heinrich M, Pischon T, Veldhuijzen DS, Slooter AJ, Spies CD, Winterer G, Zacharias N. Trail making test B in postoperative delirium: a replication study. BJA OPEN 2023; 8:100239. [PMID: 37954892 PMCID: PMC10633257 DOI: 10.1016/j.bjao.2023.100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/28/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
Background The Trail Making Test B (TMT-B) is indicative of cognitive flexibility and several other cognitive domains. Previous studies suggest that it might be associated with the risk of developing postoperative delirium, but evidence is limited and conflicting. We therefore aimed to replicate the association of preoperative TMT-B results with postoperative delirium. Methods We included older adults (≥65 yr) scheduled for major surgery and without signs of dementia to participate in this binational two-centre longitudinal observational cohort study. Presurgical TMT-B scores were obtained. Delirium was assessed twice daily using validated instruments. Logistic regression was applied and the area under the receiver operating characteristic curve calculated to determine the predictive performance of TMT-B. We subsequently included covariates used in previous studies for consecutive sensitivity analyses. We further analysed the impact of outliers, missing or impaired data. Results Data from 841 patients were included and of those, 151 (18%) developed postoperative delirium. TMT-B scores were statistically significantly associated with the incidence of postoperative delirium {odds ratio per 10-s increment 1.06 (95% confidence interval [CI] 1.02-1.09), P=0.001}. The area under the receiver operating characteristic curve was 0.60 ([95% CI 0.55-0.64], P<0.001). The association persisted after removing 21 outliers (1.07 [95% CI 1.03-1.07], P<0.001). Impaired or missing TMT-B data (n=88) were also associated with postoperative delirium (odds ratio 2.74 [95% CI 1.71-4.35], P<0.001). Conclusions The TMT-B was associated with postoperative delirium, but its predictive performance as a stand-alone test was low. The TMT-B alone is not suitable to predict delirium in a clinical setting. Clinical trial registration NCT02265263. (https://clinicaltrials.gov/ct2/show/results/NCT02265263).
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Affiliation(s)
- Marinus Fislage
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Department of Neurology, National Taiwan University Hospital, Taipei, China
| | - Insa Feinkohl
- Witten/Herdecke University, Faculty of Health/School of Medicine, Witten, Germany
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research Group, Berlin, Germany
| | - Friedrich Borchers
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Maria Heinrich
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Pischon
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research Group, Berlin, Germany
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Biobank Technology Platform, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Core Facility Biobank, Berlin, Germany
| | - Dieuwke S. Veldhuijzen
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition, Leiden, the Netherlands
| | - Arjen J.C. Slooter
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Intensive Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Claudia D. Spies
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Georg Winterer
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
| | - Norman Zacharias
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
| | - BioCog Consortium
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Witten/Herdecke University, Faculty of Health/School of Medicine, Witten, Germany
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research Group, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Biobank Technology Platform, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Core Facility Biobank, Berlin, Germany
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition, Leiden, the Netherlands
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Intensive Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
- Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
- Department of Neurology, National Taiwan University Hospital, Taipei, China
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Olotu C, Lebherz L, Ascone L, Scherwath A, Kühn S, Härter M, Kiefmann R. Cognitive Deficits in Executive and Language Functions Predict Postoperative Delirium. J Cardiothorac Vasc Anesth 2023; 37:2552-2560. [PMID: 37778949 DOI: 10.1053/j.jvca.2023.08.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/18/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES Postoperative delirium (POD) remains the most common complication in older adults, with cognitive impairment being the main risk factor. Patients with mild cognitive impairment, in particular, have much to lose from delirium; despite this, their cognitive impairment might be clinically overlooked. Understanding which cognitive domains are particularly predictive in this regard may improve the sensitivity of preoperative testing and allow for a more targeted application of resource-intensive measures to prevent delirium in the perioperative period. The authors conducted this study with the aim of identifying the most indicative cognitive domains. DESIGN A secondary analysis of a randomized controlled trial. SETTING At a single center, the University Medical Centre Hamburg in Hamburg, Germany. PARTICIPANTS Patients ≥60 years without major neurocognitive disorders (dementia, Mini-Mental State Examination score ≤23) scheduled for cardiovascular surgery. MEASUREMENTS AND MAIN RESULTS Preoperative neuropsychologic testing and delirium screening were performed twice daily until postoperative day 5. A multiple logistic regression model was applied to determine the predictive ability of test performances for the development of delirium. RESULTS A total of 541 patients were included in the analysis; the delirium rate was 15.6%. After controlling for confounders, only low performance within the Trail Making Test B/A (odds ratio [OR] = 1.32; 95% CI: 1.05-1.66) and letter fluency (OR = 0.66; 95% CI: 0.45-0.96) predicted a particularly high risk for delirium development. The discriminative ability of the final multiple logistic regression model to predict POD had an area under the curve of 0.786. CONCLUSIONS Impairment in the cognitive domains of executive function and language skills associated with memory, inhibition, and access speed seem to be particularly associated with the development of delirium after surgery in adults ≥65 years of age without apparent preoperative neurocognitive impairment.
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Affiliation(s)
- Cynthia Olotu
- Department of Anaesthesiology, University Medical Center Hamburg, Hamburg, Germany.
| | - Lisa Lebherz
- Institute of Medical Psychology, University Medical Center Hamburg, Hamburg, Germany
| | - Leonie Ascone
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg, Hamburg, Germany
| | - Angela Scherwath
- Institute of Medical Psychology, University Medical Center Hamburg, Hamburg, Germany; Department of Stem Cell Transplantation, University Medical Center Hamburg, Hamburg, Germany
| | - Simone Kühn
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg, Hamburg, Germany
| | - Martin Härter
- Institute of Medical Psychology, University Medical Center Hamburg, Hamburg, Germany
| | - Rainer Kiefmann
- Department of Anaesthesiology, University Medical Center Hamburg, Hamburg, Germany; Anesthesia Department, Rotkreuzklinikum Munich, Munich, Germany
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Dammavalam V, Murphy J, Johnkutty M, Elias M, Corn R, Bergese S. Perioperative cognition in association with malnutrition and frailty: a narrative review. Front Neurosci 2023; 17:1275201. [PMID: 38027517 PMCID: PMC10651720 DOI: 10.3389/fnins.2023.1275201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Postoperative delirium (POD) is a prevalent clinical entity characterized by reversible fluctuating altered mental status and cognitive impairment with acute and rapid onset a few days after major surgery. Postoperative cognitive decline (POCD) is a more permanent extension of POD characterized by prolonged global cognitive impairment for several months to years after surgery and anesthesia. Both syndromes have been shown to increase morbidity and mortality in postoperative patients making their multiple risk factors targets for optimization. In particular, nutrition imparts a significant and potentially reversible risk factor. Malnutrition and frailty have been linked as risk factors and predictive indicators for POD and less so for POCD. This review aims to outline the association between nutrition and perioperative cognitive outcomes as well as potential interventions such as prehabilitation.
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Affiliation(s)
- Vikalpa Dammavalam
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Jasper Murphy
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Meenu Johnkutty
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Murad Elias
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Ryan Corn
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY, United States
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Alviz Núñez M, Villa García MM, Gonzalez MC, Urrea MB, Velásquez-Tirado JD, Ocampo MV, Trzepacz PT, Franco JG. Practical Application of a Battery of Brief Tools to Evaluate Geriatric Medical Inpatients for the Three Ds. J Neuropsychiatry Clin Neurosci 2023; 36:63-69. [PMID: 37667628 DOI: 10.1176/appi.neuropsych.20230029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
OBJECTIVE The investigators aimed to identify the clinical characteristics of patients with or without delirium and preexisting depression, dementia, both, or neither by using validated tools easily administered in clinical practice. METHODS In this cross-sectional prospective observational study conducted in Medellín, Colombia, 200 geriatric inpatients were evaluated with the Delirium Diagnostic Tool-Provisional (DDT-Pro), Informant Questionnaire on Cognitive Decline in the Elderly, Hachinski Ischemic Scale, Cornell Scale for Depression in Dementia, and Charlson Comorbidity Index-short form. Delirium motor subtype, mortality, and length of hospital stay were assessed. RESULTS The study included 134 patients without delirium (67%), 14 with delirium only (7%), 16 with delirium and dementia (8%), 13 with delirium and depression (7%), and 23 with delirium, dementia, and depression (the three Ds) (12%). Prevalence rates of dementia (59%) and depression (55%) among 66 patients with delirium were higher than prevalence rates among patients without delirium (13% and 28%, respectively), suggesting that both conditions are risk factors. Main medical diagnoses, mortality, and dementia type did not differ among groups. Motor subtypes were similar among delirium groups. Patients in the delirium groups, except those in the delirium and depression group, were older than patients without delirium. Medical burden was highest among the patients with delirium and dementia and those with all three conditions. Delirium and dementia were more severe when comorbid with each other. Depression was most severe among patients with delirium and depression. Patients with all three conditions had a longer length of hospital stay than those without delirium. CONCLUSIONS Using brief tools to detect dementia and depression in conjunction with the DDT-Pro to assess delirium diagnosis and severity is feasible and enables a more in-depth evaluation of elderly hospitalized patients. Because previous longitudinal research suggests that these comorbid conditions influence prognosis following a delirium episode, better identification of the three Ds offers proactive interventional opportunities. Depression is an underrecognized risk factor for delirium.
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Affiliation(s)
- Marcela Alviz Núñez
- Liaison Psychiatry Research Group, Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia (Alviz Núñez, Villa García, Gonzalez, Botero Urrea, Velásquez-Tirado, Ocampo, Franco); Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - María Margarita Villa García
- Liaison Psychiatry Research Group, Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia (Alviz Núñez, Villa García, Gonzalez, Botero Urrea, Velásquez-Tirado, Ocampo, Franco); Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Maria Carolina Gonzalez
- Liaison Psychiatry Research Group, Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia (Alviz Núñez, Villa García, Gonzalez, Botero Urrea, Velásquez-Tirado, Ocampo, Franco); Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - María Botero Urrea
- Liaison Psychiatry Research Group, Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia (Alviz Núñez, Villa García, Gonzalez, Botero Urrea, Velásquez-Tirado, Ocampo, Franco); Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Juan D Velásquez-Tirado
- Liaison Psychiatry Research Group, Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia (Alviz Núñez, Villa García, Gonzalez, Botero Urrea, Velásquez-Tirado, Ocampo, Franco); Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - María V Ocampo
- Liaison Psychiatry Research Group, Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia (Alviz Núñez, Villa García, Gonzalez, Botero Urrea, Velásquez-Tirado, Ocampo, Franco); Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - Paula T Trzepacz
- Liaison Psychiatry Research Group, Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia (Alviz Núñez, Villa García, Gonzalez, Botero Urrea, Velásquez-Tirado, Ocampo, Franco); Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
| | - José G Franco
- Liaison Psychiatry Research Group, Medicine Faculty, Universidad Pontificia Bolivariana, Medellín, Colombia (Alviz Núñez, Villa García, Gonzalez, Botero Urrea, Velásquez-Tirado, Ocampo, Franco); Department of Psychiatry, Indiana University School of Medicine, Indianapolis (Trzepacz)
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Farrer TJ, Monk TG, McDonagh DL, Martin G, Pieper CF, Koltai D. A prospective randomized study examining the impact of intravenous versus inhalational anesthesia on postoperative cognitive decline and delirium. APPLIED NEUROPSYCHOLOGY. ADULT 2023:1-7. [PMID: 37572422 DOI: 10.1080/23279095.2023.2246612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
The present prospective randomized study was designed to investigate whether the development of Post Operative Cognitive Decline (POCD) is related to anesthesia type in older adults. All patients were screened for delirium and mental status, received baseline neuropsychological assessment, and evaluation of activities of daily living (ADLs). Follow-up assessments were performed at 3-6 months and 12-18 months. Patients were randomized to receive either inhalation anesthesia (ISO) with isoflurane or total intravenous anesthesia (TIVA) with propofol for maintenance anesthesia. ISO (n = 99) and TIVA (n = 100) groups were similar in demographics, preoperative cognition, and incidence of post-operative delirium. Groups did not differ in terms of mean change in memory or executive function from baseline to follow-up. Pre-surgical cognitive function is the only variable predictive of the development of POCD. Anesthetic type was not predictive of POCD. However, ADLs were predictive of post-operative delirium development. Overall, this pilot study represents a prospective, randomized study demonstrating that when examining ISO versus TIVA for maintenance of general anesthesia, there is no significant difference in cognition between anesthetic types. There is also no difference in the occurrence of postoperative delirium. Postoperative cognitive decline was best predicted by lower baseline cognition and functional status.
