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Brummel NE, Hughes CG, McNeil JB, Pandharipande PP, Thompson JL, Orun OM, Raman R, Ware LB, Bernard GR, Harrison FE, Ely EW, Girard TD. Systemic inflammation and delirium during critical illness. Intensive Care Med 2024; 50:687-696. [PMID: 38647548 DOI: 10.1007/s00134-024-07388-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/10/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE The purpose of this study was to determine associations between markers of inflammation and endogenous anticoagulant activity with delirium and coma during critical illness. METHODS In this prospective cohort study, we enrolled adults with respiratory failure and/or shock treated in medical or surgical intensive care units (ICUs) at 5 centers. Twice per day in the ICU, and daily thereafter, we assessed mental status using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method-Intensive Care Unit (CAM-ICU). We collected blood samples on study days 1, 3, and 5, measuring levels of C-reactive protein (CRP), interferon gamma (IFN-γ), interleukin (IL)-1 beta (IL-1β), IL-6, IL-8, IL-10, IL-12, matrix metalloproteinase-9 (MMP-9), tumor necrosis factor-alpha (TNF-α), tumor necrosis factor receptor 1 (TNFR1), and protein C using validated protocols. We used multinomial logistic regression to analyze associations between biomarkers and the odds of delirium or coma versus normal mental status the following day, adjusting for age, sepsis, Sequential Organ Failure Assessment (SOFA), study day, corticosteroids, and sedatives. RESULTS Among 991 participants with a median age (interquartile range, IQR) of 62 [53-72] years and enrollment SOFA of 9 [7-11], higher concentrations of IL-6 (odds ratio [OR] [95% CI]: 1.8 [1.4-2.3]), IL-8 (1.3 [1.1-1.5]), IL-10 (1.5 [1.2-1.8]), TNF-α (1.2 [1.0-1.4]), and TNFR1 (1.3 [1.1-1.6]) and lower concentrations of protein C (0.7 [0.6-0.8])) were associated with delirium the following day. Higher concentrations of CRP (1.4 [1.1-1.7]), IFN-γ (1.3 [1.1-1.5]), IL-6 (2.3 [1.8-3.0]), IL-8 (1.8 [1.4-2.3]), and IL-10 (1.5 [1.2-2.0]) and lower concentrations of protein C (0.6 [0.5-0.8]) were associated with coma the following day. IL-1β, IL-12, and MMP-9 were not associated with mental status. CONCLUSION Markers of inflammation and possibly endogenous anticoagulant activity are associated with delirium and coma during critical illness.
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Affiliation(s)
- Nathan E Brummel
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Christopher G Hughes
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Memory and Alzheimer's Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - J Brennan McNeil
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Memory and Alzheimer's Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jennifer L Thompson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Onur M Orun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Lorraine B Ware
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fiona E Harrison
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Vanderbilt Brain Institute, Vanderbilt University School of Medicine, Nashville, TN, USA
- Vanderbilt Memory and Alzheimer's Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Timothy D Girard
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
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Reese M, Wong MK, Cheong V, Ha CI, Cooter Wright M, Browndyke J, Moretti E, Devinney MJ, Habib AS, Moul JW, Shaw LM, Waligorska T, Whitson HE, Cohen HJ, Welsh-Bohmer KA, Plassman BL, Mathew JP, Berger M. Cognitive and Cerebrospinal Fluid Alzheimer's Disease-related Biomarker Trajectories in Older Surgical Patients and Matched Nonsurgical Controls. Anesthesiology 2024; 140:963-978. [PMID: 38324729 PMCID: PMC11003848 DOI: 10.1097/aln.0000000000004924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND Anesthesia and/or surgery accelerate Alzheimer's disease pathology and cause memory deficits in animal models, yet there is a lack of prospective data comparing cerebrospinal fluid (CSF) Alzheimer's disease-related biomarker and cognitive trajectories in older adults who underwent surgery versus those who have not. Thus, the objective here was to better understand whether anesthesia and/or surgery contribute to cognitive decline or an acceleration of Alzheimer's disease-related pathology in older adults. METHODS The authors enrolled 140 patients 60 yr or older undergoing major nonneurologic surgery and 51 nonsurgical controls via strata-based matching on age, sex, and years of education. CSF amyloid β (Aβ) 42, tau, and p-tau-181p levels and cognitive function were measured before and after surgery, and at the same time intervals in controls. RESULTS The groups were well matched on 25 of 31 baseline characteristics. There was no effect of group or interaction of group by time for baseline to 24-hr or 6-week postoperative changes in CSF Aβ, tau, or p-tau levels, or tau/Aβ or p-tau/Aβ ratios (Bonferroni P > 0.05 for all) and no difference between groups in these CSF markers at 1 yr (P > 0.05 for all). Nonsurgical controls did not differ from surgical patients in baseline cognition (mean difference, 0.19 [95% CI, -0.06 to 0.43]; P = 0.132), yet had greater cognitive decline than the surgical patients 1 yr later (β, -0.31 [95% CI, -0.45 to -0.17]; P < 0.001) even when controlling for baseline differences between groups. However, there was no difference between nonsurgical and surgical groups in 1-yr postoperative cognitive change in models that used imputation or inverse probability weighting for cognitive data to account for loss to follow up. CONCLUSIONS During a 1-yr time period, as compared to matched nonsurgical controls, the study found no evidence that older patients who underwent anesthesia and noncardiac, nonneurologic surgery had accelerated CSF Alzheimer's disease-related biomarker (tau, p-tau, and Aβ) changes or greater cognitive decline. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Melody Reese
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
- DUMC, Center for the Study of Aging and Human Development, Durham, NC, USA
| | - Megan K. Wong
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Vanessa Cheong
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
- Duke University-National University of Singapore Medical School, Singapore
| | - Christine I. Ha
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Mary Cooter Wright
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Jeffrey Browndyke
- DUMC, Department of Psychiatry and Behavioral Medicine, Durham, NC, USA
| | - Eugene Moretti
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Michael J. Devinney
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Ashraf S. Habib
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Judd W. Moul
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
- DUMC, Department of Surgery, Durham, NC, USA
| | - Leslie M. Shaw
- Perelman School of Medicine University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, PA, USA
| | - Teresa Waligorska
- Perelman School of Medicine University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, PA, USA
| | - Heather E. Whitson
- DUMC, Center for the Study of Aging and Human Development, Durham, NC, USA
- DUMC, Department of Medicine, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
| | - Harvey J. Cohen
- DUMC, Center for the Study of Aging and Human Development, Durham, NC, USA
- DUMC, Department of Medicine, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
| | - Kathleen A. Welsh-Bohmer
- DUMC, Department of Psychiatry and Behavioral Medicine, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
| | - Brenda L. Plassman
- DUMC, Department of Psychiatry and Behavioral Medicine, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
| | - Joseph P. Mathew
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Miles Berger
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
- DUMC, Center for the Study of Aging and Human Development, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
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Potter KM, Kennedy JN, Onyemekwu C, Prendergast NT, Pandharipande PP, Ely EW, Seymour C, Girard TD. Data-derived subtypes of delirium during critical illness. EBioMedicine 2024; 100:104942. [PMID: 38169220 PMCID: PMC10797145 DOI: 10.1016/j.ebiom.2023.104942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND To understand delirium heterogeneity, prior work relied on psychomotor symptoms or risk factors to identify subtypes. Data-driven approaches have used machine learning to identify biologically plausible, treatment-responsive subtypes of other acute illnesses but have not been used to examine delirium. METHODS We conducted a secondary analysis of a large, multicenter prospective cohort study involving adults in medical or surgical ICUs with respiratory failure or shock who experienced delirium per the Confusion Assessment Method for the ICU. We used data collected before delirium diagnosis in an unsupervised latent class model to identify delirium subtypes and then compared demographics, clinical characteristics, and outcomes between subtypes in the final model. FINDINGS The 731 patients who developed delirium during critical illness had a median age of 63 [IQR, 54-72] years, a median Sequential Organ Failure Assessment score of 8.0 [6.0-11.0] and 613 [83.4%] were mechanically ventilated at delirium identification. A four-class model best fit the data with 50% of patients in subtype (ST) 1, 18% in subtype 2, 17% in subtype 3, and 14% in subtype 4. Subtype 2-which had more shock and kidney impairment-had the highest mortality (33% [ST2] vs. 17% [ST1], 25% [ST3], and 17% [ST4], p = 0.003). Subtype 4-which received more benzodiazepines and opioids-had the longest duration of delirium (6 days [ST4] vs. 3 [ST1], 4 [ST2], and 3 days [ST3], p < 0.001) and coma (4 days [ST4] vs. 2 [ST1], 1 [ST2], and 2 days [ST3], p < 0.001). Each of the four data-derived delirium subtypes was observed within previously identified psychomotor and risk factor-based delirium subtypes. Clinically significant cognitive impairment affected all subtypes at follow-up, but its severity did not differ by subtype (3-month, p = 0.26; 12-month, p = 0.80). INTERPRETATION The four data-derived delirium subtypes identified in this study should now be validated in independent cohorts, examined for differential treatment effects in trials, and inform mechanistic work evaluating treatment targets. FUNDING National Institutes of Health (T32HL007820, R01AG027472).
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Affiliation(s)
- Kelly M Potter
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Jason N Kennedy
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Chukwudi Onyemekwu
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Pratik P Pandharipande
- Division of Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Allergy, Pulmonary, and Critical Care Medicine in the Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Allergy, Pulmonary, and Critical Care Medicine in the Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
| | - Christopher Seymour
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
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4
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Lobo-Valbuena B, Molina R, Castañeda-Vozmediano R, Lopez de la Oliva Calvo L, Abella A, Garcia-Arias MM, Salinas Gabiña I, Gordo F. Functional independence, frailty and perceived quality of life in patients who developed delirium during ICU stay: a prospective cohort study. Eur J Med Res 2023; 28:560. [PMID: 38049839 PMCID: PMC10696684 DOI: 10.1186/s40001-023-01530-8] [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: 03/28/2023] [Accepted: 11/15/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Survivors of critical illness are frequently left with a long-lasting disability. We hypothesised that patients who developed delirium during ICU stay, compared with patients who did not, would have worse health-related quality of life following a critical illness. METHODS Prospective longitudinal observational and analytical study assessing functional independence, frailty and perceived quality of life measured with the Barthel Index, the Clinical Frailty Scale, and the SF-36, comparing patients who developed delirium during ICU stay and patients who did not. The questionnaires were used at different times during the follow-up (upon ICU admission, at ICU discharge, at hospital discharge and 2 years after hospital discharge). RESULTS In a cohort of 1462 patients, we matched 93 patients who developed delirium (delirium group) with 93 patients who did not develop delirium (no-delirium group). Of 156 completed questionnaires (84.7%), we observed that (a) in each of the two groups of patients, the scores related to functional independence (Barthel Index) and frailty (Clinical Frailty Scale) tended to improve over time (p < 0.001), being consistently less favourable in the delirium group compared to the no-delirium group (p < 0.001); (b) the patients who developed delirium also presented lower scores on the SF-36 scale, these differences being statistically significant, and therefore evidencing a worse quality of life, with impact on both the psychological and social spheres (p < 0.001). CONCLUSIONS Patients who developed delirium had significantly lower scores 2 years after hospital discharge on the three used questionnaires, displaying a clear negative impact on the physical, psychological, and social dimensions. The study's results reinforce the need to support and strengthen the care of ICU survivors.