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Affiliation(s)
- Thomas J Farrer
- WWAMI Medical Eduction Program, University of Idaho, Moscow, ID, United States
| | - Terri G Monk
- Department of Anesthesiology and Critical Care, SSM Saint Louis University Hospital St Louis, MO, United States
| | - David L McDonagh
- Departments of Anesthesiology & Pain Management, Neurology, and Neurosurgery, University of Texas Southwestern, Dallas, TX, United States
| | - Gavin Martin
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Carl F Pieper
- Department of Biostatistics and Bioinformatics, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, United States
| | - Deborah Koltai
- Departments of Neurology, Psychiatry and Behavioral Sciences, and Neurosurgery, Duke University Medical Center, Durham, NC, United States
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Falk A, Kåhlin J, Nymark C, Hultgren R, Stenman M. Depression is associated with delirium after cardiac surgery—a population-based cohort study. Interact Cardiovasc Thorac Surg 2022; 35:6595028. [PMID: 35640560 PMCID: PMC9297521 DOI: 10.1093/icvts/ivac151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/26/2022] [Accepted: 05/27/2022] [Indexed: 12/29/2022] Open
Abstract
Abstract
OBJECTIVES
Depression is common in patients with cardiac disease, and preoperative depression is associated with worse outcomes after cardiac surgery. Depression is also correlated with postoperative delirium (POD) after major surgery. However, the association between preoperative depression and POD after cardiac surgery is sparsely studied. The aim of this study was to investigate depression as a predictor for POD in cardiac surgery patients.
METHODS
This population-based cohort study included 1133 cardiac surgery patients in Stockholm 2013–2016. Depression was defined by the Patient Health Questionnaire-9, and POD was evaluated by assessing medical records for symptoms of POD according to Diagnostic and Statistical Manual of Mental Disorders criteria. The association between depression and POD was determined through multivariable logistic regression analysis.
RESULTS
A total of 162 (14%) individuals reported depressive symptoms preoperatively. The incidence of POD was 26% and highest among elderly patients. Among patients with depression, 34% developed POD. In the group of non-depressed patients, 24% developed POD. The overall adjusted odds of delirium were 2.19 times higher in individuals with depressive symptoms compared to controls (95% confidence interval 1.43–3.34). The onset of delirium was most common on Days 0–2 after surgery.
CONCLUSIONS
This unique population-based study in patients undergoing cardiac surgery shows that preoperative depression is associated with POD in a large proportion of treated patients. The findings support the need for improved preoperative screening for depression, especially in younger patients, and enhanced clinical surveillance in the early postoperative period for all patients.
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Affiliation(s)
- Anna Falk
- Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm, Sweden
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital , Stockholm, Sweden
| | - Jessica Kåhlin
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital , Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet , Stockholm, Sweden
| | - Carolin Nymark
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet , Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital , Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital , Stockholm, Sweden
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm, Sweden
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital , Stockholm, Sweden
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Lewis C, Dokucu ME, Brown CH, Balmert L, Srdanovic N, Madhan AS, Samra SS, Csernansky J, Grafman J, Hogue CW. Postoperative but not preoperative depression is associated with cognitive impairment after cardiac surgery: exploratory analysis of data from a randomized trial. BMC Anesthesiol 2022; 22:157. [PMID: 35606688 PMCID: PMC9125857 DOI: 10.1186/s12871-022-01672-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this study we hypothesize that depression is associated with perioperative neurocognitive dysfunction and altered quality of life one month after surgery. METHODS Data were obtained as part of a study evaluating cerebral autoregulation monitoring for targeting arterial pressure during cardiopulmonary bypass. Neuropsychological testing was performed before surgery and one month postoperatively. Testing included the Beck Depression Inventory, a depression symptoms questionnaire (0-63 scale), as well as anxiety and quality of life assessments. Depression was defined as a Beck Depression Inventory score > 13. RESULTS Beck Depression data were available from 320 patients of whom cognitive domain endpoints were available from 88-98% at baseline and 69-79% after surgery. This range in end-points data was due to variability in the availability of each neuropsychological test results between patients. Depression was present in 50 (15.6%) patients before surgery and in 43 (13.4%) after surgery. Baseline depression was not associated with postoperative domain-specific neurocognitive function compared with non-depressed patients. Those with depression one month after surgery, though, had poorer performance on tests of attention (p = 0.017), memory (p = 0.049), verbal fluency (p = 0.010), processing speed (p = 0.017), and fine motor speed (p = 0.014). Postoperative neurocognitive dysfunction as a composite outcome occurred in 33.3% versus 14.5% of patients with and without postoperative depression (p = 0.040). Baseline depression was associated with higher anxiety and lower self-ratings on several quality of life domains, these measures were generally more adversely affected by depression one month after surgery. CONCLUSIONS The results of this exploratory analysis suggests that preoperative depression is not associated with perioperative neurocognitive dysfunction, but depression after cardiac surgery may be associated with impairment in in several cognitive domains, a higher frequency of the composite neurocognitive outcome, and altered quality of life. TRIAL REGISTRATION www. CLINICALTRIALS gov, NCT00981474 (parent study).
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Affiliation(s)
- Choy Lewis
- Department of Anesthesiology, The Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 251 East Huron St, Feinberg 5-704, Chicago, IL, 60611, USA
| | - Mehmet E Dokucu
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Charles H Brown
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lauren Balmert
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nina Srdanovic
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ashwin Shaan Madhan
- Medical Student, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sahej Singh Samra
- Medical Student, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John Csernansky
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jordan Grafman
- Department of Physical Medicine & Rehabilitation, Neurology, Cognitive Neurology and Alzheimer's Center, Department of Psychiatry, Northwestern University Feinberg School of Medicine, Weinberg College of Arts and Sciences, Northwestern University, Chicago, IL, USA
| | - Charles W Hogue
- Department of Anesthesiology, The Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 251 East Huron St, Feinberg 5-704, Chicago, IL, 60611, USA.
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10
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O'Hanlon S, Baxter M, Hosie A. Postoperative delirium in older patients with cancer: the role of psychological distress and social support. Curr Opin Support Palliat Care 2022; 16:38-47. [PMID: 34939608 DOI: 10.1097/spc.0000000000000588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Delirium is a common and important adverse event in the perioperative period. Older people with cancer are at significant risk, and outcomes are poor. There is increasing awareness of the effect of psychological distress and social support on pathogenesis and outcomes of delirium in this setting. This review aimed to describe recent research in this evolving area. RECENT FINDINGS Across six recent studies of postoperative delirium in older people with cancer, delirium incidence ranged from 8 to 19.8%. Poor social support and high levels of distress are implicated in the development of postoperative delirium. Distress can be related to negative emotional reaction to diagnosis, preconception of cancer diagnosis and interactions with the healthcare system. Prevention of delirium is key, and multicomponent interventions show evidence of effectiveness. 'Emotional distress' has been included in a new core outcome set for studies of interventions to prevent and/or treat delirium. SUMMARY Postoperative delirium in older adults with cancer is common and is associated with increased morbidity and mortality. Psychological distress and social support play an important role, but there are many unmet research needs in this area.
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Affiliation(s)
- Shane O'Hanlon
- Department of Geriatric Medicine, St Vincent's University Hospital
- University College Dublin, Dublin, Ireland
| | - Mark Baxter
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee
- Tayside Cancer Centre, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Annmarie Hosie
- School of Nursing and Midwifery, Sydney, The University of Notre Dame Australia
- St Vincent's Health Network Sydney, Darlinghurst
- IMPACCT - Improving Palliative, Aged and Chronic Care through Research and Translation, University of Technology Sydney, Ultimo, New South Wales, Australia
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11
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Huai X, Jiao Y, Gu X, Zhu H, Chen L, Fan Y, Yu W, Su D, Xie H. Preoperative Chronic Pain as a Risk Factor for Early Postoperative Cognitive Dysfunction in Elderly Patients Undergoing Hip Joint Replacement Surgery: A Prospective Observational Cohort Study. Front Neurosci 2022; 15:747362. [PMID: 34975369 PMCID: PMC8718925 DOI: 10.3389/fnins.2021.747362] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/30/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Although major joint replacement surgery has a high overall success rate, postoperative cognitive dysfunction (POCD) is a common complication after anesthesia and surgery, increasing morbidity and mortality. Identifying POCD risk factors would be helpful to prevent and decrease the occurrence of POCD. We hypothesized that preoperative chronic pain increases the risk of POCD. Methods: A single-center, observational, prospective cohort study was conducted from January 2018 to March 2020. All consecutive elderly patients (>65 years) who underwent elective total hip arthroplasty or hemiarthroplasty with general anesthesia by the same surgeon were enrolled. The patients underwent neuropsychological testing preoperatively and at 7 days and 2 months after surgery. To determine POCD, a nonsurgical control group was recruited from the general community. Results: Of the 141 patients who finished the neuropsychological testing 7 days after surgery, 61 (43.2%) had preoperative chronic pain. Of the 61 patients, 17 (27.9%) developed POCD; of the 79 patients with no chronic pain, 10 (12.7%) had developed POCD by 7 days after surgery. Multivariate logistic regression analysis identified preoperative chronic pain as a risk factor of POCD assessed 7 days after surgery (odds ratio 6.527; P = 0.009). There was no significant difference in the POCD incidence 2 months after surgery between patients with and without preoperative chronic pain. Conclusion: Preoperative chronic pain was a risk factor of developing POCD within 7 days after surgery in elderly patients following hip joint replacement surgery. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [NCT03393676].
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Affiliation(s)
- Xiaorong Huai
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yingfu Jiao
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiyao Gu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Huichen Zhu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lingke Chen
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yichen Fan
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Diansan Su
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hong Xie
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
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12
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Price CC. The New Frontier of Perioperative Cognitive Medicine for Alzheimer's Disease and Related Dementias. Neurotherapeutics 2022; 19:132-142. [PMID: 35084722 PMCID: PMC9130373 DOI: 10.1007/s13311-021-01180-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 01/03/2023] Open
Abstract
This is a review of preoperative cognitive assessment and other healthcare gaps in the care of older adults at risk for Alzheimer's disease and related dementias (ADRD) who have elected surgery with anesthesia. It summarizes concerns regarding ADRD perioperative healthcare, perioperative cognitive, and neuronal domains of vulnerability. It also offers a plan for phased preoperative cognitive screening and perioperative cognitive intervention opportunities. An argument is made for why medical professionals in the perioperative setting need fundamental training in cognitive-behavioral principles, an understanding of neurodegenerative diseases of aging, and an appreciation of the immediate and long-term medical risks for such patients undergoing anesthesia. The author's goal is to encourage readers to consider perioperative cognitive medicine as a new frontier for generating evidence-based care approaches for at-risk older adults with neurodegenerative disorders who require procedures with anesthesia.
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Affiliation(s)
- Catherine C Price
- Clinical and Health Psychology, Anesthesiology, University of Florida, Gainesville, FL, USA.
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13
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Oyeyemi DM, Cooter M, Chung S, Whitson HE, Browndyke JN, Devinney MJ, Smith PJ, Garrigues GE, Moretti E, Moul JW, Cohen HJ, Mathew JP, Berger M. Relationship Between Depression/Anxiety and Cognitive Function Before and 6 Weeks After Major Non-Cardiac Surgery in Older Adults. J Geriatr Psychiatry Neurol 2022; 35:145-154. [PMID: 33380241 PMCID: PMC8243391 DOI: 10.1177/0891988720978791] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the relationship between affective measures and cognition before and after non-cardiac surgery in older adults. METHODS Observational prospective cohort study in 103 surgical patients age ≥ 60 years old. All participants underwent cognitive testing, Center for Epidemiologic Studies-Depression, and State Anxiety Inventory screening before and 6 weeks after surgery. Cognitive test scores were combined by factor analysis into 4 cognitive domains, whose mean was defined as the continuous cognitive index (CCI). Postoperative global cognitive change was defined by CCI change from before to after surgery, with negative CCI change indicating worsened postoperative global cognition and vice versa. RESULTS Lower global cognition before surgery was associated with greater baseline depression severity (Spearman's r = -0.30, p = 0.002) and baseline anxiety severity (Spearman's r = -0.25, p = 0.010), and these associations were similar following surgery (r = -0.36, p < 0.001; r = -0.26, p = 0.008, respectively). Neither baseline depression or anxiety severity, nor postoperative changes in depression or anxiety severity, were associated with pre- to postoperative global cognitive change. CONCLUSIONS Greater depression and anxiety severity were each associated with poorer cognitive performance both before and after surgery in older adults. Yet, neither baseline depression or anxiety symptoms, nor postoperative change in these symptoms, were associated with postoperative cognitive change.
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Affiliation(s)
- Deborah M Oyeyemi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Stacey Chung
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Heather E Whitson
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey N Browndyke
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Center for Cognitive Neuroscience, Duke Institute for Brain Sciences, Duke University, Durham, NC, USA
| | - Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Eugene Moretti
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Judd W Moul
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Harvey Jay Cohen
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
- Center for Cognitive Neuroscience, Duke Institute for Brain Sciences, Duke University, Durham, NC, USA
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14
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Chen W, Sun JN, Hu ZH, Zhang Y, Chen XY, Feng S. Cognitive behavioral therapy cannot relieve postoperative pain and improve joint function after total knee arthroplasty in patients aged 70 years and older. Aging Clin Exp Res 2021; 33:3293-3302. [PMID: 33991330 DOI: 10.1007/s40520-021-01870-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/22/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE A randomized controlled trial was conducted to investigate whether cognitive behavioral therapy (CBT) can improve postoperative pain, knee function, and negative emotion in patients aged 70 years and older who underwent total knee arthroplasty (TKA). METHODS This study used randomized, parallel group, controlled trial to divide the included 90 patients into CBT group and usual care group. The primary outcome measure of the study was the Visual Analogue Scale (VAS) at activity. The secondary outcome measures included the Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Knee Range of Motion (ROM), Oxford Knee Score (OKS), Hospital for Special Surgery Knee Rating Scale (HSS), analgesics dose, and postoperative complications. RESULTS 83 patients who met the criteria were randomized into CBT group and usual care group. In the SAS, score of the CBT group decreased by 4.3 points at 7th day and 8.2 at 14th day after surgery with respect to preoperative SAS score, the usual care group increased by 1.5 at 7th day and decreased 1.1 at 14th day, and tended to be similar at 3rd month after surgery. There were no significant differences at 7th and 14th day in SDS, however, score of the CBT group was 5.8 and the usual care group was 1.9 at 3rd month after surgery. No statistically significant differences in VAS at activity, ROM, OKS, HSS, analgesics frequency, and postoperative complications between two groups. CONCLUSIONS CBT was superior to usual care group in relieving anxiety at 7th day and 14th day, and depression at 3rd month, however, CBT cannot relieve postoperative pain and improve joint function after TKA in patients aged 70 years and older.
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Affiliation(s)
- Wang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China
| | - Jian-Ning Sun
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China
| | - Zheng-Hao Hu
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China
| | - Ye Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China
| | - Xiang-Yang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China.
| | - Shuo Feng
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, Xuzhou, 221002, Jiangsu, China.
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15
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Ghezzi ES, Ross TJ, Sharman R, Davis D, Boord MS, Thanabalan T, Thomas J, Keage HAD. The neuropsychological profile of delirium vulnerability: A systematic review and meta-analysis. Neurosci Biobehav Rev 2021; 132:248-259. [PMID: 34863781 DOI: 10.1016/j.neubiorev.2021.11.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 12/17/2022]
Abstract
Delirium is a common neurocognitive disorder in hospitalised older adults with substantial negative consequences. Impaired global cognition is a well-established delirium risk factor. However, poor performance on attention tests and higher intra-subject variability may be more sensitive delirium risk factors, given the disorder is characterised by a fluctuating course and attentional deficits. We systematically searched databases (Embase, PsycINFO, MEDLINE) and 44 studies satisfied inclusion criteria. Random-effects meta-analysis models showed poor performance in all cognitive domains except perception was significantly associated with incident delirium. Largest effects were for orientation (g=-1.20) and construction and motor performance (g=-0.60). These effects were no longer significant in the subgroup without pre-existing cognitive impairment, where executive functions and verbal functions and language skills were associated with incident delirium. A small, non-significant association between intra-subject variability and incident delirium was found (g=0.42). Cognitive domain specific tests may be quicker and more sensitive predictors of incident delirium. This pattern of neuropsychological findings supports the proposition that vulnerability for delirium manifests as a dysfunction of whole-brain information integration.
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Affiliation(s)
- Erica S Ghezzi
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia.
| | - Tyler J Ross
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Rhianna Sharman
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing Unit at UCL, London, United Kingdom
| | - Monique S Boord
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Thivina Thanabalan
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Jessica Thomas
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
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16
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O’Gara BP, Gao L, Marcantonio ER, Subramaniam B. Sleep, Pain, and Cognition: Modifiable Targets for Optimal Perioperative Brain Health. Anesthesiology 2021; 135:1132-1152. [PMID: 34731233 PMCID: PMC8578455 DOI: 10.1097/aln.0000000000004046] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The prevention of perioperative neurocognitive disorders is a priority for patients, families, clinicians, and researchers. Given the multiple risk factors present throughout the perioperative period, a multicomponent preventative approach may be most effective. The objectives of this narrative review are to highlight the importance of sleep, pain, and cognition on the risk of perioperative neurocognitive disorders and to discuss the evidence behind interventions targeting these modifiable risk factors. Sleep disruption is associated with postoperative delirium, but the benefit of sleep-related interventions is uncertain. Pain is a risk factor for postoperative delirium, but its impact on other postoperative neurocognitive disorders is unknown. Multimodal analgesia and opioid avoidance are emerging as best practices, but data supporting their efficacy to prevent delirium are limited. Poor preoperative cognitive function is a strong predictor of postoperative neurocognitive disorder, and work is ongoing to determine whether it can be modified to prevent perioperative neurocognitive disorders.
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Affiliation(s)
- Brian P O’Gara
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
| | - Lei Gao
- Massachusetts General Hospital. Department of Anesthesia. Harvard Medical School. Boston, MA, USA
| | - Edward R Marcantonio
- Beth Israel Deaconess Medical Center. Department of Medicine. Harvard Medical School. Boston, MA, USA
| | - Balachundhar Subramaniam
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
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17
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Zhang GQ, Canner JK, Prince EJ, Stem M, Taylor JP, Efron JE, Atallah C, Safar B. History of depression is associated with worsened postoperative outcomes following colectomy. Colorectal Dis 2021; 23:2559-2566. [PMID: 34166552 DOI: 10.1111/codi.15790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/21/2021] [Accepted: 06/10/2021] [Indexed: 02/08/2023]
Abstract
AIM Depression is a prevalent disorder that is associated with adverse health outcomes, but an understanding of its effect in colorectal surgery remains limited. The purpose of this study was to examine the impact of history of depression among patients undergoing colectomy. METHOD United States patients from Marketscan (2010-2017) who underwent colectomy were included and stratified by whether they had a history of depression within the past year, defined as (1) a diagnosis of depression during the index admission, (2) a diagnosis of depression during any inpatient or (3) outpatient admission within the year, and/or (4) a pharmacy claim for an antidepressant within the year. The primary outcomes were length of stay (LOS) and inpatient hospital charge. Secondary outcomes included in-hospital mortality and postoperative complications. Logistic, negative binomial, and quantile regressions were performed. RESULTS Among 88 981 patients, 21 878 (24.6%) had a history of depression. Compared to those without, patients with a history of depression had significantly longer LOS (IRR = 1.06, 95% CI [1.05, 1.07]), increased inpatient charge (β = 467, 95% CI [167, 767]), and increased odds of in-hospital mortality (OR = 1.37, 95% CI [1.08, 1.73]) after adjustment. History of depression was also independently associated with increased odds of respiratory complication, pneumonia, and delirium (all P < 0.05). CONCLUSION History of depression was prevalent among individuals undergoing colectomy, and associated with greater mortality and inpatient charge, longer LOS, and higher odds of postoperative complication. These findings highlight the impact of depression in colorectal surgery patients and suggest that proper identification and treatment may reduce postoperative morbidity.
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Affiliation(s)
- George Q Zhang
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth J Prince
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James P Taylor
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Falk A, Kåhlin J, Nymark C, Hultgren R, Stenman M. Depression as a predictor of postoperative delirium after cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2021; 32:371-379. [PMID: 33831217 DOI: 10.1093/icvts/ivaa277] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Depression is common in patients with cardiac disease. The importance of preoperative depression for development of postoperative delirium (POD) following cardiac surgery is not well known. The aim is to provide a summary estimate of depression as a predictor of POD following cardiac surgery. METHODS Systematic search of MEDLINE, EMBASE, Cochrane Library, Web of Science Core Collection and Psycinfo (Ovid) was performed from inception to October 2019, including cohort studies reporting odds ratios (ORs) and 95% confidence intervals (CIs) for POD following cardiac surgery in patients with preoperative depression compared to patients without depression. ORs and 95% CIs for POD were calculated using random-effects meta-analyses. Subgroup and sensitivity analyses were performed. RESULTS Seven studies were included with a combined study population of 2066 patients. The pooled prevalence of POD in the combined study population was 26% and preoperative depression was present in ∼9% of the total study population. All studies showed a positive association between preoperative depression and POD; and in 5 studies, the association was statistically significant. Patients with depression had a pooled OR of 2.31 (95% CI 1.37-3.90) for POD. CONCLUSIONS This systematic review and meta-analysis confirm the findings that the previous association between preoperative depression and increased risk for developing POD reported for other patient groups is found also in cardiac surgery. Depression screening prior to cardiac surgery may be effective in identifying patients at higher risk for POD.
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Affiliation(s)
- Anna Falk
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Jessica Kåhlin
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Carolin Nymark
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
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19
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Mychajliw C, Herrmann ML, Suenkel U, Brand K, von Thaler AK, Wurster I, Yilmaz R, Eschweiler GW, Metzger FG. Impaired Executive Function and Depression as Independent Risk Factors for Reported Delirium Symptoms: An Observational Cohort Study Over 8 Years. Front Aging Neurosci 2021; 13:676734. [PMID: 34163350 PMCID: PMC8215445 DOI: 10.3389/fnagi.2021.676734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/21/2021] [Indexed: 12/26/2022] Open
Abstract
Background Acute medical illnesses, surgical interventions, or admissions to hospital in older individuals are frequently associated with a delirium. In this cohort study, we investigated the impact of specific cognitive domains and depression before the occurrence of delirium symptoms in an 8-year observation of older non-hospitalized individuals. Methods In total, we included 807 participants (48–83 years). Deficits in specific cognitive domains were measured using the CERAD test battery, and depressive symptoms were measured using Beck Depression Inventory and the Geriatric Depression Scale (GDS) before the onset of a delirium. Delirium symptoms were retrospectively assessed by a questionnaire based on the established Nursing Delirium Screening Scale. Results Fifty-eight of eight hundred seven participants (7.2%) reported delirium symptoms over the 8-year course of the study. Sixty-nine percent (n = 40) of reported delirium symptoms were related to surgeries. In multivariate regression analysis, impaired executive function was an independent risk factor (p = 0.034) for the occurrence of delirium symptoms. Furthermore, age (p = 0.014), comorbidities [captured by the Charlson Comorbidity Index (CCI)] (p < 0.001), and depression (p = 0.012) were significantly associated with reported delirium symptoms. Conclusion Especially prior to elective surgery or medical interventions, screening for impaired executive function and depression could be helpful to identify patients who are at risk to develop delirium symptoms.