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Affiliation(s)
- Beatriz Lobo-Valbuena
- Intensivist - Intensive Care Unit, Hospital Universitario del Henares, Coslada, Madrid, Spain.
- Grupo de Investigación en Patología Crítica, Facultad de Ciencias de La Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain.
| | - Rosario Molina
- Intensivist - Intensive Care Unit, Hospital Universitario del Henares, Coslada, Madrid, Spain
- Grupo de Investigación en Patología Crítica, Facultad de Ciencias de La Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Raúl Castañeda-Vozmediano
- Research Support Unit, Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | | | - Ana Abella
- Intensivist - Intensive Care Unit, Hospital Universitario del Henares, Coslada, Madrid, Spain
- Grupo de Investigación en Patología Crítica, Facultad de Ciencias de La Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - María-Mercedes Garcia-Arias
- Intensivist - Intensive Care Unit, Hospital Universitario del Henares, Coslada, Madrid, Spain
- Grupo de Investigación en Patología Crítica, Facultad de Ciencias de La Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Irene Salinas Gabiña
- Intensivist - Intensive Care Unit, Hospital Universitario del Henares, Coslada, Madrid, Spain
- Grupo de Investigación en Patología Crítica, Facultad de Ciencias de La Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Federico Gordo
- Intensivist - Intensive Care Unit, Hospital Universitario del Henares, Coslada, Madrid, Spain
- Grupo de Investigación en Patología Crítica, Facultad de Ciencias de La Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
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Godoy-González M, Navarra-Ventura G, Gomà G, de Haro C, Espinal C, Fortià C, Ridao N, Miguel Rebanal N, Oliveras-Furriols L, Subirà C, Jodar M, Santos-Pulpón V, Sarlabous L, Fernández R, Ochagavía A, Blanch L, Roca O, López-Aguilar J, Fernández-Gonzalo S. Objective and subjective cognition in survivors of COVID-19 one year after ICU discharge: the role of demographic, clinical, and emotional factors. Crit Care 2023; 27:188. [PMID: 37189173 PMCID: PMC10184095 DOI: 10.1186/s13054-023-04478-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Intensive Care Unit (ICU) COVID-19 survivors may present long-term cognitive and emotional difficulties after hospital discharge. This study aims to characterize the neuropsychological dysfunction of COVID-19 survivors 12 months after ICU discharge, and to study whether the use of a measure of perceived cognitive deficit allows the detection of objective cognitive impairment. We also explore the relationship between demographic, clinical and emotional factors, and both objective and subjective cognitive deficits. METHODS Critically ill COVID-19 survivors from two medical ICUs underwent cognitive and emotional assessment one year after discharge. The perception of cognitive deficit and emotional state was screened through self-rated questionnaires (Perceived Deficits Questionnaire, Hospital Anxiety and Depression Scale and Davidson Trauma Scale), and a comprehensive neuropsychological evaluation was carried out. Demographic and clinical data from ICU admission were collected retrospectively. RESULTS Out of eighty participants included in the final analysis, 31.3% were women, 61.3% received mechanical ventilation and the median age of patients was 60.73 years. Objective cognitive impairment was observed in 30% of COVID-19 survivors. The worst performance was detected in executive functions, processing speed and recognition memory. Almost one in three patients manifested cognitive complaints, and 22.5%, 26.3% and 27.5% reported anxiety, depression and post-traumatic stress disorder (PTSD) symptoms, respectively. No significant differences were found in the perception of cognitive deficit between patients with and without objective cognitive impairment. Gender and PTSD symptomatology were significantly associated with perceived cognitive deficit, and cognitive reserve with objective cognitive impairment. CONCLUSIONS One-third of COVID-19 survivors suffered objective cognitive impairment with a frontal-subcortical dysfunction 12 months after ICU discharge. Emotional disturbances and perceived cognitive deficits were common. Female gender and PTSD symptoms emerged as predictive factors for perceiving worse cognitive performance. Cognitive reserve emerged as a protective factor for objective cognitive functioning. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04422444; June 9, 2021.
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Affiliation(s)
- Marta Godoy-González
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Guillem Navarra-Ventura
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Gemma Gomà
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Candelaria de Haro
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina Espinal
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Cristina Fortià
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Natalia Ridao
- Physical and Rehabilitation Medicine Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Nuria Miguel Rebanal
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Clinical Psychology and Psychobiology Department, Universitat de Barcelona, Barcelona, Spain
| | - Laia Oliveras-Furriols
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Carles Subirà
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Department, Althaia Xarxa Assistencial Universitària de Manresa, IRIS Research Institute, Manresa, Spain
| | - Mercè Jodar
- Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Neurology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain
| | - Verónica Santos-Pulpón
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Leonardo Sarlabous
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Fernández
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Department, Althaia Xarxa Assistencial Universitària de Manresa, IRIS Research Institute, Manresa, Spain
| | - Ana Ochagavía
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Lluís Blanch
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Roca
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Medicine Department, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Josefina López-Aguilar
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Sol Fernández-Gonzalo
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain
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Ramnarain D, Pouwels S, Fernández-Gonzalo S, Navarra-Ventura G, Balanzá-Martínez V. Delirium-related psychiatric and neurocognitive impairment and the association with post-intensive care syndrome-A narrative review. Acta Psychiatr Scand 2023; 147:460-474. [PMID: 36744298 DOI: 10.1111/acps.13534] [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: 06/28/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest. These new-onset or worsening conditions, together with physical alterations, are called post-intensive care syndrome (PICS). Our aim is to update on the latest screening and follow-up options for psychological and cognitive sequelae of PICS. METHOD This narrative review discusses the occurrence of delirium in ICU settings and the relatively new concept of PICS. Psychiatric and neurocognitive morbidities that may occur in survivors of critical illness following delirium are addressed. Future perspectives for practice and research are discussed. RESULTS There is no "gold standard" for diagnosing delirium in the ICU, but two extensively validated tools, the confusion assessment method for the ICU and the intensive care delirium screening checklist, are often used. PICS complaints are frequent in ICU survivors who have suffered delirium and have been recognized as an important public health and socio-economic problem worldwide. Depression, anxiety, post-traumatic stress disorder, and long-term cognitive impairment are recurrently exhibited. Screening tools for these deficits are discussed, as well as the suggestion of early assessment after discharge and at 3 and 12 months. CONCLUSIONS Delirium is a complex but common phenomenon in the ICU and a risk factor for PICS. Its diagnosis is challenging with potential long-term adverse outcomes, including psychiatric and cognitive difficulties. The implementation of screening and follow-up protocols for PICS sequelae is warranted to ensure early detection and appropriate management.
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Affiliation(s)
- Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Intensive Care Medicine, Saxenburgh Medical Center, Hardenberg, The Netherlands.,Departmentof Medical and Clinical Psychology, Center of Research on Psychological and Somatic disease (CoRPS), Tilburg University, Tilburg, The Netherlands
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of General, Abdominal and Minimally Invasive Surgery, Helios Klinikum, Krefeld, Germany
| | - Sol Fernández-Gonzalo
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Guillem Navarra-Ventura
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Vicent Balanzá-Martínez
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Teaching Unit of Psychiatry and Psychological Medicine, Department of Medicine, University of Valencia, Valencia, Spain
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7
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Park D, Kim HS, Kim JH. The effect of all-cause hospitalization on cognitive decline in older adults: a longitudinal study using databases of the National Health Insurance Service and the memory clinics of a self-run hospital. BMC Geriatr 2023; 23:61. [PMID: 36721117 PMCID: PMC9890792 DOI: 10.1186/s12877-022-03701-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/25/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Cognitive decline is common in older adults and imposes a burden on public health. Especially for older adults, hospitalization can be related to decreased physical fitness. This study aimed to investigate the quantitative association between hospitalization and cognitive decline. METHODS This was a retrospective cohort study. We performed a longitudinal study by using the combined database from the Korean National Health Insurance Service (NHIS) and memory clinic data of its self-run hospital. We identified whether hospitalized, the number of hospitalizations, and the total hospitalization days through the claim information from the NHIS database. We also identified whether hospitalization was accompanied by delirium or surgery with general anesthesia for subgroup analysis. Primary outcome was the clinical dementia rating-sum of boxes (CDR-SB) score. Secondary outcomes were mini-mental state examination (MMSE) score, clinical dementia rating (CDR) grade, and Korean-instrumental activities of daily living (KIADL) score. Multivariable mixed models were established. RESULTS Of the 1810 participants, 1200 experienced hospitalization at least once during the observation period. The increase in CDR-SB was significantly greater in the hospitalized group (β = 1.5083, P < .001). The same results were seen in the total number of hospitalizations (β = 0.0208, P < .001) or the total hospitalization days (β = 0.0022, P < .001) increased. In the group that experienced hospitalization, cognitive decline was also significant in terms of CDR grade (β = 0.1773, P < .001), MMSE score (β = - 1.2327, P < .001), and KIADL score (β = 0.2983, P < .001). Although delirium (β = 0.2983, P < .001) and nonsurgical hospitalization (β = 0.2983, P < .001) were associated with faster cognitive decline, hospitalization without delirium and with surgery were also related to faster cognitive decline than in the no hospitalization group. CONCLUSION Cognitive decline was quantitatively related to all-cause hospitalization in older adults. Moreover, hospitalizations without delirium and surgery were also related to cognitive decline. It is vital to prevent various conditions that need hospitalization to avoid and manage cognitive dysfunction.
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Affiliation(s)
- Dougho Park
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang, South Korea ,grid.49100.3c0000 0001 0742 4007Department of Medical Science and Engineering, School of Convergence Science and Technology, Pohang University of Science and Technology, Pohang, South Korea
| | - Hyoung Seop Kim
- grid.416665.60000 0004 0647 2391Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Goyang, 10444 Republic of Korea
| | - Jong Hun Kim
- grid.416665.60000 0004 0647 2391Department of Neurology, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Goyang, 10444 Republic of Korea
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8
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Association between cholinesterase activity and critical illness brain dysfunction. Crit Care 2022; 26:377. [PMID: 36474266 PMCID: PMC9724294 DOI: 10.1186/s13054-022-04260-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a frequent manifestation of acute brain dysfunction and is associated with cognitive impairment. The hypothesized mechanism of brain dysfunction during critical illness is centered on neuroinflammation, regulated in part by the cholinergic system. Point-of-care serum cholinesterase enzyme activity measurements serve as a real-time index of cholinergic activity. We hypothesized that cholinesterase activity during critical illness would be associated with delirium in the intensive care unit (ICU) and cognitive impairment after discharge. METHODS We enrolled adults with respiratory failure and/or shock and measured plasma acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activity on days 1, 3, 5, and 7 after enrollment. AChE values were also normalized per gram of hemoglobin (AChE/Hgb). We assessed for coma and delirium twice daily using the Richmond Agitation Sedation Scale and the Confusion Assessment Method for the ICU to evaluate daily mental status (delirium, coma, normal) and days alive without delirium or coma. Cognitive impairment, disability, and health-related quality of life were assessed at up to 6 months post-discharge. We used multivariable regression to determine whether AChE, AChE/Hgb, and BChE activity were associated with outcomes after adjusting for relevant covariates. RESULTS We included 272 critically ill patients who were a median (IQR) age 56 (39-67) years and had a median Sequential Organ Failure Assessment score at enrollment of 8 (5-11). Higher daily AChE levels were associated with increased odds of being delirious versus normal mental status on the same day (Odds Ratio [95% Confidence Interval] 1.64 [1.11, 2.43]; P = 0.045). AChE/Hgb and BChE activity levels were not associated with delirious mental status. Lower enrollment BChE was associated with fewer days alive without delirium or coma (P = 0.048). AChE, AChE/Hgb, and BChE levels were not significantly associated with cognitive impairment, disability, or quality of life after discharge. CONCLUSION Cholinesterase activity during critical illness is associated with delirium but not with outcomes after discharge, findings that may reflect mechanisms of acute brain organ dysfunction. TRIAL REGISTRATION NCT03098472. Registered 31 March 2017.
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Chinnappa-Quinn L, Lam BCP, Harvey L, Kochan NA, Bennett M, Crawford JD, Makkar SR, Brodaty H, Sachdev PS. Surgical Hospitalization Is Not Associated With Cognitive Trajectory Over 6 Years in Healthy Older Australians. J Am Med Dir Assoc 2022; 23:608-615. [PMID: 35304131 DOI: 10.1016/j.jamda.2022.01.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim was to investigate the association of cognitive trajectories and overnight surgical hospitalization in older adults, while controlling for and comparing with the association with acute medical hospitalizations. DESIGN This is a secondary analysis of data from a population-based, longitudinal cohort study of older Australians. SETTING AND PARTICIPANTS Cognition was assessed with 4 biennial waves of prospective neuropsychological data from 1026 Sydney Memory and Aging Study participants age 70 to 90 years at baseline. Hospitalization exposure was obtained from 10 years of electronically linked data from the New South Wales Admitted Patient Data Collection. METHODS Latent growth curve modeling estimated global cognition z score baseline and slope over 6 years, and the effects of contemporaneous surgical and medical hospitalization predictors while controlling for potential demographic and comorbidity confounders. RESULTS After controlling for confounding variables, this analysis showed that overnight surgical hospitalizations were not associated with worse baseline global cognition or accelerated cognitive decline over 6 years. This was despite this cohort having more surgeries and more complex surgeries compared with Australian data for overnight hospitalizations in over 70-year-olds. Conversely, recent medical hospitalizations were associated with accelerated cognitive decline. CONCLUSIONS AND IMPLICATIONS This analysis finds that surgery and anesthesia are unlikely to be risk factors for medium to long-term global cognitive decline in healthy older adults, while controlling for contemporaneous medical hospitalizations. These findings are contrary to prior conclusions from several surgical studies that may have been impeded by insufficient comparison groups. They are, however, consistent with recent population-based studies suggesting surgery has minimal association with cognitive decline in the medium to long-term. Future research needs to clarify the association of surgical hospitalization with the full spectrum of cognitive outcomes including subjective cognitive complaints and dementia, and importantly, how these cognitive outcomes correlate with clinically significant functional changes.
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Affiliation(s)
- Lucia Chinnappa-Quinn
- Department of Anesthesia, Eastern Health, Box Hill, Victoria, Australia; Center for Healthy Brain Aging (CHeBA), School of Psychiatry, Center for Healthy Brain Aging, University of New South Wales (UNSW), Sydney, Australia
| | - Ben C P Lam
- Center for Healthy Brain Aging (CHeBA), School of Psychiatry, Center for Healthy Brain Aging, University of New South Wales (UNSW), Sydney, Australia
| | - Lara Harvey
- Falls, Balance and Injury Research Center, Neuroscience Research Australia; School of Population Health, University of New South Wales, Australia
| | - Nicole A Kochan
- Center for Healthy Brain Aging (CHeBA), School of Psychiatry, Center for Healthy Brain Aging, University of New South Wales (UNSW), Sydney, Australia
| | - Michael Bennett
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Australia; Department of Anesthesia and Hyperbaric Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - John D Crawford
- Center for Healthy Brain Aging (CHeBA), School of Psychiatry, Center for Healthy Brain Aging, University of New South Wales (UNSW), Sydney, Australia
| | - Steve Robert Makkar
- Center for Healthy Brain Aging (CHeBA), School of Psychiatry, Center for Healthy Brain Aging, University of New South Wales (UNSW), Sydney, Australia
| | - Henry Brodaty
- Dementia Center for Research Collaboration, School of Psychiatry, University of New South Wales (UNSW), Sydney, Australia
| | - Perminder S Sachdev
- Center for Healthy Brain Aging (CHeBA), School of Psychiatry, Center for Healthy Brain Aging, University of New South Wales (UNSW), Sydney, Australia; Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, New South Wales, Australia.
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10
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Tian LJ, Yuan S, Zhou CH, Yan FX. The Effect of Intraoperative Cerebral Oximetry Monitoring on Postoperative Cognitive Dysfunction and ICU Stay in Adult Patients Undergoing Cardiac Surgery: An Updated Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:814313. [PMID: 35178431 PMCID: PMC8846308 DOI: 10.3389/fcvm.2021.814313] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 12/31/2021] [Indexed: 12/29/2022] Open
Abstract
Aim Determining whether intraoperative cerebral oximetry monitoring-guided intervention reduces the risk of postoperative cognitive dysfunction remains controversial. The objective of this study was to conduct an up-to-date meta-analysis to comprehensively assess the effects of regional cerebral oxygen saturation (rSO2) monitoring-guided intervention on cognitive outcomes after cardiac surgery. Methods PubMed, EMBASE, Ovid, and Cochrane Library databases were systematically searched using the related keywords for cardiac surgical randomized-controlled trials (RCTs) published from their inception to July 31, 2021. The primary outcome was postoperative delirium (POD). The secondary outcomes were postoperative cognitive decline (POCD) and other major postoperative outcomes. The odds ratio (OR) or weighted mean differences (WMDs) with 95% confidence interval (CI) were used to pool the data. The random-effect model was used for the potential clinical inconsistency. We performed meta-regression and subgroup analyses to assess the possible influence of rSO2 monitoring-guided intervention on clinical outcomes. Results In total, 12 RCTs with 1,868 cardiac surgical patients were included. Compared with controls, the incidences of POD (n = 6 trials; OR, 0.28; 95% CI, 0.09–0.84; p = 0.02; I2 = 81%) and POCD (n = 5 trials; OR, 0.38; 95% CI, 0.16–0.93; p = 0.03; I2 = 78%) were significantly lower in the intervention group. Cerebral oximetry desaturation also showed a positive association with the incidence of POD (n = 5 trials; OR, 2.02; 95% CI, 1.25–3.24; p = 0.004; I2 = 81%). The duration of intensive care unit (ICU) stay was markedly shorter in the intervention group than in the control group (n = 10 trials; WMD, −0.22 days; 95% CI, −0.44 to −0.00; p = 0.05; I2 = 74%). Univariate meta-regression analyses showed that the major sources of heterogeneity were age (p = 0.03), body mass index (BMI, p = 0.05), and the proportion of congenital heart disease (CHD, p = 0.02) for POD, age (p = 0.04) for POCD, diabetes mellitus (DM, p = 0.07), cerebrovascular accident (CVA, p = 0.02), and chronic obstructive pulmonary disease (COPD, p = 0.09) for ICU stay. Subsequent subgroup analyses also confirmed these results. Conclusion Available evidence from the present study suggests that an intraoperative cerebral oximetry desaturation is associated with an increased POD risk, and the rSO2 monitoring-guided intervention is correlated with a lower risk of POD and POCD, and a shorter ICU stay in adults undergoing cardiac surgery. These clinical benefits may be limited in patients with older age, diabetes status, high BMI, non-CHD, non-COPD, or a previous cardiovascular accident. Systematic Review Registration: [PROSPREO], identifier: [CRD42021252654].
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Affiliation(s)
- Li-Juan Tian
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cheng-Hui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fu-Xia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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11
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Rengel KF, Boncyk CS, Hughes CG. Postoperative Delirium Prevention and Novel Cognitive Therapy Interventions. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00501-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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12
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Zhang T, Ou L, Chen Z, Li J, Shang Y, Hu G. Transcutaneous Electrical Acupoint Stimulation for the Prevention of Postoperative Cognitive Dysfunction: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:756366. [PMID: 34938745 PMCID: PMC8685241 DOI: 10.3389/fmed.2021.756366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/04/2021] [Indexed: 01/09/2023] Open
Abstract
Background: No specific treatment is available for postoperative cognitive dysfunction (POCD). Recently, interest in the prevention of POCD during the perioperative period has increased. Although some studies suggest that transcutaneous electrical acupoint stimulation (TEAS) may be beneficial, the relevant evidence remains uncertain. Objective: To evaluate the preventive effects of TEAS on POCD. Methods: Seven databases including PubMed, EMBASE, CENTRAL, China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), Wanfang Database, and Chinese Biomedical Literature Database (CBM) were electronically searched up to April 2021. Two reviewers independently selected the studies, collected data, and assessed the risks of bias and grading of recommendations, assessment, development, and evaluations certainty of the evidence. A meta-analysis of the incidence of POCD, cognitive function score, pain, adverse reactions, and length of hospital stay after surgery was also performed. Results: Twenty-nine randomized controlled trials with 1,994 participants were included. The results of the meta-analysis showed that the TEAS group has a significantly lower incidence of POCD compared with the control group on postoperative days 1 [OR = 0.33 (95%CI: 0.23, 0.47); p < 0.001, I 2 = 0%, moderate certainty], 3 [OR = 0.38 (95%CI: 0.29, 0.50); p < 0.001, I 2 = 0%, low certainty], and 7 [OR = 0.51 (95%CI: 0.32, 0.81); p = 0.005, I 2 = 0%, low certainty] but not on day 5 (p > 0.05, low certainty). Moreover, TEAS improved the Mini-Mental State Examination scores on postoperative days 1, 3, and 7 [MD = 2.44 (95%CI: 1.61, 3.27); p < 0.001, I 2 = 93%, low certainty]; [MD = 2.07 (95%CI: 1.53, 2.62); p < 0.001, I 2 = 87%, low certainty]; and [MD = 0.49 (95%CI: 0.18, 0.79); p = 0.002, I 2 = 21%, low certainty], respectively, but not on day 5 (p > 0.05, very low certainty). TEAS promoted a postoperative analgesic effect within 24 h after surgery. Furthermore, patients receiving TEAS showed a lower incidence of postoperative nausea and vomiting and a shorter hospital stay. Conclusions: Limited evidence suggests that the application of TEAS in the perioperative period is associated with a reduced POCD rate and a protected early postoperative cognitive function.