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Affiliation(s)
- Christian Mychajliw
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany.,Geriatric Center, University Hospital of Tübingen, Tübingen, Germany
| | - Matthias L Herrmann
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany.,Geriatric Center, University Hospital of Tübingen, Tübingen, Germany.,Department of Neurology and Neuroscience, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrike Suenkel
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
| | - Katharina Brand
- Geriatric Center, University Hospital of Tübingen, Tübingen, Germany
| | - Anna-Katharina von Thaler
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany.,Department of Neurology, University Hospital of Tübingen, Tübingen, Germany
| | - Isabel Wurster
- Department of Neurology, University Hospital of Tübingen, Tübingen, Germany.,German Center of Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany
| | - Rezzak Yilmaz
- Department of Neurology, University of Ankara Medical School, Ankara, Turkey
| | - Gerhard W Eschweiler
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany.,Geriatric Center, University Hospital of Tübingen, Tübingen, Germany
| | - Florian G Metzger
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany.,Geriatric Center, University Hospital of Tübingen, Tübingen, Germany.,Vitos Hospital for Psychiatry and Psychotherapy Haina, Haina, Germany
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20
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Kalra SS, Jaber J, Alzghoul BN, Hyde R, Parikh S, Urbine D, Reddy R. Pre-Existing Psychiatric Illness Is Associated With an Increased Risk of Delirium in Patients With Acute Respiratory Distress Syndrome. J Intensive Care Med 2021; 37:647-654. [PMID: 34041934 DOI: 10.1177/08850666211019009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with acute respiratory distress syndrome (ARDS) are highly susceptible to developing delirium for a multitude of reasons. Previous studies have linked pre-existing depression with an increased risk of postoperative delirium in patients undergoing cardiac and non-cardiac surgery. However, the evidence regarding the association between pre-existing psychiatric illnesses and delirium in ARDS patients is unknown. In this study, we aim to determine the relationship between pre-existing psychiatric illness and the risk of development of delirium amongst ARDS patients. STUDY DESIGN AND METHODS We performed a retrospective study of a mixed group of patients admitted to the intensive care unit (ICU) between January 2016 and December 2019 with a diagnosis of ARDS per the Berlin definition. The study group was divided into 2 cohorts: subjects with delirium and subjects without delirium. Comparison between the 2 groups was conducted to examine the impact of pre-existing psychiatric illnesses including major depressive disorder (MDD), generalized anxiety disorder (GAD), bipolar disorder, schizophrenia, or post-traumatic stress disorder. Multivariable logistic regression analysis was performed adjusting for benzodiazepine use, sedatives, analgesics, sequential organ failure assessment score, and corticosteroid use to determine the association between pre-existing psychiatric disorders and delirium. RESULTS 286 patients with ARDS were identified; 124 (43%) of whom were diagnosed with ICU delirium. In patients diagnosed with ICU delirium, 49.2% were found to have preexisting psychiatric illnesses, compared to 34.0% without any preexisting psychiatric illness (OR = 1.94, P = 0.01). In a subgroup analysis of individual psychiatric illnesses, GAD and MDD were associated with the development of delirium (OR = 1.88, P = 0.04 and OR = 1.76, P = 0.05 respectively). INTERPRETATION ARDS patients with preexisting psychiatric illnesses, particularly GAD and MDD are associated with an increased risk of developing ICU delirium. Clinicians should be aware of the effect of psychiatric co-morbidities on developing delirium in critically ill patients.
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Affiliation(s)
- Saminder Singh Kalra
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Johnny Jaber
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Bashar N Alzghoul
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Ryan Hyde
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sarina Parikh
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Daniel Urbine
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Raju Reddy
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA.,Oregon Health and Science University, Portland, Oregon
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21
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Jing Z, Wu D. Application of regional cerebral oxygen saturation monitoring with near-infrared spectroscopy in peri-anesthesia management of elderly hypertensive patients undergoing shoulder arthroscopic surgery. Am J Transl Res 2021; 13:5568-5574. [PMID: 34150159 PMCID: PMC8205658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 02/01/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore the effect of using regional cerebral oxygen saturation (rScO2) monitoring with near-infrared spectroscopy in peri-anesthesia management of elderly hypertensive patients undergoing shoulder arthroscopic surgery. METHODS Sixty elderly patients with hypertension undergoing shoulder arthroscopic surgery under general anesthesia were enrolled as the research objects for this prospective study, and they were randomly divided into an observation group and a control group. The observation group received bispectral index (BIS) + rScO2, while the control group only adopted BIS. The changes in BIS, mean arterial pressure (MAP), heart rate (HR), and rScO2 at 5 min after intubation (T1), 10 min after intubation (T2), immediately after changing position (T3), 5 min after changing position (T4), and 10 min after changing position (T5) of the two groups were recorded. The correlation between MAP and rScO2 was analyzed. Preoperative and postoperative Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA) scores, serum neuron-specific enolase (NSE) and s100β levels were compared between the two groups. The incidence of postoperative cognitive dysfunction (POCD) at 1-3 days was recorded. RESULTS There were no significant differences in BIS, MAP, HR, or rScO2 between the two groups at T1 and T2 (all P>0.05). At T3-T5, the levels of BIS, MAP, HR, and rScO2 in the two groups decreased, and the control group had lower levels of the above indicators (all P<0.05). Correlation analysis showed that MAP and rScO2 levels were positively correlated in the two groups (r>0, P<0.05). There were no significant differences in the MMSE or MoCA scores, NSE or s100β levels between the two groups before surgery (all P>0.05). After surgery, the MMSE and MoCA scores of the two groups were decreased (both P<0.05), while the NSE and s100β levels were increased (both P<0.05). The control group showed greater changes in the above four indexes (all P<0.05). The incidence of POCD in the observation group was lower than that of controls at 1, 2, and 3 days after surgery (all P<0.05). CONCLUSION rScO2 monitoring with near-infrared spectroscopy in peri-anesthesia management of elderly patients with hypertension undergoing shoulder arthroscopic surgery can effectively stabilize hemodynamics and reduce the incidence of postoperative POCD.
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Affiliation(s)
- Zhili Jing
- Department of Anesthesiology, Beijing Luhe Hospital, Capital Medical University Beijing, China
| | - Di Wu
- Department of Anesthesiology, Beijing Luhe Hospital, Capital Medical University Beijing, China
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22
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Wiggins ME, Dion C, Formanski E, Davoudi A, Amini S, Heilman KM, Penney D, Davis R, Garvan CW, Arnaoutakis GJ, Tighe P, Libon DJ, Price CC. Proof of concept: digital clock drawing behaviors prior to transcatheter aortic valve replacement may predict length of hospital stay and cost of care. EXPLORATION OF MEDICINE 2021; 2:110-121. [PMID: 34263257 PMCID: PMC8276939 DOI: 10.37349/emed.2021.00036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aims Reduced pre-operative cognitive functioning in older adults is a risk factor for postoperative complications, but it is unknown if preoperative digitally-acquired clock drawing test (CDT) cognitive screening variables, which allow for more nuanced examination of patient performance, may predict lengthier hospital stay and greater cost of hospital care. This issue is particularly relevant for older adults undergoing transcatheter aortic valve replacement (TAVR), as this surgical procedure is chosen for intermediate-risk older adults needing aortic replacement. This proof of concept research explored if specific latency and graphomotor variables indicative of planning from digitally-acquired command and copy clock drawing would predict post-TAVR duration and cost of hospitalization, over and above age, education, American Society of Anesthesiologists (ASA) physical status classification score, and frailty. Methods Form January 2018 to December 2019, 162 out of 190 individuals electing TAVR completed digital clock drawing as part of a hospital wide cognitive screening program. Separate hierarchical regressions were computed for the command and copy conditions of the CDT and assessed how a-priori selected clock drawing metrics (total time to completion, ideal digit placement difference, and hour hand distance from center; included within the same block) incrementally predicted outcome, as measured by R2 change significance values. Results Above and beyond age, education, ASA physical status classification score, and frailty, only digitally-acquired CDT copy performance explained significant variance for length of hospital stay (9.5%) and cost of care (8.9%). Conclusions Digital variables from clock copy condition provided predictive value over common demographic and comorbidity variables. We hypothesize this is due to the sensitivity of the copy condition to executive dysfunction, as has been shown in previous studies for subtypes of cognitive impairment. Individuals undergoing TAVR procedures are often frail and executively compromised due to their cerebrovascular disease. We encourage additional research on the value of digitally-acquired clock drawing within different surgery types. Type of cognitive impairment and the value of digitally-acquired CDT command and copy parameters in other surgeries remain unknown.
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Affiliation(s)
- Margaret Ellenora Wiggins
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL 32610, USA.,Perioperative Cognitive Anesthesia Network (PeCAN), University of Florida, Gainesville, FL 32610, USA
| | - Catherine Dion
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL 32610, USA.,Perioperative Cognitive Anesthesia Network (PeCAN), University of Florida, Gainesville, FL 32610, USA
| | - Erin Formanski
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL 32610, USA.,Perioperative Cognitive Anesthesia Network (PeCAN), University of Florida, Gainesville, FL 32610, USA
| | - Anis Davoudi
- Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, USA
| | - Shawna Amini
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA.,Perioperative Cognitive Anesthesia Network (PeCAN), University of Florida, Gainesville, FL 32610, USA
| | - Kenneth M Heilman
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Dana Penney
- Department of Neurology, Lahey Hospital and Medical Center, Boston, Mass 02421, USA
| | - Randall Davis
- Department of Electronical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Mass 02139, USA
| | - Cynthia W Garvan
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA.,Perioperative Cognitive Anesthesia Network (PeCAN), University of Florida, Gainesville, FL 32610, USA
| | - George J Arnaoutakis
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Patrick Tighe
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA.,Perioperative Cognitive Anesthesia Network (PeCAN), University of Florida, Gainesville, FL 32610, USA
| | - David J Libon
- Department of Geriatrics and Gerontology, New Jersey Institute for Successful Aging, Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA
| | - Catherine C Price
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL 32610, USA.,Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA.,Perioperative Cognitive Anesthesia Network (PeCAN), University of Florida, Gainesville, FL 32610, USA
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23
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Ma J, Li C, Zhang W, Zhou L, Shu S, Wang S, Wang D, Chai X. Preoperative anxiety predicted the incidence of postoperative delirium in patients undergoing total hip arthroplasty: a prospective cohort study. BMC Anesthesiol 2021; 21:48. [PMID: 33579195 PMCID: PMC7879687 DOI: 10.1186/s12871-021-01271-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/08/2021] [Indexed: 12/16/2022] Open
Abstract
Background Delirium was characterized with a series of symptoms of a sudden onset of disturbances in attention, a loss in memory loss and defects in other cognitive abilities that were also appeared in the syndrome of anxiety. Even though there are overlapped clinical symptoms existed in anxiety and delirium, the relationship between anxiety and delirium was still unclear. The propose of this study was to investigated the effect of preoperative anxiety on postoperative delirium. Methods Three hundred and seventy-two adults undergoing total hip arthroplasty were enrolled from October 2019 to May 2020 in the study. The preoperative anxiety was measured with the Hospital Anxiety and Depression Scale-Anxiety (HADS-A). The participants were allocated into anxiety group (HADS-A≧7) and non-anxiety group (HADS-A < 7). The primary outcome was the incidence of the postoperative delirium assessed with the Confusion Assessment Method (CAM). The secondary outcomes were the duration and the severity of delirium evaluated with the Memorial Delirium assessment Scale (MDAS). The risks of delirium were also evaluated with logistic regression analysis. Results There were 325 patients enrolled in the end, 95 of whom met the criteria for anxiety. The incidence of delirium was 17.8% in all participants. The patients with anxiety had a higher incidence of delirium than the non-anxiety patients (25.3% vs. 14.8%, odds ratio (OR) = 0.51, 95% confidence interval (CI) = 0.92–0.29, p = 0.025). However, no significant differences were found in the duration and the severity of the delirium between the above two groups. The age, alcohol abuse, history of stroke, scores of the HADS-A, and education level were considered to be predictors of delirium. Conclusions The preoperative anxiety predicted the incidence of the postoperative delirium in total hip arthroplasty patients. The related intervention may be a good point for delirium prophylaxis. Trial registration It was registered at Chinese Clinical Trial Registry (www.chictr.org.cn) with the name of “the effect of preoperative anxiety on the postoperative cognitive function” (ChiCTR1900026054) at September 19, 2019.
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Affiliation(s)
- Jun Ma
- Anhui Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China.,Department of Anesthesiology, The First Affiliated Hospital of USTC, Hefei, 230001, Anhui, China
| | - Chuanyao Li
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Hefei, 230001, Anhui, China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Hefei, 230001, Anhui, China
| | - Ling Zhou
- Anhui Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China.,Department of Anesthesiology, The First Affiliated Hospital of USTC, Hefei, 230001, Anhui, China
| | - Shuhua Shu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Hefei, 230001, Anhui, China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Hefei, 230001, Anhui, China
| | - Di Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Hefei, 230001, Anhui, China
| | - Xiaoqing Chai
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Hefei, 230001, Anhui, China.