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Affiliation(s)
- Tiantian Zhang
- Department of Neurology, The First Hospital of Hunan University of Chinese Medicine, Changsha, China.,The Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Liang Ou
- Department of Orthopedics, The Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Zehua Chen
- The Fifth Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiamin Li
- The Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Yan Shang
- The Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Guoheng Hu
- Department of Neurology, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
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13
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Hughes CG, Hayhurst CJ, Pandharipande PP, Shotwell MS, Feng X, Wilson JE, Brummel NE, Girard TD, Jackson JC, Ely EW, Patel MB. Association of Delirium during Critical Illness With Mortality: Multicenter Prospective Cohort Study. Anesth Analg 2021; 133:1152-1161. [PMID: 33929361 PMCID: PMC8542584 DOI: 10.1213/ane.0000000000005544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The temporal association of delirium during critical illness with mortality is unclear, along with the associations of hypoactive and hyperactive motoric subtypes of delirium with mortality. We aimed to evaluate the relationship of delirium during critical illness, including hypoactive and hyperactive motoric subtypes, with mortality in the hospital and after discharge up to 1 year. METHODS We analyzed a prospective cohort study of adults with respiratory failure and/or shock admitted to university, community, and Veterans Affairs hospitals. We assessed patients using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the intensive care unit (ICU) and defined the motoric subtype according to the corresponding Richmond Agitation-Sedation Scale if delirium was present. We used Cox proportional hazard models, adjusted for baseline characteristics, coma, and daily hospital events, to determine whether delirium on a given day predicted mortality the following day in patients in the hospital and also to determine whether delirium presence and duration predicted mortality after discharge up to 1 year in patients who survived to hospital discharge. We performed similar analyses for hypoactive and hyperactive subtypes of delirium. RESULTS Among 1040 critically ill patients, 214 (21%) died in the hospital and 204 (20%) died out-of-hospital by 1 year. Delirium was common, occurring in 740 (71%) patients for a median (interquartile range [IQR]) of 4 (2-7) days. Hypoactive delirium occurred in 733 (70%) patients, and hyperactive occurred in 185 (18%) patients, with a median (IQR) of 3 (2-7) days and 1 (1-2) days, respectively. Delirium on a given day (hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.32-6.21; P = .008), in particular the hypoactive subtype (HR, 3.35; 95% CI, 1.51-7.46; P = .003), was independently associated with an increased risk of death the following day in the hospital. Hyperactive delirium was not associated with an increased risk of death in the hospital (HR, 4.00; 95% CI, 0.49-32.51; P = .19). Among hospital survivors, neither delirium presence (HR, 1.01; 95% CI, 0.82-1.24; P = .95) nor duration (HR, 0.99; 95% CI, 0.97-1.01; P = .56), regardless of motoric subtype, was associated with mortality after hospital discharge up to 1 year. CONCLUSIONS Delirium during critical illness is associated with nearly a 3-fold increased risk of death the following day for patients in the hospital but is not associated with mortality after hospital discharge. This finding appears primarily driven by the hypoactive motoric subtype. The independent relationship between delirium and mortality occurs early during critical illness but does not persist after hospital discharge.
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Affiliation(s)
- Christopher G. Hughes
- Professor, Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine and Center for Health Services Research, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center
| | - Christina J. Hayhurst
- Assistant Professor, Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center
| | - Pratik P. Pandharipande
- Professor, Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center; Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Matthew S. Shotwell
- Assistant Professor, Department of Biostatistics and Anesthesiology, Vanderbilt University Medical Center
| | - Xiaoke Feng
- Biostatistician, Department of Biostatistics, Vanderbilt University Medical Center
| | - Jo Ellen Wilson
- Assistant Professor, Department of Psychiatry, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center
| | - Nathan E. Brummel
- Associate Professor, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center
| | - Timothy D. Girard
- Associate Professor, Department of Critical Care Medicine and Clinical Research, Investigation, and Systems Modeling of Acute Illnesses Center, University of Pittsburgh; Critical Illness, Brain Dysfunction, and Survivorship Center; Vanderbilt University Medical Center
| | - James C. Jackson
- Research Associate Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center; Research Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - E. Wesley Ely
- Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center; Geriatric Research, Education and Clinical Center (GRECC), Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Mayur B. Patel
- Associate Professor, Section of Surgical Sciences, Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Division of Trauma and Surgical Critical Care, Vanderbilt Brain Institute, Center for Health Services Research, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center; Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
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14
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Stollings JL, Kotfis K, Chanques G, Pun BT, Pandharipande PP, Ely EW. Delirium in critical illness: clinical manifestations, outcomes, and management. Intensive Care Med 2021; 47:1089-1103. [PMID: 34401939 PMCID: PMC8366492 DOI: 10.1007/s00134-021-06503-1] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 07/29/2021] [Indexed: 12/22/2022]
Abstract
Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.
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Affiliation(s)
- Joanna L Stollings
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA.
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Katarzyna Kotfis
- Department Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Gerald Chanques
- Department of Anaesthesia and Critical Care Medicine, Saint Eloi Hospital, Montpellier University Hospital Center, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Brenda T Pun
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN, USA
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15
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Incidence and influencing factors of post-intensive care cognitive impairment. Intensive Crit Care Nurs 2021; 67:103106. [PMID: 34246526 DOI: 10.1016/j.iccn.2021.103106] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/27/2021] [Accepted: 05/14/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the incidence and risks factors of short-term post-intensive care (ICU) cognitive impairment. DESIGN Prospective, observational study. SETTING Closed university-affiliated intensive care unit. PATIENTS We enrolled consecutive patients >18 yrs of age expected to be in intensive care unit for ≥24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The score of Montreal Cognitive Assessment (MoCA) less than 26 was defined as cognitive impairment at hospital discharge and short-term post-ICU cognitive impairment was diagnosed in 185 of 409 assessed patients (45.2%). According to univariate analysis, age, years of education, occupation, past medical history, main ICU diagnosis, Acute Physiology and Chronic Evaluation Scoring System (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, Charlson comorbidity index, ICU length-of-stay (LOS), total hospital LOS, sedation, vasoactive agents, muscle relaxants, mechanical ventilation and duration of mechanical ventilation, constraints, early active mobilisation, hypoxemia, frequency and severity of delirium, blood pressure, rescue experience, and infection were significant predictors of post-ICU cognitive impairment. Multivariate analysis results showed that the frequency and severity of delirium, and advanced age were risk factors of post-ICU cognitive impairment; high years of education and early active mobilisation were protective factors. CONCLUSIONS Incidence of post-ICU cognitive impairment is at a high level, which is similar to former researches' results; the frequency and severity of delirium, and advanced age were risk factors of post-ICU cognitive impairment; high years of education and early active mobilisation were protective factors of post-ICU cognitive impairment.
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Association of Hypoactive and Hyperactive Delirium With Cognitive Function After Critical Illness. Crit Care Med 2021; 48:e480-e488. [PMID: 32317589 DOI: 10.1097/ccm.0000000000004313] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Delirium, a heterogenous syndrome, is associated with worse long-term cognition after critical illness. We sought to determine if duration of motoric subtypes of delirium are associated with worse cognition. DESIGN Secondary analysis of prospective multicenter cohort study. SETTING Academic, community, and Veteran Affairs hospitals. PATIENTS Five-hundred eighty-two survivors of respiratory failure or shock. INTERVENTIONS We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale daily during hospitalization. We defined a day with hypoactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score less than or equal to 0 and a day with hyperactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score greater than 0. At 3 and 12 months, we assessed global cognition with the Repeatable Battery for the Assessment of Neurologic Status and executive function with the Trail Making Test Part B. We used multivariable regression to examine the associations between days of hypoactive and hyperactive delirium with cognition outcomes. We allowed for interaction between days of hypoactive and hyperactive delirium and adjusted for baseline and in-hospital covariates. MEASUREMENTS AND RESULTS Hypoactive delirium was more common and persistent than hyperactive delirium (71% vs 17%; median 3 vs 1 d). Longer duration of hypoactive delirium was associated with worse global cognition at 3 (-5.13 [-8.75 to -1.51]; p = 0.03) but not 12 (-5.76 [-9.99 to -1.53]; p = 0.08) months and with worse executive functioning at 3 (-3.61 [-7.48 to 0.26]; p = 0.03) and 12 (-6.22 [-10.12 to -2.33]; p = 0.004) months; these associations were not modified by hyperactive delirium. Hyperactive delirium was not associated with global cognition or executive function in this cohort. CONCLUSIONS Longer duration of hypoactive delirium was independently associated with worse long-term cognition. Assessing motoric subtypes of delirium in the ICU might aid in prognosis and intervention allocation. Future studies should consider delineating motoric subtypes of delirium.
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Rengel KF, Hayhurst CJ, Jackson JC, Boncyk CS, Patel MB, Brummel NE, Shi Y, Shotwell MS, Ely EW, Pandharipande PP, Hughes CG. Motoric Subtypes of Delirium and Long-Term Functional and Mental Health Outcomes in Adults After Critical Illness. Crit Care Med 2021; 49:e521-e532. [PMID: 33729717 PMCID: PMC8634774 DOI: 10.1097/ccm.0000000000004920] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Adult ICU survivors that experience delirium are at high risk for developing new functional disabilities and mental health disorders. We sought to determine if individual motoric subtypes of delirium are associated with worse disability, depression, and/or post-traumatic stress disorder in ICU survivors. DESIGN Secondary analysis of a prospective multicenter cohort study. SETTING Academic, community, and Veteran Affairs hospitals. PATIENTS Adult ICU survivors of respiratory failure and/or shock. INTERVENTIONS We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation and Sedation Scale daily during hospitalization. We classified delirium as hypoactive (Richmond Agitation and Sedation Scale ≤ 0) or hyperactive (Richmond Agitation and Sedation Scale > 0). At 3- and 12-month postdischarge, we assessed for dependence in activities of daily living and instrumental activities of daily living, symptoms of depression, and symptoms of post-traumatic stress disorder. Adjusting for baseline and inhospital covariates, multivariable regression examined the association of exposure to delirium motoric subtype and long-term outcomes. MEASUREMENTS AND MAIN RESULTS In our cohort of 556 adults with a median age of 62 years, hypoactive delirium was more common than hyperactive (68.9% vs 16.8%). Dependence on the activities of daily living was present in 37% at 3 months and 31% at 12 months, whereas dependence on instrumental activities of daily living was present in 63% at 3 months and 56% at 12 months. At both time points, depression and post-traumatic stress disorder rates were constant at 36% and 5%, respectively. Each additional day of hypoactive delirium was associated with higher instrumental activities of daily living dependence at 3 months only (0.24 points [95% CI, 0.07-0.41; p = 0.006]). There were no associations between the motoric delirium subtype and activities of daily living dependence, depression, or post-traumatic stress disorder. CONCLUSIONS Longer duration of hypoactive delirium, but not hyperactive, was associated with a minimal increase in early instrumental activities of daily living dependence scores in adult survivors of critical illness. Motoric delirium subtype was neither associated with early or late activities of daily living functional dependence or mental health outcomes, nor late instrumental activities of daily living functional dependence.
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Affiliation(s)
- Kimberly F Rengel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina J Hayhurst
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C Jackson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Surgery, Section of Surgical Sciences, Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
- Departments of Neurosurgery, and Hearing & Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Internal Medicine, Division of Pulmonary, Allery, Critical Care, and Sleep Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | | | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Christopher G Hughes
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
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18
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Brummel NE, Hughes CG, Thompson JL, Jackson JC, Pandharipande P, McNeil JB, Raman R, Orun OM, Ware LB, Bernard GR, Ely EW, Girard TD. Inflammation and Coagulation during Critical Illness and Long-Term Cognitive Impairment and Disability. Am J Respir Crit Care Med 2021; 203:699-706. [PMID: 33030981 DOI: 10.1164/rccm.201912-2449oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Rationale: The biological mechanisms of long-term cognitive impairment and disability after critical illness are unclear.Objectives: To test the hypothesis that markers of acute inflammation and coagulation are associated with subsequent long-term cognitive impairment and disability.Methods: We obtained plasma samples from adults with respiratory failure or shock on Study Days 1, 3, and 5 and measured concentrations of CRP (C-reactive protein), IFN-γ, IL-1β, IL-6, IL-8, IL-10, IL-12, MMP-9 (matrix metalloproteinase-9), TNF-α (tumor necrosis factor-α), soluble TNF receptor 1, and protein C. At 3 and 12 months after discharge, we assessed global cognition, executive function, and activities of daily living. We analyzed associations between markers and outcomes using multivariable regression, adjusting for age, sex, education, comorbidities, baseline cognition, doses of sedatives and opioids, stroke risk (in cognitive models), and baseline disability scores (in disability models).Measurements and Main Results: We included 548 participants who were a median (interquartile range) of 62 (53-72) years old, 88% of whom were mechanically ventilated, and who had an enrollment Sequential Organ Failure Assessment score of 9 (7-11). After adjusting for covariates, no markers were associated with long-term cognitive function. Two markers, CRP and MMP-9, were associated with greater disability in basic and instrumental activities of daily living at 3 and 12 months. No other markers were consistently associated with disability outcomes.Conclusions: Markers of systemic inflammation and coagulation measured early during critical illness are not associated with long-term cognitive outcomes and demonstrate inconsistent associations with disability outcomes. Future studies that pair longitudinal measurement of inflammation and related pathways throughout the course of critical illness and during recovery with long-term outcomes are needed.
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Affiliation(s)
- Nathan E Brummel
- Division of Pulmonary, Critical Care, and Sleep Medicine and.,Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee
| | - Christopher G Hughes
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Division of Anesthesiology Critical Care Medicine in the Department of Anesthesiology
| | - Jennifer L Thompson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee
| | - James C Jackson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Division of Allergy, Pulmonary, and Critical Care Medicine.,Department of Psychiatry.,Center for Health Services Research, and
| | - Pratik Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Division of Anesthesiology Critical Care Medicine in the Department of Anesthesiology
| | - J Brennan McNeil
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Division of Allergy, Pulmonary, and Critical Care Medicine
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Onur M Orun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Lorraine B Ware
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Division of Allergy, Pulmonary, and Critical Care Medicine
| | - Gordon R Bernard
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Division of Allergy, Pulmonary, and Critical Care Medicine
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Division of Allergy, Pulmonary, and Critical Care Medicine.,Center for Health Services Research, and.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee; and
| | - Timothy D Girard
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee.,Clinical Research, Investigation, and Systems Modeling of Acute illness Center in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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19
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Nordness MF, Bipin Patel M, Erickson CR, Kiehl A, Jackson JC, Raman R, Pandharipande PP, Ely EW, Wilson JE. Depression predicts long-term cognitive impairment in survivors of critical illness. J Trauma Acute Care Surg 2021; 90:79-86. [PMID: 33017354 DOI: 10.1097/ta.0000000000002955] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Intensive care unit (ICU) survivorship is associated with long-term cognitive impairment (LTCI). Our work has found post-ICU depression in up to 30% and posttraumatic stress disorder (PTSD) in up to 10% of ICU survivors. We hypothesized that post-ICU depression and PTSD are independently associated with LTCI in ICU survivors. METHODS This is a five-center nested prospective cohort of critically ill patients admitted to medical and surgical ICUs who underwent neuropsychological assessments at 3 and 12 months posthospital discharge. Our primary outcome was global cognition using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Trail Making Test, Part B, a test of executive functioning, at 3- and 12-month follow-up. Our independent variables were Beck Depression Inventory II and the PTSD Checklist-Specific Version measured at 3 and 12 months. We performed multivariable linear regression models controlling for covariates such as age, years of education, preexisting cognitive impairment, comorbidities, ventilator days, hypoxemia episodes, and days of delirium or coma. RESULTS Of 1,047 patients in the combined cohort, 679 were alive and available for follow-up at 3 months. A total of 590 (87%) ICU survivors completed at least one 3-month assessment, and of the 554 who survived to 12 months, 519 (94%) completed both a 3- and 12-month assessment with a median age of 61 years (52-70 years) and mean daily Sequential Organ Failure Assessment score of 6 (4-8), 520 (88%) were mechanically ventilated, and 420 (71%) were with delirium. Of these, 113 (19%) had PTSD and 187 (32%) had depression at 3 months with similar rates at 12 months. Depression at 3 months was associated with lower 3-month RBANS (coefficient, -2.25; -3.10 to -1.39) and lower Trails B scores at both 3 months (odds ratio, 0.69; 0.56-0.85) and 12 months (odds ratio, 0.66; 0.52-0.84). Posttraumatic stress disorder at 3 months had no association with RBANS or Trails B scores at 3 or 12 months. CONCLUSION Early post-ICU depression, but not PTSD, is independently associated with coexisting LTCI, even when controlling for past ICU delirium. Treatment for early depression represents a novel intervention area for LTCI prevention in ICU survivors. LEVEL OF EVIDENCE Prognostic/epidemiological, level III.
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Affiliation(s)
- Mina Faye Nordness
- From the Critical Illness, Brain Dysfunction and Survivorship Center, Center for Health Services Research (M.F.N., M.B.P., C.R.E., A.K., J.C.J., P.P.P., E.W.E., J.E.W.), Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, (M.F.N., M.B.P.), Department of Hearing and Speech Sciences (M.B.P), Department of Neurosurgery (M.B.P) Department of Psychiatry (J.E.W.), Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine (J.C.J., E.W.E.), Division of Anesthesiology Critical Care, Department of Anesthesiology (P.P.P.), and Department of Biostatistics (R.R.), Vanderbilt University Medical Center, Nashville, TN; Geriatric Research Education and Clinical Center (M.B.P., J.C.J., P.P.P., E.W.E., J.E.W.), Tennessee Valley Healthcare System, Nashville TN; and Vanderbilt University School of Medicine (M.B.P., C.R.E., P.P.P., E.W.E., J.E.W.)
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20
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Abstract
OBJECTIVE We aimed to identify socioeconomic and clinical risk factors for post-intensive care unit (ICU)-related long-term cognitive impairment (LTCI). SUMMARY BACKGROUND DATA After delirium during ICU stay, LTCI has been increasingly recognized, but without attention to socioeconomic factors. METHODS We enrolled a prospective, multicenter cohort of ICU survivors with shock or respiratory failure from surgical and medical ICUs across 5 civilian and Veteran Affairs (VA) hospitals from 2010 to 2016. Our primary outcome was LTCI at 3- and 12 months post-hospital discharge defined by the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS) global score. Covariates adjusted using multivariable linear regression included age, sex, race, AHRQ socioeconomic index, Charlson comorbidity, Framingham stroke risk, Sequential Organ Failure Assessment, duration of coma, delirium, hypoxemia, sepsis, education level, hospital type, insurance status, discharge disposition, and ICU drug exposures. RESULTS Of 1040 patients, 71% experienced delirium, and 47% and 41% of survivors had RBANS scores >1 standard deviation below normal at 3- and 12 months, respectively. Adjusted analysis indicated that delirium, non-White race, lower education, and civilian hospitals (as opposed to VA), were associated with at least a half standard deviation lower RBANS scores at 3- and 12 months (P ≤ 0.03). Sex, AHRQ socioeconomic index, insurance status, and discharge disposition were not associated with RBANS scores. CONCLUSIONS Socioeconomic and clinical risk factors, such as race, education, hospital type, and delirium duration, were linked to worse PICS ICU-related, LTCI. Further efforts may focus on improved identification of higher-risk groups to promote survivorship through emerging improvements in cognitive rehabilitation.
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21
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Approaches to Addressing Post-Intensive Care Syndrome among Intensive Care Unit Survivors. A Narrative Review. Ann Am Thorac Soc 2020; 16:947-956. [PMID: 31162935 DOI: 10.1513/annalsats.201812-913fr] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Critical illness can be lethal and devastating to survivors. Improvements in acute care have increased the number of intensive care unit (ICU) survivors. These survivors confront a range of new or worsened health states that collectively are commonly denominated post-intensive care syndrome (PICS). These problems include physical, cognitive, psychological, and existential aspects, among others. Burgeoning interest in improving long-term outcomes for ICU survivors has driven an array of potential interventions to improve outcomes associated with PICS. To date, the most promising interventions appear to relate to very early physical rehabilitation. Late interventions within aftercare and recovery clinics have yielded mixed results, although experience in heart failure programs suggests the possibility that very early case management interventions may help improve intermediate-term outcomes, including mortality and hospital readmission. Predictive models have tended to underperform, complicating study design and clinical referral. The complexity of the health states associated with PICS suggests that careful and rigorous evaluation of multidisciplinary, multimodality interventions-tied to the specific conditions of interest-will be required to address these important problems.
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22
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Long-term cognitive impairment after ICU treatment: a prospective longitudinal cohort study (Cog-I-CU). Sci Rep 2020; 10:15518. [PMID: 32968099 PMCID: PMC7511316 DOI: 10.1038/s41598-020-72109-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/21/2020] [Indexed: 01/16/2023] Open
Abstract
In this prospective cohort study we aimed to investigate the trajectory of the cognitive performance of patients after discharge from an intensive care unit (ICU). Special consideration was given to patients with suspected premorbid cognitive impairment who might be at risk for the development of dementia. Clinical characteristics were collected until discharge. The premorbid cognitive state was estimated by a structured interview with a close relative. Cognitive outcome was assessed using the Consortium to Establish a Registry of Alzheimer’s Disease (CERAD) Plus battery and the Stroop Color and Word Test at the time of discharge from ICU and 9 months later. The results of the study group were compared to an established healthy control group and to normative data. A total number of 108 patients were finally included. At the time of discharge, patients underperformed the healthy control group. In linear regression models, delirium during the ICU stay and the factor premorbid cognitive impairment were associated with poorer cognitive outcome (p = 0.047 and p = 0.001). After 9 months, in 6% of patients without evidence of premorbid cognitive impairment long-lasting deficits were found. In patients with suspected premorbid cognitive impairment, performance in tests of executive function failed to improve.
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Sprung J, Abcejo ASA, Knopman DS, Petersen RC, Mielke MM, Hanson AC, Schroeder DR, Schulte PJ, Martin DP, Weingarten TN, Pasternak JJ, Warner DO. Anesthesia With and Without Nitrous Oxide and Long-term Cognitive Trajectories in Older Adults. Anesth Analg 2020; 131:594-604. [PMID: 31651458 DOI: 10.1213/ane.0000000000004490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND We evaluated the hypothesis that the rate of postoperative decline in global cognition is greater in older adults exposed to general anesthesia with nitrous oxide (N2O) compared to general anesthesia without N2O. METHODS Longitudinal measures of cognitive function were analyzed in nondemented adults, 70-91 years of age, enrolled in the Mayo Clinic Study of Aging. Linear mixed-effects models with time-varying covariates assessed the relationship between exposure to surgery with general anesthesia (surgery/GA) with or without N2O and the rate of long-term cognitive changes. Global cognition and domain-specific cognitive outcomes were defined using z scores, which measure how far an observation is, in standard deviations, from the unimpaired population mean. RESULTS The analysis included 1819 participants: 280 exposed to GA without N2O following enrollment and before censoring during follow-up (median [interquartile range {IQR}] follow-up of 5.4 [3.9-7.9] years); 256 exposed to GA with N2O (follow-up 5.6 [4.0-7.9] years); and 1283 not exposed to surgery/GA (follow-up 4.1 [2.5-6.4] years). The slope of the global cognitive z score was significantly more negative following exposure to surgery/GA after enrollment (change in slope of -0.062 [95% confidence interval {CI}, -0.085 to -0.039] for GA without N2O, and -0.058 [95% CI, -0.080 to -0.035] for GA with N2O, both P < .001). The change in slope following exposure to surgery/GA did not differ between those exposed to anesthesia without versus with N2O (estimated difference -0.004 [95% CI, -0.035 to 0.026], P = .783). CONCLUSIONS Exposure to surgery/GA is associated with a small, but statistically significant decline in cognitive z scores. Cognitive decline did not differ between anesthetics with and without N2O. This finding provides evidence that the use of N2O in older adults does not need to be avoided because of concerns related to decline in cognition.