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24
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Arias F, Chen F, Fong TG, Shiff H, Alegria M, Marcantonio ER, Gou Y, Jones RN, Travison TG, Schmitt EM, Kind AJ, Inouye SK. Neighborhood-Level Social Disadvantage and Risk of Delirium Following Major Surgery. J Am Geriatr Soc 2020; 68:2863-2871. [PMID: 32865254 PMCID: PMC7744425 DOI: 10.1111/jgs.16782] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/13/2020] [Accepted: 07/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND/OBJECTIVES Delirium is a common postoperative complication associated with prolonged length of stay, hospital readmission, and premature mortality. We explored the association between neighborhood-level characteristics and delirium incidence and severity, and compared neighborhood- with individual-level indicators of socioeconomic status in predicting delirium incidence. DESIGN A prospective observational cohort of patients enrolled between June 18, 2010, and August 8, 2013. Baseline interviews were conducted before surgery, and delirium/delirium severity was evaluated daily during hospitalization. Research staff evaluating delirium were blinded to baseline cognitive status. SETTING Two academic medical centers in Boston, MA. PARTICIPANTS A total of 560 older adults, aged 70 years or older, undergoing major noncardiac surgery. INTERVENTION The Area Deprivation Index (ADI) was used to characterize each neighborhood's socioeconomic disadvantage. MEASUREMENTS Delirium was assessed using the Confusion Assessment Method (CAM) long form. Delirium severity was calculated using the highest value of CAM Severity score (CAM-S) occurring during daily hospital assessments (CAM-S Peak). RESULTS Residing in the most disadvantaged neighborhoods (ADI > 44) was associated with a higher risk of incident delirium (12/26; 46%), compared with the least disadvantaged neighborhoods (122/534; 23%) (risk ratio (RR) (95% confidence interval (CI)) = 2.0 (1.3-3.1). The CAM-S Peak score was significantly associated with ADI (Spearman rank correlation, ρ = 0.11; P = .009). Mean CAM-S Peak scores generally rose from 3.7 to 5.3 across levels of increasing neighborhood disadvantage. The RR (95% CI) values associated with individual-level markers of socioeconomic status and cultural background were: 1.2 (0.9-1.7) for education of 12 years or less; 1.3 (0.8-2.1) for non-White race; and 1.7 (1.1-2.6) for annual household income of less than $20,000. None of these individual-level markers exceeded the ADI in terms of effect size or significance for prediction of delirium risk. CONCLUSIONS Neighborhood-level makers of social disadvantage are associated with delirium incidence and severity, and demonstrated an exposure-response relationship. Future studies should consider contextual-level metrics, such as the ADI, as risk markers of social disadvantage that can help to guide delirium treatment and prevention.
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Affiliation(s)
- Franchesca Arias
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Fan Chen
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA 02131, USA
| | - Tamara G. Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Haley Shiff
- Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Margarita Alegria
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Medicine and Psychiatry, Harvard Medical School, Boston, MA 02115
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA 02115, USA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA 02131, USA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University, Warren Alpert Medical School, Providence, RI 02912, USA
| | - Thomas G. Travison
- Harvard Medical School, Boston, MA 02115, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA 02131, USA
| | - Eva M. Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
| | - Amy J.H. Kind
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison WI 53705, USA
- Madison VA Geriatrics Research Education and Clinical Center (GRECC), Middleton VA Hospital, Madison WI 53705, USA
| | - Sharon K. Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Harvard Medical School, Boston, MA 02115, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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25
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 394] [Impact Index Per Article: 98.5] [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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26
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Preoperative Anxiety and Depression Increases the Incidence of Delirium After Coronary Artery Bypass Graft Surgery. J Perianesth Nurs 2020; 35:496-501. [DOI: 10.1016/j.jopan.2020.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/19/2020] [Accepted: 01/19/2020] [Indexed: 12/18/2022]
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27
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Wiggins M, Arias F, Urman RD, Richman DC, Sweitzer BJ, Edwards AF, Armstrong MJ, Chopra A, Libon DJ, Price C. Common neurodegenerative disorders in the perioperative setting: Recommendations for screening from the Society for Perioperative Assessment and Quality Improvement (SPAQI). PERIOPERATIVE CARE AND OPERATING ROOM MANAGEMENT 2020; 20:100092. [PMID: 32577538 PMCID: PMC7311090 DOI: 10.1016/j.pcorm.2020.100092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Aging is associated with normal and abnormal brain and cognitive changes. Due to the expected increase in older adults requiring surgery, perioperative clinicians will be increasingly encountering patients with neurodegenerative disease. To help perioperative clinicians understand signs of abnormal behaviors that may mark an undiagnosed neurodegenerative disorder and alert additional patient monitoring, The Society for Perioperative Assessment and Quality Improvement (SPAQI) worked with experts in dementia, neuropsychology, geriatric medicine, neurology, and anesthesiology to provide a summary of cognitive and behavioral considerations for patients with common neurodegenerative disorders being evaluated at preoperative centers. Patients with neurodegenerative disorders are at high risk for delirium due to known neurochemical disruptions, medication interactions, associated frailty, or vascular risk profiles presenting risk for repeat strokes. We provide basic information on the expected cognitive changes with aging, most common neurodegenerative disorders, a list of behavioral features and considerations to help differentiate neurodegenerative disorders. Finally, we propose screening recommendations intended for a multidisciplinary team in the perioperative setting.
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Affiliation(s)
- Margaret Wiggins
- Department of Clinical and Health Psychology, University of Florida, 1225 Center Drive, Gainesville, FL 32603
| | - Franchesca Arias
- Department of Clinical and Health Psychology, University of Florida, 1225 Center Drive, Gainesville, FL 32603
- Pain Research and Intervention Center of Excellence (PRICE), 101 S. Newell Drive, Gainesville, FL 32610
- Perioperative Cognitive Anesthesia Network (PeCAN), UF Health Shands Hospital, 1600 SW Archer Road Suite 1111, Gainesville, FL 32608
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115
| | - Deborah C Richman
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480
| | - Bobbie Jean Sweitzer
- Northwestern University Feinberg School of Medicine, 251 East Huron, Chicago, IL 60611
| | - Angela F Edwards
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Melissa J Armstrong
- Norman Fixel Institute for Neurological Diseases, University of Florida, 3009 Williston Road, Gainesville, Florida 32608
- Neurology Department, University of Florida, 101 S Newell Drive, Gainesville, FL 32610
| | - Anita Chopra
- Department of Geriatrics and Gerontology, Department of Psychology, New Jersey Institute for Successful Aging, School of Osteopathic Medicine, Rowan University, Stratford, NJ 08084
| | - David J Libon
- Department of Geriatrics and Gerontology, Department of Psychology, New Jersey Institute for Successful Aging, School of Osteopathic Medicine, Rowan University, Stratford, NJ 08084
| | - Catherine Price
- Department of Clinical and Health Psychology, University of Florida, 1225 Center Drive, Gainesville, FL 32603
- Perioperative Cognitive Anesthesia Network (PeCAN), UF Health Shands Hospital, 1600 SW Archer Road Suite 1111, Gainesville, FL 32608
- Department of Anesthesiology, The University of Florida, Department of Anesthesiology, 1600 SW Archer Road PO Box 100254, Gainesville, FL 32610
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Eshmawey M, Arlt S, Ledschbor-Frahnert C, Guenther U, Popp J. Preoperative Depression and Plasma Cortisol Levels as Predictors of Delirium after Cardiac Surgery. Dement Geriatr Cogn Disord 2020; 48:207-214. [PMID: 32008004 DOI: 10.1159/000505574] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/19/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Delirium is common in old patients who undergo cardiac surgery, and it is associated with adverse outcomes. The genesis of delirium is thought to be multi-factorial, but it is still not well understood. Symptoms of depression and elevated cortisol level have been described in some previous studies as factors associated with delirium, suggesting a shared pathophysiology. AIMS The objective of the present study was to determine whether preoperative depression symptoms and increased cortisol level represent risk factors for delirium after cardiac surgery. METHODS We performed a prospective cohort study in 183 patients aged >50 years undergoing elective cardiac surgery. The Geriatric Depression Scale (GDS) was used to assess patients for depressive symptoms before surgery. Preoperative plasma cortisol levels were available in 145 participants. Delirium was diagnosed using the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) during the first 7 days after surgery. Spearman correlation was used for correlations between GDS, Mini-Mental State Examination (MMSE), Charlson comorbidity index, and age. Binary logistic regression was used to determine whether GDS and cortisol levels predict postoperative delirium. RESULTS Delirium occurred in 60 patients out of 183 (32.8%) included and lasted 2.3 days (SD 1.36). GDS was correlated with age (p = 0.001) and comorbidity index (p = 0.003) and inversely correlated with MMSE score (p < 0.001). Higher preoperative GDS scores were associated with incidence of delirium in the postoperative period (p = 0.002). The association was significant after controlling for age, MMSE score, history of stroke, and Charlson comorbidity index (p = 0.045). Preoperative cortisol level was not associated with the development of postoperative delirium. CONCLUSION Our results suggest that a higher preoperative depression score is associated with an increased risk of postoperative delirium. On the other hand, preoperative plasma cortisol level does not seem to be a predictor of delirium after surgery. Further studies are needed to determine the potential of preoperative depression treatment to prevent postoperative delirium.
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Affiliation(s)
- Mohamed Eshmawey
- Geriatric Psychiatry, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland,
| | - Sönke Arlt
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Ulf Guenther
- University Clinic of Anesthesiology, Intensive Care, Emergency Medicine, Pain Therapy, Klinikum Oldenburg, Oldenburg, Germany
| | - Julius Popp
- Geriatric Psychiatry, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland.,Department of Geriatric Psychiatry, University Hospital of Psychiatry Zurich, Zurich, Switzerland
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Franco JG, Trzepacz PT, Velásquez-Tirado JD, Ocampo MV, Serna PA, Giraldo AM, López C, Zuluaga A, Zaraza-Morales D. Discriminant Performance of Dysexecutive and Frontal Release Signs for Delirium in Patients With High Dementia Prevalence: Implications for Neural Network Impairment. J Acad Consult Liaison Psychiatry 2020; 62:56-69. [PMID: 32444154 DOI: 10.1016/j.psym.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prevalence of signs of abnormal executive function (EF) and primitive reflexes (PR) with delirium in older hospitalized patients with or without comorbid dementia has not been reported. OBJECTIVE To describe prevalence of signs of EF deficits and PR in older inpatients and their discriminant value for delirium while accounting for dementia. METHODS Participants were evaluated for delirium using the Diagnostic and Statistical Manual of Mental Disorders 5th edition and the Delirium Rating Scale Revised-98, dementia using Informant Questionnaire on Cognitive Decline in the Elderly, and signs of PR (n = 5) and EF deficits (n = 3) using bedside neuropsychiatric examination. Three indices (PR, EF, and Combined) and 4 diagnostic groups were created for correlational and discriminant analyses. RESULTS Correlations of indices were higher with the Delirium Rating Scale Revised-98 than with the Informant Questionnaire on Cognitive Decline in the Elderly and even higher in those with dementia, especially the Combined index (Delirium Frontal Index). Among individual signs, glabellar and Simple Luria Hand Sequence were most common in delirium and the best for delirium discrimination irrespective of dementia status. The Combined index had about 80% sensitivity and specificity at the ≥2 cutoff in the whole cohort (positive and negative predictive values and likelihood ratios: PPV 50.0%, NPV 93.8%, +LR 3.82, -LR 0.25). The Combined index also had the best performance on discriminating delirium in dementia patients at the ≥3 cutoff, with about 80% for both sensitivity and specificity. CONCLUSIONS PR and EF deficit signs are consistent with reduced neural network integration during delirium, even worse in those with dementia whose baseline structural injury impairs network connectivity with frontal regions. We recommend simple bedside assessment of PR and EF signs to help assess for delirium as an indicator of cerebral cortical neural network impairment in older persons.