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Affiliation(s)
- Juraj Sprung
- From the Department of Anesthesiology and Perioperative Medicine
| | | | - David S Knopman
- Department of Neurology.,Division of Epidemiology, Department of Health Sciences Research
| | - Ronald C Petersen
- Department of Neurology.,Division of Epidemiology, Department of Health Sciences Research
| | - Michelle M Mielke
- Department of Neurology.,Division of Epidemiology, Department of Health Sciences Research
| | - Andrew C Hanson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Phillip J Schulte
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - David P Martin
- From the Department of Anesthesiology and Perioperative Medicine
| | | | | | - David O Warner
- From the Department of Anesthesiology and Perioperative Medicine
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Perioperative neurocognitive dysfunction: thinking from the gut? Aging (Albany NY) 2020; 12:15797-15817. [PMID: 32805716 PMCID: PMC7467368 DOI: 10.18632/aging.103738] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022]
Abstract
With the aging of the world population, and improvements in medical and health technologies, there are increasing numbers of elderly patients undergoing anaesthesia and surgery. Perioperative neurocognitive dysfunction has gradually attracted increasing attention from academics. Very recently, 6 well-known journals jointly recommended that the term perioperative neurocognitive dysfunction (defined according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition) should be adopted to improve the quality and consistency of academic communications. Perioperative neurocognitive dysfunction currently includes preoperatively diagnosed cognitive decline, postoperative delirium, delayed neurocognitive recovery, and postoperative cognitive dysfunction. Increasing evidence shows that the gut microbiota plays a pivotal role in neuropsychiatric diseases, and in central nervous system functions via the microbiota-gut-brain axis. We recently reported that abnormalities in the composition of the gut microbiota might underlie the mechanisms of postoperative cognitive dysfunction and postoperative delirium, suggesting a critical role for the gut microbiota in perioperative neurocognitive dysfunction. This article therefore reviewed recent findings on the linkage between the gut microbiota and the underlying mechanisms of perioperative neurocognitive dysfunction.
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Association between surgery with anesthesia and cognitive decline in older adults: Analysis using shared parameter models for informative dropout. J Clin Transl Sci 2020; 5:e27. [PMID: 33948250 PMCID: PMC8057447 DOI: 10.1017/cts.2020.519] [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] [Indexed: 12/22/2022] Open
Abstract
Objectives/Goals: The association between surgery with general anesthesia (exposure) and cognition (outcome) among older adults has been studied with mixed conclusions. We revisited a recent analysis to provide missing data education and discuss implications of biostatistical methodology for informative dropout following dementia diagnosis. Methods/study population: We used data from the Mayo Clinic Study of Aging, a longitudinal study of prevalence, incidence, and risk factors for mild cognitive impairment (MCI) and dementia. We fit linear mixed effects models (LMMs) to assess the association between anesthesia exposure and subsequent trajectories of cognitive z-scores assuming data missing at random, hypothesizing that exposure is associated with greater decline in cognitive function. Additionally, we used shared parameter models for informative dropout assuming data missing not at random. Results: A total of 1948 non-demented participants were included. Median age was 79 years, 49% were female, and 16% had MCI at enrollment. Among median follow-up of 4 study visits over 6.6 years, 172 subjects developed dementia, 270 died, and 594 participants underwent anesthesia. In LMMs, exposure to anesthesia was associated with decline in cognitive function over time (change in annual cognitive z-score slope = −0.063, 95% CI: (−0.080, −0.046), p < 0.001). Accounting for informative dropout using shared parameter models, exposure was associated with greater cognitive decline (change in annual slope = −0.081, 95% CI: (−0.137, −0.026), p = 0.004). Discussion: We revisited prior work by our group with a focus on informative dropout. Although the conclusions are similar, we demonstrated the potential impact of novel biostatistics methodology in longitudinal clinical research.
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Connors JR, Deep NL, Huncke TK, Roland JT. Cochlear Implantation Under Local Anesthesia With Conscious Sedation in the Elderly: First 100 Cases. Laryngoscope 2020; 131:E946-E951. [PMID: 32663339 DOI: 10.1002/lary.28853] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To report the outcomes on a large series of elderly patients who underwent cochlear implantation (CI) surgery under local anesthesia with conscious sedation (LA-CS). METHODS Retrospective chart review on 100 consecutive elderly patients (> 65 years) who underwent CI with LA-CS at a tertiary care center between August 2013 and January 2020. An age-matched control group of 50 patients who underwent CI with general anesthesia (GA) are used for comparison. Outcomes measured included time in the operating room, time in the postanesthesia care unit (PACU), and rate of adverse events. RESULTS Cochlear implant surgery under LA-CS was successfully performed in 99 (99%) patients. One patient requiring conversion to GA intraoperatively. No patients in the LA-CS group experienced cardiopulmonary adverse events; however, three patients (6%) in the GA group experienced minor events including atrial fibrillation and/or demand ischemia. Overnight observation in the hospital due to postoperative medical concerns or prolonged wake-up from anesthesia was required in one patient (1%) from the LA-CS cohort and 12 patients (24%) from the GA cohort. Perioperative adverse events exclusive to the LA-CS group included severe intraoperative vertigo (8%), temporary facial nerve paresis (3%), and wound infection (1%). The average amount of time spent in the operating room was 37 minutes less for procedures performed under LA-CS compared to GA (P < .05). The average amount of time in recovery was similar for both groups (P > .05). CONCLUSION Cochlear implant surgery under LA-CS offers many benefits and is a safe, feasible, and cost-effective alternative to GA when performed by experienced CI surgeons. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E946-E951, 2021.
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Affiliation(s)
- Joseph R Connors
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, NY, USA
| | - Nicholas L Deep
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, NY, USA
| | - T Kate Huncke
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, NY, USA
| | - J Thomas Roland
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, NY, USA
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Hughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, McDonagh DL, Gan TJ, McEvoy MD, Miller TE. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesth Analg 2020; 130:1572-1590. [PMID: 32022748 DOI: 10.1213/ane.0000000000004641] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.
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Affiliation(s)
- Christopher G Hughes
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, and Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Abstract
PURPOSE OF REVIEW Cognitive decline is frequently reported after hospitalisation in the contexts of surgery, delirium and critical care. The question not adequately addressed is whether all types of acute hospitalisations increase the risk of cognitive decline. As acute hospitalisations are common in the elderly, who are also vulnerable to cognitive decline, this possible association is of significant concern. RECENT FINDINGS This review summarises cognitive outcomes from recent observational studies investigating acute hospitalisation (emergent and elective) in older age adults. Studies were identified from searching Medline, Embase and PsycINFO databases and citations lists. The highest incidence of cognitive decline has been reported following critical care admissions and admissions complicated by delirium, although all types of acute hospitalisations are implicated. Age is the most consistent risk factor for cognitive decline. Several etiological and therapeutic aspects are being investigated, particularly the measurement of inflammatory biomarkers and treatment with anti-inflammatory medications. SUMMARY Acute hospitalisation for any reason appears to increase the risk of cognitive decline in older adults, but the cause remains elusive. Future research must clarify the nature and modifiers of posthospitalisation cognitive change, a priority in the face of an ageing population.
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Chandrasekhar R, Ely EW, Patel MB. Challenges With Postoperative Cognitive Impairment Research. JAMA Surg 2020; 154:334-335. [PMID: 30649134 DOI: 10.1001/jamasurg.2018.5110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rameela Chandrasekhar
- Critical Illness, Brain Dysfunction, and Survivorship Center, 2525 West End Avenue, 4th Floor, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, 2525 West End Avenue, 4th Floor, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville Veterans Affairs Medical Center, Nashville, Tennessee.,Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, 2525 West End Avenue, 4th Floor, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville Veterans Affairs Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, & Surgical Critical Care, Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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Kapoor MC. Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 2: Cognitive dysfunction after critical illness; potential contributors in surgery and intensive care; pathogenesis; and therapies to prevent/treat perioperative neurological dysfunction. Ann Card Anaesth 2020; 23:391-400. [PMID: 33109793 PMCID: PMC7879886 DOI: 10.4103/aca.aca_139_19] [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] [Indexed: 01/06/2023] Open
Abstract
Severe cognitive decline and cognitive dysfunction has been attributed to patient's stay in the cardiovascular intensive care unit. Prolonged mechanical ventilation, long duration of stay, sedation protocols, and sleep deprivation contribute to patients developing neurocognitive disorder after intensive care admission and it is associated with poor clinical outcomes. Trauma of surgery, stress of critical care, and administration of anaesthesia evoke a systemic inflammatory response and trigger neuroinflammation and oxidative stress. Anaesthetic agents modulate the function of the GABA receptors. The persistence of these effects in the postoperative period promotes development of cognitive dysfunction. A number of drugs are under investigation to restrict or prevent this cognitive decline.
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Affiliation(s)
- Mukul C Kapoor
- Department of Anaesthesia, Max Smart Super Specialty Hospital, Saket, Delhi, India
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Incidence and risk factors of postoperative delirium in patients admitted to the ICU after elective intracranial surgery. Eur J Anaesthesiol 2020; 37:14-24. [DOI: 10.1097/eja.0000000000001074] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kapoor MC. Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 1: The problem; nomenclature; delirium and postoperative neurocognitive disorder; and the role of cardiac surgery and anesthesia. Ann Card Anaesth 2020; 23:383-390. [PMID: 33109792 PMCID: PMC7879912 DOI: 10.4103/aca.aca_138_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The association with cardiac surgery with cognitive decline was first reported in the 1960s after the introduction of coronary artery surgery. The incidence in cognitive decline was thought to be more after cardiac surgery, especially with the use of the cardiopulmonary bypass. Anesthesia and surgery are both associated with cognitive decline but many other factors appear to contribute its genesis. On-pump surgery, microembolization during manipulation of the heart and great vessels, temperature changes, pH changes, and altered cerebral perfusion, during cardiac surgery, have all been blamed for this. Postoperative cognitive decline is associated with poor clinical outcomes and higher mortality. Several studies have been conducted in the last decade to determine the genesis of this malady. Current evidence is absolving cardiac surgery and anesthesia to be the primary causes per se of cognitive dysfunction.
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Affiliation(s)
- Mukul C Kapoor
- Department of Anaesthesia, Max Smart Super Specialty Hospital, Saket, Delhi, India
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Bateman JR, Filley CM, Kaplan RI, Heffernan KS, Bettcher BM. Lifetime surgical exposure, episodic memory, and forniceal microstructure in older adults. J Clin Exp Neuropsychol 2019; 41:1048-1059. [PMID: 31370773 PMCID: PMC6764849 DOI: 10.1080/13803395.2019.1647151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 07/14/2019] [Indexed: 12/14/2022]
Abstract
Introduction: Aging is associated with heterogeneous cognitive trajectories. There is considerable interest in identifying risk factors for pathological aging, with recent studies demonstrating a link between surgical procedures and proximal cognitive decline; however, the role of lifetime exposure to surgical procedures and cognitive function has been relatively unexplored. This pilot study aimed to evaluate the association between total lifetime surgical procedures and memory function in older adults. Methods: A cohort of 62 older adults underwent a neuropsychological evaluation and health history assessment. Self-reported lifetime surgical history was categorized as "cardiac" or "non-cardiac." General linear models were fit with demographics as nuisance covariates, and the total number of non-cardiac surgeries as our predictor of interest. Total scores on measures of episodic memory, language, working memory, fluency, and visuospatial function were separate outcome variables. In a secondary analysis, vascular risk factors were included as covariates. Diffusion tensor imaging was obtained for exploratory analyses of selected regions of interest. Results: The mean age of participants was 70, and 0-13 lifetime non-cardiac surgical procedures were reported. Higher numbers of lifetime non-cardiac surgical procedures were associated with worse verbal learning and memory (p = .04). The negative association between lifetime non-cardiac procedures and cognition was specific to memory. Exploratory analyses showed that higher number of lifetime non-cardiac procedures was related to lower FA in the fornix body (p = .02). Conclusions: These results of this pilot study suggest that greater lifetime exposure to surgery may be associated with worse verbal learning and memory in healthy older adults. These findings add to a growing body of literature suggesting that cumulative medical events may be risk factors for negative cognitive outcomes.
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Affiliation(s)
- James R. Bateman
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC; Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC), Research and Education Service Line, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC
| | - Christopher M. Filley
- Behavioral Neurology Section, Departments of Neurology and Psychiatry, Marcus Institute for Brain Health, Rocky Mountain Alzheimer’s Disease Center, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Rini I. Kaplan
- Department of Neurology, Rocky Mountain Alzheimer’s Disease Center, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kate S. Heffernan
- Behavioral Neurology Section, Departments of Neurology and Neurosurgery, Rocky Mountain Alzheimer’s Disease Center, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Brianne M. Bettcher
- Behavioral Neurology Section, Departments of Neurology and Neurosurgery, Rocky Mountain Alzheimer’s Disease Center, University of Colorado Anschutz Medical Campus, Aurora, CO
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Sprung J, Kruthiventi SC, Warner DO, Knopman DS, Petersen RC, Mielke MM, Jack CR, Graff-Radford J, Martin DP, Hanson AC, Schroeder DR, Przybelski SA, Schulte PJ, Weingarten TN, Vemuri P. Exposure to surgery under general anaesthesia and brain magnetic resonance imaging changes in older adults. Br J Anaesth 2019; 123:808-817. [PMID: 31587833 PMCID: PMC6883493 DOI: 10.1016/j.bja.2019.08.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/08/2019] [Accepted: 08/26/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Preclinical studies suggest that exposure to general anaesthesia (GA) could cause neurodegeneration consistent with Alzheimer's disease (AD) pathology. Brain magnetic resonance imaging (MRI) is useful to study structural brain changes. We tested the hypothesis that exposure to surgery with GA (surgery/GA) is associated with greater cortical thinning and increased frequency of white matter lesions. METHODS This is a cross-sectional analysis of 70-91-yr-old participants enrolled in the Mayo Clinic Study of Aging who had baseline MRI. The thickness of selected cortical regions, the volume of white matter hyperintensities, and the frequency of cortical infarctions were compared in participants who were and were not exposed to surgery/GA within 20 yr before the first MRI obtained after enrolment. RESULTS Of 1410 participants with MRI scans, 932 were exposed to surgery/GA before scanning. In adjusted analyses, cortical thickness in regions vulnerable to AD was significantly less in those exposed to surgery/GA in the prior 20 yr (difference -0.023 mm, [95% confidence interval (CI) -0.041 to -0.005], P=0.014). Those with surgery in the prior 20 yr were more likely to have 'abnormal thickness' compared with those without surgery (odds ratio=1.45, [95% CI 1.10-1.90], P=0.009). Exposure was not associated with white matter hyperintensities or the presence of brain infarcts. CONCLUSIONS This study suggests that exposure of older adults to surgical anaesthesia is associated with thinning in cortical regions implicated in AD. The pathogenesis and mechanisms driving these neurodegenerative changes, and the potential clinical significance of these findings, require further study.
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Affiliation(s)
- Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - S Chandralekha Kruthiventi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - David S Knopman
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Ronald C Petersen
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Michelle M Mielke
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Clifford R Jack
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jonathan Graff-Radford
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Andrew C Hanson
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Darrell R Schroeder
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Scott A Przybelski
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Phillip J Schulte
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Prashanthi Vemuri
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Abstract
PURPOSE OF REVIEW Evaluating longer term mortality, morbidity, and quality of life in survivors of critical illness is a research priority. This review details the challenges of long-term follow-up studies of critically ill patients and highlights recently proposed methodological solutions. RECENT FINDINGS Barriers to long-term follow-up studies of critical care survivors include high rates of study attrition because of death or loss to follow-up, data missingness from experienced morbidity, and lack of standardized outcome as well as reporting of key covariates. A number of recent methods have been proposed to reduce study patients attrition, including minimum data set selection and visits to transitional care or home settings, yet these have significant downsides as well. Conducting long-term follow-up even in the absence of such models carries a high expense, as personnel are very costly, and patients/families require reimbursement for their time and inconvenience. SUMMARY There is a reason why many research groups do not conduct long-term outcomes in critical care: it is very difficult. Challenges of long-term follow-up require careful consideration by study investigators to ensure our collective success in data integration and a better understanding of underlying mechanisms of mortality and morbidity seen in critical care survivorship.
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Affiliation(s)
- M. Elizabeth Wilcox
- Department of Medicine (Critical Care Medicine), Division of Respirology, University Health Network, Toronto, Canada
- Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research, Department of Medicine, and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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Sprung J, Schulte PJ, Knopman DS, Mielke MM, Petersen RC, Weingarten TN, Martin DP, Hanson AC, Schroeder DR, Warner DO. Cognitive function after surgery with regional or general anesthesia: A population-based study. Alzheimers Dement 2019; 15:1243-1252. [PMID: 31495602 DOI: 10.1016/j.jalz.2019.06.4949] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/14/2019] [Accepted: 06/19/2019] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Our aim was to examine whether surgery with regional anesthesia (RA) is associated with accelerated long-term cognitive decline comparable with that previously reported after general anesthesia (GA). METHODS Longitudinal cognitive function was analyzed in a cohort of 1819 older adults. Models assessed the rate of change in global and domain-specific cognition over time in participants exposed to RA or GA. RESULTS When compared with those unexposed to anesthesia, the postoperative rate of change of the cognitive global z-score was greater in those exposed to both RA (difference in annual decline of -0.041, P = .011) and GA (-0.061, P < .001); these rates did not differ. In analysis of the domain-specific scores, an accelerated decline in memory was observed after GA (-0.065, P < .001) but not RA (-0.011, P = .565). CONCLUSIONS Older adults undergoing surgery with RA experience decline of global cognition similar to those receiving GA; however, memory was not affected.
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Affiliation(s)
- Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Phillip J Schulte
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - David S Knopman
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | | | - Ronald C Petersen
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andrew C Hanson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Rengel KF, Pandharipande PP, Hughes CG. Special Considerations for the Aging Brain and Perioperative Neurocognitive Dysfunction. Anesthesiol Clin 2019; 37:521-536. [PMID: 31337482 DOI: 10.1016/j.anclin.2019.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Postoperative delirium and postoperative cognitive dysfunction (POCD) occur commonly in older adults after surgery and are frequently underrecognized. Delirium has been associated with worse outcomes, and both delirium and cognitive dysfunction increase the risk of long-term cognitive decline. Although the pathophysiology of delirium and POCD have not been clearly defined, risk factors for both include increasing age, lower levels of education, and baseline cognitive impairment. In addition, developing delirium increases the risk of POCD. This article examines interventions that may reduce the risk of developing delirium and POCD and improve long-term recovery and outcomes in the vulnerable older population.
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Affiliation(s)
- Kimberly F Rengel
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA.
| | - Pratik P Pandharipande
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
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Delirium after Cardiac Surgery and Cognitive Change: Comment. Anesthesiology 2019; 130:857-859. [PMID: 30994565 DOI: 10.1097/aln.0000000000002698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rengel KF, Hayhurst CJ, Pandharipande PP, Hughes CG. Long-term Cognitive and Functional Impairments After Critical Illness. Anesth Analg 2019; 128:772-780. [DOI: 10.1213/ane.0000000000004066] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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van der Veen GJ, Slagt C. A clearer view on postoperative cognitive dysfunction? [Letter]. Local Reg Anesth 2019; 12:27-28. [PMID: 30881109 PMCID: PMC6420101 DOI: 10.2147/lra.s201896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Gijsbert J van der Veen
- Department of Anaesthesia, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands, ,Correspondence: Gijsbert J van der Veen, Department of Anaesthesia, Pain and Palliative Medicine, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6500 HB Nijmegen, The Netherlands, Email
| | - Cornelis Slagt
- Department of Anaesthesia, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands,
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James BD, Wilson RS, Capuano AW, Boyle PA, Shah RC, Lamar M, Ely EW, Bennett DA, Schneider JA. Cognitive decline after elective and nonelective hospitalizations in older adults. Neurology 2019; 92:e690-e699. [PMID: 30635482 DOI: 10.1212/wnl.0000000000006918] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 12/14/2018] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To determine whether emergent and urgent (nonelective) hospitalizations are associated with faster acceleration of cognitive decline compared to elective hospitalizations, accounting for prehospital decline. METHODS Data came from the Rush Memory and Aging Project, a prospective cohort study of community-dwelling older persons without baseline dementia. Annual measures of cognition via a battery of 19 tests were linked to 1999 to 2010 Medicare claims records. RESULTS Of 777 participants, 460 (59.2%) were hospitalized over a mean of 5.0 (SD = 2.6) years; 222 (28.6%) had at least one elective and 418 (53.8%) at least one nonelective hospitalization. Mixed-effects regression models estimated change in global cognition before and after each type of hospitalization compared to no hospitalization, adjusted for age, sex, education, medical conditions, length of stay, surgery, intensive care unit, and comorbidities. Persons who were not hospitalized had a mean loss of 0.051 unit global cognition per year. In comparison, there was no significant difference in rate of decline before (0.044 unit per year) or after (0.048 unit per year) elective hospitalizations. In contrast, decline before nonelective hospitalization was faster (0.076 unit per year; estimate = -0.024, SE = 0.011, p = 0.032), and accelerated by 0.036 unit (SE = 0.005, p < 0.001) to mean loss of 0.112 unit per year after nonelective hospitalizations, more than doubling the rate in those not hospitalized. CONCLUSIONS Nonelective hospitalizations are related to more dramatic acceleration in cognitive decline compared to elective hospitalizations, even after accounting for prehospital decline. These findings may inform which hospital admissions pose the greatest risk to the cognitive health of older adults.