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Affiliation(s)
- José G Franco
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Paula T Trzepacz
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Juan D Velásquez-Tirado
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - María V Ocampo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Paola A Serna
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Alejandra M Giraldo
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Carolina López
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Adolfo Zuluaga
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Daniel Zaraza-Morales
- Grupo de Investigación en Cuidado, Facultad de Enfermería, Universidad Pontificia Bolivariana, Medellín, Colombia
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Hindiskere S, Kim HS, Han I. Postoperative delirium in patients undergoing surgery for bone metastases. Medicine (Baltimore) 2020; 99:e20159. [PMID: 32443331 PMCID: PMC7254856 DOI: 10.1097/md.0000000000020159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 11/28/2022] Open
Abstract
Postoperative delirium (PD), characterized by acute onset of global impairment in consciousness and cognition, is a common complication following major surgeries and is often associated with adverse outcomes. Because of the multiple comorbidities of the patient along with extensive nature of the surgery, patients undergoing surgery for bone metastases may be prone to developing PD. However, no study exists regarding PD in patients who undergo surgery for bone metastases.Two hundred seventy six patients with mean age of 64 years (range, 16-94) who underwent surgery for bone metastases were reviewed. The diagnosis of PD was made by the psychiatrist, according to fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Possible perioperative clinic-pathologic factors that may be associated with the development of PD were investigated.Among the 276 patients, 9% (n = 25) developed PD. On multivariate logistic regression analysis, history of psychiatric disorders (odds ratio [OR] = 9.63; 95% confidence interval [CI] 1.78-21.74, P = .004), high preoperative serum C-reactive protein (CRP) level (OR = 1.17; 95% CI 1.06-1.29, P = .001), low preoperative serum albumin level (OR = 0.13; 95% CI 0.03-0.48, P = 0.002), and high dose of opioid analgesics received in the immediate postoperative period (OR = 1.05; 95% CI 1.01-1.07, P = .001) were independently associated with the development of PD. Patients with PD had lower survival (log rank, P = .001) than patients without PD.Incidence of PD is considerable in patients undergoing surgery for bone metastases. History of psychiatric disorders, preoperative serum albumin and CRP levels, and the dose of postoperative opioid analgesics are associated with the development of PD.
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Affiliation(s)
- Suraj Hindiskere
- Department of Orthopaedic Surgery, Seoul National University Hospital
| | - Han-Soo Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ilkyu Han
- Department of Orthopaedic Surgery, Seoul National University Hospital
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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The Devil Is in the Details: Comparison of Postoperative Delirium and Neurocognitive Dysfunction. Anesthesiology 2019; 131:456-458. [PMID: 31166239 DOI: 10.1097/aln.0000000000002823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lindroth H, Bratzke L, Twadell S, Rowley P, Kildow J, Danner M, Turner L, Hernandez B, Brown R, Sanders RD. Predicting postoperative delirium severity in older adults: The role of surgical risk and executive function. Int J Geriatr Psychiatry 2019; 34:1018-1028. [PMID: 30907449 PMCID: PMC6579704 DOI: 10.1002/gps.5104] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/20/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Delirium is an important postoperative complication, yet predictive risk factors for postoperative delirium severity remain elusive. We hypothesized that the NSQIP risk calculation for serious complications (NSQIP-SC) or risk of death (NSQIP-D), and cognitive tests of executive function (Trail Making Tests A and B [TMTA and TMTB]), would be predictive of postoperative delirium severity. Further, we demonstrate how advanced statistical techniques can be used to identify candidate predictors. METHODS/DESIGN Data from an ongoing perioperative prospective cohort study of 100 adults (65 y old or older) undergoing noncardiac surgery were analyzed. In addition to NSQIP-SC, NSQIP-D, TMTA, and TMTB, participant age, sex, American Society of Anesthesiologists (ASA) score, tobacco use, surgery type, depression, Framingham risk score, and preoperative blood pressure were collected. The Delirium Rating Scale-R-98 (DRS) measured delirium severity; the Confusion Assessment Method (CAM) identified delirium. LASSO and best subsets linear regression were employed to identify predictive risk factors. RESULTS Ninety-seven participants with a mean age of 71.68 ± 4.55, 55% male (31/97 CAM+, 32%), and a mean peak DRS of 21.5 ± 6.40 were analyzed. LASSO and best subsets regression identified NSQIP-SC and TMTB to predict postoperative delirium severity (P < 00.001, adjusted R2 : 0.30). NSQIP-SC and TMTB were also selected as predictors for postoperative delirium incidence (AUROC 0.81, 95% CI, 0.72-0.90). CONCLUSIONS In this cohort, we identified NSQIP risk score for serious complications and a measure of executive function, TMT-B, to predict postoperative delirium severity using advanced modeling techniques. Future studies should investigate the utility of these variables in a formal delirium severity prediction model.
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Affiliation(s)
- Heidi Lindroth
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI,School of Nursing, University of Wisconsin-Madison, Madison, WI,School of Medicine-Center for Aging Research, Department of Medicine, Indiana University, Indianapolis, IN @minipixie26
| | - Lisa Bratzke
- School of Nursing, University of Wisconsin-Madison, Madison, WI
| | - Sara Twadell
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI,Charles E. Schmidt College of Medicine, Florida Atlantic University
| | - Paul Rowley
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Janie Kildow
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI,School of Medicine, Indiana University, Indianapolis, IN
| | - Mara Danner
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Lily Turner
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Brandon Hernandez
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Roger Brown
- School of Nursing, University of Wisconsin-Madison, Madison, WI
| | - Robert D. Sanders
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI,Corresponding author: Robert D. Sanders, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC Madison, WI 53792-3272 Telephone: 608-263-8100 Fax: 608-263-0575 Madison, USA.
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Wada S, Inoguchi H, Sadahiro R, Matsuoka YJ, Uchitomi Y, Sato T, Shimada K, Yoshimoto S, Daiko H, Shimizu K. Preoperative Anxiety as a Predictor of Delirium in Cancer Patients: A Prospective Observational Cohort Study. World J Surg 2019; 43:134-142. [PMID: 30128769 DOI: 10.1007/s00268-018-4761-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Postoperative delirium is a common and important complication in cancer patients. We need to identify patients at high risk of postoperative delirium such that it can be prevented preoperatively or in early postoperative phase. The aim of this study was to investigate whether preoperative anxiety predicted onset of postoperative delirium in cancer patients, not only in order to identify high-risk groups but also to help develop new preventive approaches. METHODS This was a prospective observational cohort study of cancer patients undergoing tumor resections. Postoperative delirium was assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Preoperative anxiety was evaluated with the Hospital Anxiety and Depression Scale-Anxiety (HADS-A), and we defined HADS-A > 7 as clinical anxiety. We conducted multivariate logistic regression to determine which factors were predictors of delirium. RESULTS The final analysis included 91 patients, 29 of whom met the criteria for postoperative delirium. In multivariable logistic regression, age (5-year increments; odds ratio (OR) = 1.565, 95% confidence interval (CI) = 1.057-2.317, p = 0.025) and HADS-A > 7 (OR = 4.370, 95% CI = 1.051-18.178, p = 0.043) predicted delirium onset. These variables explained 74.2% of the variance. CONCLUSIONS Preoperative anxiety strongly predicted postoperative delirium in cancer patients. Our findings suggest that preoperative anxiety may be a new target for prevention of postoperative delirium. Trial registration number This study was registered at UMIN000018980.
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Affiliation(s)
- Saho Wada
- Department of Psycho-Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
- Division of Health Care Research, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center Japan, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Hironobu Inoguchi
- Department of Psycho-Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
- Division of Health Care Research, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center Japan, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Yutaka J Matsuoka
- Department of Psycho-Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
- Division of Health Care Research, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center Japan, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
- Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Yosuke Uchitomi
- Department of Psycho-Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
- Division of Health Care Research, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center Japan, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
- Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center Japan, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Tetsufumi Sato
- Department of Anesthesia and Intensive Care, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Kazuaki Shimada
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Seichi Yoshimoto
- Department of Head and Neck Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan
| | - Ken Shimizu
- Department of Psycho-Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan.
- Division of Health Care Research, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center Japan, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan.
- Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan.
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Sauër AC, Veldhuijzen DS, Ottens TH, Slooter AJC, Kalkman CJ, van Dijk D. Association between delirium and cognitive change after cardiac surgery. Br J Anaesth 2018; 119:308-315. [PMID: 28854542 DOI: 10.1093/bja/aex053] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 12/16/2022] Open
Abstract
Background Previous studies provide inconsistent data on whether postoperative delirium (POD) is a risk factor for postoperative cognitive decline (POCD). We thus investigated the relationship between POD and cognitive change after cardiac surgery and assessed the relationship between preoperative cognitive domain scores and POD. Methods Postoperative delirium was assessed with the Confusion Assessment Method (CAM) adapted for the intensive care unit and the conventional CAM accompanied by chart review. Cognitive function was assessed with a neuropsychological test battery before elective cardiac surgery and 1 month and 1 yr afterwards. Cognitive change was calculated using the Reliable Change Index (RCI). Multiple linear regression was used to adjust for confounding. Results Of the 184 patients who completed baseline assessment, 23 (12.5%) developed POD. At 1 month, the decline in cognitive performance was worse in patients with POD [median composite RCI -1.00, interquartile range (IQR) -1.67 to 0.28] than in patients without POD (RCI -0.04, IQR -0.70 to 0.63, P =0.02). At 1 yr, both groups showed cognitive improvement on average compared with baseline (POD patients median composite RCI 0.25, IQR -0.42 to 1.31, vs non-POD patients RCI 0.92, IQR 0.18-1.53; P =0.08). Correction for differences in age and level of education did not change the results. Patients with POD performed less well than patients without POD on the preoperative Trailmaking test part A ( P =0.03). Conclusions Postoperative delirium is independently associated with cognitive decline 1 month after surgery, but cognitive performance generally recovers in 1 yr. Patients with a predisposition to POD can be identified before surgery by worse performance in an attention task. Clinical trial registration NCT00293592.
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Affiliation(s)
- A C Sauër
- Department of Anesthesiology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - D S Veldhuijzen
- Department of Anesthesiology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.,Institute of Psychology, Health, Medical, and Neuropsychology Unit, Faculty of Social Sciences, Leiden University, PO Box 9555, RB 2300 Leiden, The Netherlands
| | - T H Ottens
- Department of Anesthesiology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - C J Kalkman
- Department of Anesthesiology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - D van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Maldonado JR. Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure. Int J Geriatr Psychiatry 2018; 33:1428-1457. [PMID: 29278283 DOI: 10.1002/gps.4823] [Citation(s) in RCA: 268] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/19/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delirium is the most common neuropsychiatric syndrome encountered by clinicians dealing with older adults and the medically ill and is best characterized by 5 core domains: cognitive deficits, attentional deficits, circadian rhythm dysregulation, emotional dysregulation, and alteration in psychomotor functioning. DESIGN An extensive literature review and consolidation of published data into a novel interpretation of known pathophysiological causes of delirium. RESULTS Available data suggest that numerous pathological factors may serve as precipitants for delirium, each having differential effects depending on patient-specific patient physiological characteristics (substrate). On the basis of an extensive literature search, a newly proposed theory, the systems integration failure hypothesis, was developed to bring together the most salient previously described theories, by describing the various contributions from each into a complex web of pathways-highlighting areas of intersection and commonalities and explaining how the variable contribution of these may lead to the development of various cognitive and behavioral dysfunctions characteristic of delirium. The specific cognitive and behavioral manifestations of the specific delirium picture result from a combination of neurotransmitter function and availability, variability in integration and processing of sensory information, motor responses to both external and internal cues, and the degree of breakdown in neuronal network connectivity, hence the term acute brain failure. CONCLUSIONS The systems integration failure hypothesis attempts to explain how the various proposed delirium pathophysiologic theories interact with each other, causing various clinically observed delirium phenotypes. A better understanding of the underlying pathophysiology of delirium may eventually assist in designing better prevention and management approaches.
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Safavynia SA, Arora S, Pryor KO, García PS. An update on postoperative delirium: Clinical features, neuropathogenesis, and perioperative management. CURRENT ANESTHESIOLOGY REPORTS 2018; 8:252-262. [PMID: 30555281 PMCID: PMC6290904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE OF REVIEW We present a focused review on postoperative delirium for anesthesiologists, encompassing clinical features, neuropathogenesis, and clinical identification and management strategies based on risk factors and current delirium treatments. RECENT FINDINGS The literature on postoperative delirium is dominated by non-experimental studies. We review delirium phenotypes, diagnostic criteria, and present standard nomenclature based on current literature. Disruption of cortical integration of complex information (CICI) may provide a framework to understand the neuropathogenesis of postoperative delirium, as well as risk factors and clinical modifiers in the perioperative period. We further divide risk factors into patient factors, surgical factors, and medical/pharmacological factors, and present specific considerations for each in the preoperative, intraoperative, and postoperative periods. SUMMARY Postoperative delirium is prevalent, poorly understood, and often missed with current screening techniques. Proper identification of risk factors is useful for perioperative interventions and can help tailor patient-specific management strategies.
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Affiliation(s)
- Seyed A. Safavynia
- Department of Anesthesiology, Weill Cornell Medical
College, New York, NY, USA
| | - Sona Arora
- Department of Anesthesiology, Emory University, Atlanta,
GA, USA
| | - Kane O. Pryor
- Department of Anesthesiology, Weill Cornell Medical
College, New York, NY, USA
| | - Paul S. García
- Department of Anesthesiology, Emory University, Atlanta,
GA, USA
- Neuroanesthesia Laboratory, Atlanta VA Medical Center/Emory
University, Atlanta, GA, USA
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Safavynia SA, Arora S, Pryor KO, García PS. An Update on Postoperative Delirium: Clinical Features,
Neuropathogenesis, and Perioperative Management. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0282-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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38
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Flanigan PM, Jahangiri A, Weinstein D, Dayani F, Chandra A, Kanungo I, Choi S, Sankaran S, Molinaro AM, McDermott MW, Berger MS, Aghi MK. Postoperative Delirium in Glioblastoma Patients: Risk Factors and Prognostic Implications. Neurosurgery 2018; 83:1161-1172. [DOI: 10.1093/neuros/nyx606] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 12/01/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Patrick M Flanigan
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Arman Jahangiri
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Drew Weinstein
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Fara Dayani
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ankush Chandra
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ishan Kanungo
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Sarah Choi
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Sujatha Sankaran
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Annette M Molinaro
- Departments of Neurological Surgery and Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, California
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Zietlow K, McDonald SR, Sloane R, Browndyke J, Lagoo-Deenadayalan S, Heflin MT. Preoperative Cognitive Impairment As a Predictor of Postoperative Outcomes in a Collaborative Care Model. J Am Geriatr Soc 2018; 66:584-589. [PMID: 29332302 DOI: 10.1111/jgs.15261] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To compare postoperative outcomes of individuals with and without cognitive impairment enrolled in the Perioperative Optimization of Senior Health (POSH) program at Duke University, a comanagement model involving surgery, anesthesia, and geriatrics. DESIGN Retrospective analysis of individuals enrolled in a quality improvement program. SETTING Tertiary academic center. PARTICIPANTS Older adults undergoing surgery and referred to POSH (N = 157). MEASUREMENTS Cognitive impairment was defined as a score less than 25 out of 30 (adjusted for education) on the St. Louis University Mental Status (SLUMS) Examination. Median length of stay (LOS), mean number of postoperative complications, rates of postoperative delirium (POD, %), 30-day readmissions (%), and discharge to home (%) were compared using bivariate analysis. RESULTS Seventy percent of participants met criteria for cognitive impairment (mean SLUMS score 20.3 for those with cognitive impairment and 27.7 for those without). Participants with and without cognitive impairment did not significantly differ in demographic characteristics, number of medications (including anticholinergics and benzodiazepines), or burden of comorbidities. Participants with and without cognitive impairment had similar LOS (P = .99), cumulative number of complications (P = .70), and 30-day readmission (P = .20). POD was more common in those with cognitive impairment (31% vs 24%), but the difference was not significant (P = .34). Participants without cognitive impairment had higher rates of discharge to home (80.4% vs 65.1%, P = .05). CONCLUSION Older adults with and without cognitive impairment referred to the POSH program fared similarly on most postoperative outcomes. Individuals with cognitive impairment may benefit from perioperative geriatric comanagement. Questions remain regarding the validity of available measures of cognition in the preoperative period.
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Affiliation(s)
- Kahli Zietlow
- Division of Geriatrics, Department of Internal Medicine, Duke University Health Systems, Durham, North Carolina
| | - Shelley R McDonald
- Division of Geriatrics, Department of Internal Medicine, Duke University Health Systems, Durham, North Carolina
| | - Richard Sloane
- Center for Aging, Duke University Health Systems, Durham, North Carolina
| | - Jeffrey Browndyke
- Division of Geriatric Behavioral Health, Department of Psychiatry, Duke University Health Systems, Durham, North Carolina
| | | | - Mitchell T Heflin
- Division of Geriatrics, Department of Internal Medicine, Duke University Health Systems, Durham, North Carolina.,Center for Aging, Duke University Health Systems, Durham, North Carolina
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Huang H, Tanner J, Parvataneni H, Rice M, Horgas A, Ding M, Price C. Impact of Total Knee Arthroplasty with General Anesthesia on Brain Networks: Cognitive Efficiency and Ventricular Volume Predict Functional Connectivity Decline in Older Adults. J Alzheimers Dis 2018; 62:319-333. [PMID: 29439328 PMCID: PMC5827939 DOI: 10.3233/jad-170496] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Using resting state functional magnetic resonance imaging (RS-fMRI), we explored: 1) pre- to post-operative changes in functional connectivity in default mode, salience, and central executive networks after total knee arthroplasty (TKA) with general anesthesia, and 2) the contribution of cognitive/brain reserve metrics these resting state functional declines. Individuals age 60 and older electing unilateral total knee arthroplasty (TKA; n = 48) and non-surgery peers with osteoarthritis (n = 45) completed baseline cognitive testing and baseline and post-surgery (post-baseline, 48-h post-surgery) brain MRI. We acquired cognitive and brain estimates for premorbid (vocabulary, reading, education, intracranial volume) and current (working memory, processing speed, declarative memory, ventricular volume) reserve. Functional network analyses corrected for pain severity and pain medication. The surgery group declined in every functional network of interest (p < 0.001). Relative to non-surgery peers, 23% of surgery participants declined in at least one network and 15% of the total TKA sample declined across all networks. Larger preoperative ventricular volume and lower scores on preoperative metrics of processing speed and working memory predicted default mode network connectivity decline. Premorbid cognitive and premorbid brain reserve did not predict decline. Within 48 hours after surgery, at least one fourth of the older adult sample showed significant functional network decline. Metrics of current brain status (ventricular volume), working memory, and processing speed predicted the severity of default mode network connectivity decline. These findings demonstrate the relevance of preoperative cognition and brain integrity on acute postoperative functional network change.
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Affiliation(s)
- Haiqing Huang
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Jared Tanner
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Hari Parvataneni
- Department of Orthopedic Surgery, University of Florida, Gainesville, FL, USA
| | - Mark Rice
- Department of Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Ann Horgas
- College of Nursing, University of Florida, Gainesville, FL, USA
| | - Mingzhou Ding
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Catherine Price
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Department of Anesthesiology, University of Florida, Gainesville, FL, USA
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Smith PJ, Snyder LD, Palmer SM, Hoffman BM, Stonerock GL, Ingle KK, Saulino CK, Blumenthal JA. Depression, social support, and clinical outcomes following lung transplantation: a single-center cohort study. Transpl Int 2017; 31:495-502. [PMID: 29130541 DOI: 10.1111/tri.13094] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 08/28/2017] [Accepted: 10/31/2017] [Indexed: 02/03/2023]
Abstract
Depressive symptoms are common among lung transplant candidates and have been associated with poorer clinical outcomes in some studies. Previous studies have been plagued by methodologic problems, including small sample sizes, few clinical events, and uncontrolled confounders, particularly perioperative complications. In addition, few studies have examined social support as a potential protective factor. We therefore examined the association between pretransplant depressive symptoms, social support, and mortality in a large sample of lung transplant recipients. As a secondary aim, we also examined the associations between psychosocial factors, perioperative outcomes [indexed by hospital length of stay (LOS)], and mortality. We hypothesized that depression would be associated with longer LOS and that the association between depression, social support, and mortality would be moderated by LOS. Participants included lung transplant recipients, transplanted at Duke University Medical Center from January 2009 to December 2014. Depressive symptoms were evaluated using the Beck Depression Inventory (BDI-II) and social support using the Perceived Social Support Scale (PSSS). Medical risk factors included forced vital capacity (FVC), partial pressure of carbon dioxide (PCO2 ), donor age, acute rejection, and transplant type. Functional status was assessed using six-minute walk distance (6MWD). We also controlled for demographic factors, including age, gender, and native disease. Transplant hospitalization LOS was examined as a marker of perioperative clinical outcomes. Participants included 273 lung recipients (174 restrictive, 67 obstructive, 26 cystic fibrosis, and six "other"). Pretransplant depressive symptoms were common, with 56 participants (21%) exhibiting clinically elevated levels (BDI-II ≥ 14). Greater depressive symptoms were associated with longer LOS [adjusted b = 0.20 (2 days per 7-point higher BDI-II score), P < 0.01]. LOS moderated the associations between depressive symptoms (P = 0.019), social support (P < 0.001), and mortality, such that greater depressive symptoms and lower social support were associated with greater mortality only among individuals with longer LOS. For individuals with LOS ≥ 1 month, clinically elevated depressive symptoms (BDI-II ≥ 14) were associated with a threefold increased risk of mortality (HR = 2.97). Greater pretransplant depressive symptoms and lower social support may be associated with greater mortality among a subset of individuals with worse perioperative outcomes.
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Affiliation(s)
- Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Benson M Hoffman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Gregory L Stonerock
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Krista K Ingle
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Caroline K Saulino
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Kim S, Duncan PW, Groban L, Segal H, Abbott RM, Williamson JD. Patient-Reported Outcome Measures (PROM) as A Preoperative Assessment Tool. JOURNAL OF ANESTHESIA AND PERIOPERATIVE MEDICINE 2017; 4:274-281. [PMID: 29333531 PMCID: PMC5766034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM OF REVIEW Patient-reported outcomes (PRO) on functional, social, and behavioral factors might be important preoperative predictors of postoperative outcomes. We conducted a literature review to explore associations of preoperative depression, socioeconomic status, social support, functional status/frailty, cognitive status, self-management skills, health literacy, and nutritional status with surgical outcomes. METHODS Two electronic data bases, including PubMed and Google Scholar, were searched linking either depression, socioeconomic status, social support, functional status/frailty, cognitive status, self-management skills, health literacy, or nutritional status with surgery, postoperative complications, or perioperative period within the past 2 decades. RECENT FINDINGS Preoperative depression has been linked to postoperative delirium, complications, persistent pain, longer lengths of stay, and mortality. Socioeconomic status associates with overall and cancer-free survival. Low socioeconomic status has also been connected to medication non- compliance. Social support can predict overall and cancer- free survival, as well as physical, social and emotional quality of life. Poor functional status and frailty have been related to postoperative complications, longer lengths of stay, post-discharge institutionalization, and higher costs. Preoperative cognitive impairment also associates with self-medication management errors, postoperative cognitive impairment, delirium, complications and mortality. In addition, a greater tendency for reduced adherence to preoperative medication instructions has been linked to health illiteracy. Preoperative malnutrition is prevalent and associates with postoperative morbidity. CONCLUSION Efficient and effective assessments of social and behavioral determinants of health, functional status, health literacy, patient's perception of health, and preferences for self-management may improve postoperative management and surgical outcomes, particularly among vulnerable patients undergoing elective surgery who might have subtle physical, social, or psychological deficits or challenges, otherwise missed upon routine evaluation. Patient Reported Outcome Measures (PROMs) can be used to effectively and efficiently collect these factors in the preoperative period, thereby identifying areas that can be intervened preemptively. (Partially Funded by the National Institute on Aging and the Wake Forest University Claude D. Pepper Older Americans Independence Center.).
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Affiliation(s)
- Sunghye Kim
- Department of Internal Medicine, Winston-Salem, NC, USA,Sticht Center on Aging, Winston-Salem, NC, USA
| | - Pamela W. Duncan
- Sticht Center on Aging, Winston-Salem, NC, USA,Department of Neurology, Winston-Salem, NC, USA
| | - Leanne Groban
- Sticht Center on Aging, Winston-Salem, NC, USA,Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hannah Segal
- Fisher Center for Hereditary Cancer AND Clinical Genomics Research, Georgetown University, Washington, D.C., USA
| | | | - Jeff D. Williamson
- Department of Internal Medicine, Winston-Salem, NC, USA,Sticht Center on Aging, Winston-Salem, NC, USA
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Poor Performance on a Preoperative Cognitive Screening Test Predicts Postoperative Complications in Older Orthopedic Surgical Patients. Anesthesiology 2017; 127:765-774. [PMID: 28891828 DOI: 10.1097/aln.0000000000001859] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The American College of Surgeons and the American Geriatrics Society have suggested that preoperative cognitive screening should be performed in older surgical patients. We hypothesized that unrecognized cognitive impairment in patients without a history of dementia is a risk factor for development of postoperative complications. METHODS We enrolled 211 patients 65 yr of age or older without a diagnosis of dementia who were scheduled for an elective hip or knee replacement. Patients were cognitively screened preoperatively using the Mini-Cog and demographic, medical, functional, and emotional/social data were gathered using standard instruments or review of the medical record. Outcomes included discharge to place other than home (primary outcome), delirium, in-hospital medical complications, hospital length-of-stay, 30-day emergency room visits, and mortality. Data were analyzed using univariate and multivariate analyses. RESULTS Fifty of 211 (24%) patients screened positive for probable cognitive impairment (Mini-Cog less than or equal to 2). On age-adjusted multivariate analysis, patients with a Mini-Cog score less than or equal to 2 were more likely to be discharged to a place other than home (67% vs. 34%; odds ratio = 3.88, 95% CI = 1.58 to 9.55), develop postoperative delirium (21% vs. 7%; odds ratio = 4.52, 95% CI = 1.30 to 15.68), and have a longer hospital length of stay (hazard ratio = 0.63, 95% CI = 0.42 to 0.95) compared to those with a Mini-Cog score greater than 2. CONCLUSIONS Many older elective orthopedic surgical patients have probable cognitive impairment preoperatively. Such impairment is associated with development of delirium postoperatively, a longer hospital stay, and lower likelihood of going home upon hospital discharge.
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Cunningham EL, Mawhinney T, Beverland D, O'Brien S, McAuley DF, Cairns R, Passmore P, McGuinness B. Observational cohort study examining apolipoprotein E status and preoperative neuropsychological performance as predictors of post-operative delirium in an older elective arthroplasty population. Age Ageing 2017; 46:779-786. [PMID: 28383643 DOI: 10.1093/ageing/afx042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 03/08/2017] [Indexed: 01/19/2023] Open
Abstract
Introduction delirium following surgery is common and is associated with negative outcomes. Preoperative cognitive impairment has been shown to be a risk factor for post-operative delirium. Often the cognitive tests used are cumbersome. This study tests the hypothesis that the quantification of brain vulnerability, using Apolipoprotein E (ApoE) status and neuropsychological tests, both traditional and more easily administered, can quantify the risk of post-operative delirium following elective primary arthroplasty surgery. Methods this observational cohort study recruited participants aged 65 years or older admitted prior to elective primary hip or knee arthroplasty. Baseline data was collected and participants underwent neuropsychological testing and had blood taken for ApoE genotyping preoperatively. Post-operatively participants were assessed daily for delirium using the Confusion Assessment Method (CAM) and charts were reviewed where possible for reports of delirium. Univariate and multivariate analyses of preoperative factors were undertaken to identify independent predictors of delirium. Results between March 2012 and October 2014, 315 participants completed the study with an overall incidence of post-operative delirium of 40/315 (12.7%). Of these 18 fulfilled the CAM criteria for delirium and 22 were deemed delirious by consensus decision based on chart review. ApoE genotype was not associated with post-operative delirium in this cohort. Time taken to complete Colour Trails 2, errors in mini mental state examination and level of pain preoperatively were independent predictors of post-operative delirium. Conclusions this study challenges the assertion that ApoE4 genotype predicts post-operative delirium. It replicates previous work suggesting cognitive impairment predicts post-operative delirium and shows for the 1st time that simple cognitive tests can be as effective as more detailed tests.
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Affiliation(s)
- Emma Louise Cunningham
- Centre for Public Health, Institute of Clinical Sciences, Block B, Queens University Belfast, Royal Victoria Hospital, Belfast BT12 6BA, UK
| | | | | | | | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - Peter Passmore
- Centre for Public Health, Institute of Clinical Sciences, Block B, Queens University Belfast, Royal Victoria Hospital, Belfast BT12 6BA, UK
| | - Bernadette McGuinness
- Centre for Public Health, Institute of Clinical Sciences, Block B, Queens University Belfast, Royal Victoria Hospital, Belfast BT12 6BA, UK
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45
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Langan C, Sarode DP, Russ TC, Shenkin SD, Carson A, Maclullich AMJ. Psychiatric symptomatology after delirium: a systematic review. Psychogeriatrics 2017; 17:327-335. [PMID: 28127828 DOI: 10.1111/psyg.12240] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/25/2016] [Accepted: 11/21/2016] [Indexed: 01/21/2023]
Abstract
Delirium is an acute and usually transient severe neuropsychiatric syndrome associated with significant long-term physical morbidity. However, its chronic psychiatric sequelae remain poorly characterized. To investigate the prevalence of psychiatric symptoms, namely anxiety, depressive, and post-traumatic stress disorder (PTSD) symptoms after delirium, a systematic literature search of MEDLINE, EMBASE and PsycINFO databases was performed independently by two authors in March 2016. Bibliographies were hand-searched, and a forward- and backward-citation search using Web of Science was performed for all included studies. Of 6411 titles, we included eight prospective cohort studies, including 370 patients with delirium and 1073 without delirium. Studies were heterogeneous and mostly included older people from a range of clinical groups. Consideration of confounders was variable. The prevalence of depressive symptoms was almost three times higher in patients with delirium than in patients without delirium (22.2% vs 8.0%, risk ratio = 2.79; 95% confidence interval = 1.36-5.73). There was no statistically significant difference between the prevalence of anxiety symptoms between patients with and without delirium. The prevalence of PTSD symptoms after delirium was inconclusive: only one study investigated this and no association between PTSD symptoms after delirium was reported. There is limited published evidence of the prevalence of psychiatric symptoms after non-ICU delirium and the strongest evidence is for depressive symptoms. Further longitudinal studies are warranted to investigate the prevalence of anxiety and PTSD symptoms.
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Affiliation(s)
- Clare Langan
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Deep P Sarode
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Tom C Russ
- Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Susan D Shenkin
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Department of Psychology, Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J Maclullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Department of Psychology, Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
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Abstract
The ambulatory setting offers potential advantages for elderly patients undergoing elective surgery due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. This review article aims to provide a practical guide to anesthetic management of elderly outpatients. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative complications (e.g., pain, postoperative nausea and vomiting [PONV], delirium and cognitive dysfunction, and gastrointestinal dysfunction) are discussed. The role of anesthesiologists as perioperative physicians is important for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. The implementation of high-quality, evidence-based perioperative care programs for the elderly on an ambulatory basis has assumed increased importance. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving enhanced recovery after surgery.
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Culley DJ, Flaherty D, Reddy S, Fahey MC, Rudolph J, Huang CC, Liu X, Xie Z, Bader AM, Hyman BT, Blacker D, Crosby G. Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study. Anesth Analg 2017; 123:186-92. [PMID: 27028776 DOI: 10.1213/ane.0000000000001277] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preexisting cognitive impairment is emerging as a predictor of poor postoperative outcomes in seniors. We hypothesized that preoperative cognitive screening can be performed in a busy preadmission evaluation center and that cognitive impairment is prevalent in elective geriatric surgical patients. METHODS We approached 311 patients aged 65 years and older presenting for preoperative evaluation before elective surgery in a prospective, observational, single-center study. Forty-eight patients were ineligible, and 63 declined. The remaining 200 were randomly assigned to the Mini-Cog (N =100) or Clock-in-the-Box [CIB; N = 100)] test. Study staff administered the test in a quiet room, and 2 investigators scored the tests independently. Probable cognitive impairment was defined as a Mini-Cog ≤ 2 or a CIB ≤ 5. RESULTS The age of consenting patients was 73.7 ± 6.4 (mean ± SD) years. There were no significant differences between patients randomly assigned to the Mini-Cog and CIB test in age, weight, gender, education, ASA physical status, or Charlston Index. Overall, 23% of patients met criteria for probable cognitive impairment, and prevalence was virtually identical regardless of the test used; 22% screened with the Mini-Cog and 23% screened with the CIB scored as having probable cognitive impairment (P = 1.0 by χ analysis). Both tests had good interrater reliability (Krippendroff α = 0.86 [0.72-0.93] for Mini-Cog and 1 for CIB). CONCLUSIONS Preoperative cognitive screening is feasible in most geriatric elective surgical patients and reveals a substantial prevalence of probable cognitive impairment in this population.
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Affiliation(s)
- Deborah J Culley
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; †University of Cincinnati College of Medicine, Cincinnati, Ohio; ‡ Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; §Department of Anesthesiology, Perioperative and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; ∥Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; ¶ Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School and Harvard School of Public Health, Boston, Massachusetts; and #Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
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Mollon B, Mahure SA, Ding DY, Zuckerman JD, Kwon YW. The influence of a history of clinical depression on peri-operative outcomes in elective total shoulder arthroplasty: a ten-year national analysis. Bone Joint J 2017; 98-B:818-24. [PMID: 27235526 DOI: 10.1302/0301-620x.98b6.37208] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/22/2016] [Indexed: 12/28/2022]
Abstract
AIMS Depression can significantly affect quality of life and is associated with higher rates of medical comorbidities and increased mortality following surgery. Although depression has been linked to poorer outcomes following orthopaedic trauma, total joint arthroplasty and spinal surgery, we wished to examine the impact of depression in elective total shoulder arthroplasty (TSA) as this has not been previously explored. PATIENTS AND METHODS The United States Nationwide Inpatient Sample (NIS) was used to identify patients undergoing elective TSA over a ten-year period. Between 2002 and 2012, 224 060 patients underwent elective TSA. RESULTS Among the identified patients who had undergone TSA, 12.4% had a diagnosis of a history of depression. A diagnosis of depression was twice as common in women compared with men (16.0% vs 8.0%, p < 0.001), and more frequent in those with low income and Medicaid insurance (p < 0.001). A diagnosis of depression was an independent risk factor for post-operative delirium (odds ratio (OR) 2.29, p < 0.001), anaemia (OR 1.65, p < 0.001), infection (2.09, p = 0.045) and hospital discharge to a placement other than home (OR 1.52, p < 0.001) CONCLUSION: A history of clinical depression is present in 12.4% of patients undergoing elective TSA and the disease burden is projected to increase further in the future. Depression is often underdiagnosed and pre-operative screening and appropriate peri-operative management of patients is encouraged. TAKE HOME MESSAGE The awareness that clinical depression is associated with increased complications following total shoulder arthroplasty provides physicians an opportunity for early intervention in this at-risk population. Cite this article: Bone Joint J 2016;98-B:818-24.
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Affiliation(s)
- B Mollon
- NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10016, USA
| | - S A Mahure
- NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10016, USA
| | - D Y Ding
- NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10016, USA
| | - J D Zuckerman
- NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10016, USA
| | - Y W Kwon
- NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10016, USA
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Price CC, Garvan C, Hizel LP, Lopez MG, Billings FT. Delayed Recall and Working Memory MMSE Domains Predict Delirium following Cardiac Surgery. J Alzheimers Dis 2017; 59:1027-1035. [PMID: 28697572 PMCID: PMC5544543 DOI: 10.3233/jad-170380] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Reduced preoperative cognition is a risk factor for postoperative delirium. The significance for type of preoperative cognitive deficit, however, has yet to be explored and could provide important insights into mechanisms and prediction of delirium. OBJECTIVE Our goal was to determine if certain cognitive domains from the general cognitive screener, the Mini-Mental State Exam (MMSE), predict delirium after cardiac surgery. METHODS Patients completed a preoperative MMSE prior to undergoing elective cardiac surgery. Following surgery, delirium was assessed throughout ICU stay using the Confusion Assessment Method for ICU delirium and the Richmond Agitation and Sedation Scale. RESULTS Cardiac surgery patients who developed delirium (n = 137) had lower total MMSE scores than patients who did not develop delirium (n = 457). In particular, orientation to place, working memory, delayed recall, and language domain scores were lower. Of these, only the working memory and delayed recall domains predicted delirium in a regression model adjusting for history of chronic obstructive pulmonary disease, age, sex, and duration of cardiopulmonary bypass. For each word not recalled on the three-word delayed recall assessment, the odds of delirium increased by 50%. For each item missed on the working memory index, the odds of delirium increased by 36%. Of the patients who developed delirium, 47% had a primary impairment in memory, 21% in working memory, and 33% in both domains. The area under the receiver operating characteristics curve using only the working memory and delayed recall domains was 0.75, compared to 0.76 for total MMSE score. CONCLUSION Delirium risk is greater for individuals with reduced MMSE scores on the delayed recall and working memory domains. Research should address why patients with memory and executive vulnerabilities are more prone to postoperative delirium than those with other cognitive limitations.
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Affiliation(s)
- Catherine C Price
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Cynthia Garvan
- Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Loren P Hizel
- Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Marcos G Lopez
- Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Pinho C, Cruz S, Santos A, Abelha FJ. Postoperative delirium: age and low functional reserve as independent risk factors. J Clin Anesth 2016; 33:507-13. [DOI: 10.1016/j.jclinane.2015.09.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 08/13/2015] [Accepted: 09/16/2015] [Indexed: 11/29/2022]
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