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Affiliation(s)
- Bryan D James
- From the Rush Alzheimer's Disease Center (B.D.J., R.S.W., A.W.C., P.A.B., R.C.S., M.L., D.A.B., J.A.S.), Departments of Internal Medicine (B.D.J.), Neurological Sciences (R.S.W., A.W.C., M.L., D.A.B., J.A.S.), Behavioral Sciences (R.S.W., P.A.B.), Family Medicine (R.C.S.), and Pathology (J.A.S.), Rush University Medical Center, Chicago, IL; Center for Quality of Aging (E.W.E.), Vanderbilt Medical School, Nashville; Division of Allergy, Pulmonary, and Critical Care Medicine (E.W.E.), Vanderbilt University, Nashville; and Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC) (E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.
| | - Robert S Wilson
- From the Rush Alzheimer's Disease Center (B.D.J., R.S.W., A.W.C., P.A.B., R.C.S., M.L., D.A.B., J.A.S.), Departments of Internal Medicine (B.D.J.), Neurological Sciences (R.S.W., A.W.C., M.L., D.A.B., J.A.S.), Behavioral Sciences (R.S.W., P.A.B.), Family Medicine (R.C.S.), and Pathology (J.A.S.), Rush University Medical Center, Chicago, IL; Center for Quality of Aging (E.W.E.), Vanderbilt Medical School, Nashville; Division of Allergy, Pulmonary, and Critical Care Medicine (E.W.E.), Vanderbilt University, Nashville; and Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC) (E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Ana W Capuano
- From the Rush Alzheimer's Disease Center (B.D.J., R.S.W., A.W.C., P.A.B., R.C.S., M.L., D.A.B., J.A.S.), Departments of Internal Medicine (B.D.J.), Neurological Sciences (R.S.W., A.W.C., M.L., D.A.B., J.A.S.), Behavioral Sciences (R.S.W., P.A.B.), Family Medicine (R.C.S.), and Pathology (J.A.S.), Rush University Medical Center, Chicago, IL; Center for Quality of Aging (E.W.E.), Vanderbilt Medical School, Nashville; Division of Allergy, Pulmonary, and Critical Care Medicine (E.W.E.), Vanderbilt University, Nashville; and Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC) (E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Patricia A Boyle
- From the Rush Alzheimer's Disease Center (B.D.J., R.S.W., A.W.C., P.A.B., R.C.S., M.L., D.A.B., J.A.S.), Departments of Internal Medicine (B.D.J.), Neurological Sciences (R.S.W., A.W.C., M.L., D.A.B., J.A.S.), Behavioral Sciences (R.S.W., P.A.B.), Family Medicine (R.C.S.), and Pathology (J.A.S.), Rush University Medical Center, Chicago, IL; Center for Quality of Aging (E.W.E.), Vanderbilt Medical School, Nashville; Division of Allergy, Pulmonary, and Critical Care Medicine (E.W.E.), Vanderbilt University, Nashville; and Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC) (E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Raj C Shah
- From the Rush Alzheimer's Disease Center (B.D.J., R.S.W., A.W.C., P.A.B., R.C.S., M.L., D.A.B., J.A.S.), Departments of Internal Medicine (B.D.J.), Neurological Sciences (R.S.W., A.W.C., M.L., D.A.B., J.A.S.), Behavioral Sciences (R.S.W., P.A.B.), Family Medicine (R.C.S.), and Pathology (J.A.S.), Rush University Medical Center, Chicago, IL; Center for Quality of Aging (E.W.E.), Vanderbilt Medical School, Nashville; Division of Allergy, Pulmonary, and Critical Care Medicine (E.W.E.), Vanderbilt University, Nashville; and Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC) (E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Melissa Lamar
- From the Rush Alzheimer's Disease Center (B.D.J., R.S.W., A.W.C., P.A.B., R.C.S., M.L., D.A.B., J.A.S.), Departments of Internal Medicine (B.D.J.), Neurological Sciences (R.S.W., A.W.C., M.L., D.A.B., J.A.S.), Behavioral Sciences (R.S.W., P.A.B.), Family Medicine (R.C.S.), and Pathology (J.A.S.), Rush University Medical Center, Chicago, IL; Center for Quality of Aging (E.W.E.), Vanderbilt Medical School, Nashville; Division of Allergy, Pulmonary, and Critical Care Medicine (E.W.E.), Vanderbilt University, Nashville; and Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC) (E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - E Wesley Ely
- From the Rush Alzheimer's Disease Center (B.D.J., R.S.W., A.W.C., P.A.B., R.C.S., M.L., D.A.B., J.A.S.), Departments of Internal Medicine (B.D.J.), Neurological Sciences (R.S.W., A.W.C., M.L., D.A.B., J.A.S.), Behavioral Sciences (R.S.W., P.A.B.), Family Medicine (R.C.S.), and Pathology (J.A.S.), Rush University Medical Center, Chicago, IL; Center for Quality of Aging (E.W.E.), Vanderbilt Medical School, Nashville; Division of Allergy, Pulmonary, and Critical Care Medicine (E.W.E.), Vanderbilt University, Nashville; and Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC) (E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - David A Bennett
- From the Rush Alzheimer's Disease Center (B.D.J., R.S.W., A.W.C., P.A.B., R.C.S., M.L., D.A.B., J.A.S.), Departments of Internal Medicine (B.D.J.), Neurological Sciences (R.S.W., A.W.C., M.L., D.A.B., J.A.S.), Behavioral Sciences (R.S.W., P.A.B.), Family Medicine (R.C.S.), and Pathology (J.A.S.), Rush University Medical Center, Chicago, IL; Center for Quality of Aging (E.W.E.), Vanderbilt Medical School, Nashville; Division of Allergy, Pulmonary, and Critical Care Medicine (E.W.E.), Vanderbilt University, Nashville; and Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC) (E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Julie A Schneider
- From the Rush Alzheimer's Disease Center (B.D.J., R.S.W., A.W.C., P.A.B., R.C.S., M.L., D.A.B., J.A.S.), Departments of Internal Medicine (B.D.J.), Neurological Sciences (R.S.W., A.W.C., M.L., D.A.B., J.A.S.), Behavioral Sciences (R.S.W., P.A.B.), Family Medicine (R.C.S.), and Pathology (J.A.S.), Rush University Medical Center, Chicago, IL; Center for Quality of Aging (E.W.E.), Vanderbilt Medical School, Nashville; Division of Allergy, Pulmonary, and Critical Care Medicine (E.W.E.), Vanderbilt University, Nashville; and Veterans Affairs Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC) (E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN
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Luo A, Yan J, Tang X, Zhao Y, Zhou B, Li S. Postoperative cognitive dysfunction in the aged: the collision of neuroinflammaging with perioperative neuroinflammation. Inflammopharmacology 2019; 27:27-37. [PMID: 30607668 DOI: 10.1007/s10787-018-00559-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/26/2018] [Indexed: 12/25/2022]
Abstract
The aging population is burgeoning globally and this trend presents great challenges to the current healthcare system as the growing number of aged individuals receives procedures of surgery and anesthesia. Postoperative cognitive dysfunction (POCD) is a severe postoperative neurological sequela. Advanced age is considered as an independent risk factor of POCD. Mounting evidence have shown that neuroinflammation plays an essential role in POCD. However, it remains debatable why this complication occurs highly in the aged individuals. As known, aging itself is the major common high-risk factor for age-associated disorders including diabetes, cardiovascular disease, cancer, and neurodegenerative diseases. Chronic low-grade neuroinflammation (dubbed neuroinflammaging in the present paper) is a hallmark alternation and contributes to age-related cognitive decline in the normal aging. Interestingly, several lines of findings show that the neuroinflammatory pathogenesis of POCD is age-dependent. It suggests that age-related changes, especially the neuroinflammaging, are possibly associated with the postoperative cognitive impairment. Understanding the role of neuroinflammaging in POCD is crucial to elucidate the mechanism of POCD and develop strategies to prevent or treat POCD. Here the focus of this review is on the potential role of neuroinflammaging in the mechanism of POCD. Lastly, we briefly review promising interventions for this neurological sequela.
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Affiliation(s)
- AiLin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Jing Yan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - XiaoLe Tang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - YiLin Zhao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - BiYun Zhou
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - ShiYong Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
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Grahl JJ, Stollings JL, Rakhit S, Person AK, Wang L, Thompson JL, Pandharipande PP, Ely EW, Patel MB. Antimicrobial exposure and the risk of delirium in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:337. [PMID: 30541600 PMCID: PMC6291937 DOI: 10.1186/s13054-018-2262-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/13/2018] [Indexed: 02/13/2023]
Abstract
Background Prior retrospective cross-sectional work has associated antimicrobials with a non-specific phrase: encephalopathy without seizures. The purpose of this study is to determine whether different classes of antimicrobials have differential associations with the daily risk of delirium after critical illness is adjusted for. Methods Our study was a nested cohort that enrolled non-neurological critically ill adults from a medical or surgical intensive care unit (ICU) with daily follow-up to 30 days. Our independent variable was exposure to previous-day antimicrobial class: beta-lactams (subclasses: penicillins, first- to third-generation cephalosporins, fourth-generation cephalosporins, and carbapenems), macrolides, fluoroquinolones, and other. We adjusted for baseline covariates (age, comorbidities, cognition scores, sepsis, and mechanical ventilation), previous-day covariates (delirium, doses of analgesics/sedatives, and antipsychotic use), and same-day covariates (illness severity). Our primary outcome of delirium was measured by using the Confusion Assessment Method for the ICU. A daily delirium logistic regression model was used with an ICU time-restricted sensitivity analysis including daily adjustment for sepsis and mechanical ventilation. Results Of 418 ICU patients, delirium occurred in 308 (74%) with a median of 3 days (interquartile range 2–6) among those affected and 318 (76%) were exposed to antimicrobials. When covariates and ICU type were adjusted for, only first- to third-generation cephalosporins were associated with delirium (logistic regression model odds ratio (OR) = 2.2, 95% confidence interval (CI) 1.28–3.79, P = 0.004; sensitivity analysis OR = 2.13, 95% CI 1.10–4.10, P = 0.024). Conclusions First-, second-, and third-generation cephalosporins doubled the odds of delirium after baseline co-morbidities, ICU type, the course of critical care, and other competing antimicrobial and psychotropic medication risks were adjusted for. We did not find an association between delirium and cefepime, penicillins, carbapenems, fluoroquinolones, or macrolides. Electronic supplementary material The online version of this article (10.1186/s13054-018-2262-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jessica J Grahl
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37212, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37212, USA. .,Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.
| | - Shayan Rakhit
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA
| | - Anna K Person
- Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue S, Nashville, TN, 37232-2650, USA
| | - Li Wang
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, TN, 37232, USA
| | - Jennifer L Thompson
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, TN, 37232, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA.,Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue S, Nashville, TN, 37212, USA.,Center for Health Services Research, Vanderbilt University Medical Center, 1215 21st Avenue S, Nashville, TN, 27232-8300, USA
| | - E Wesley Ely
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA.,Center for Health Services Research, Vanderbilt University Medical Center, 1215 21st Avenue S, Nashville, TN, 27232-8300, USA.,Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, 1310 24th Avenue S, Nashville, TN, 37212, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue S, Nashville, TN, 37232-2650, USA
| | - Mayur B Patel
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA. .,Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA. .,Center for Health Services Research, Vanderbilt University Medical Center, 1215 21st Avenue S, Nashville, TN, 27232-8300, USA. .,Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, 1310 24th Avenue S, Nashville, TN, 37212, USA. .,Division of Trauma and Surgical Critical Care, Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Section of Surgical Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, 1211 Medical Center Drive, 404 Medical Arts Building, Nashville, TN, 37212, USA.
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Schulte PJ, Martin DP, Deljou A, Sabov M, Roberts RO, Knopman DS, Petersen RC, Weingarten TN, Hanson AC, Schroeder DR, Warner DO, Sprung J. Effect of Cognitive Status on the Receipt of Procedures Requiring Anesthesia and Critical Care Admissions in Older Adults. Mayo Clin Proc 2018; 93:1552-1562. [PMID: 30274907 DOI: 10.1016/j.mayocp.2018.06.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/04/2018] [Accepted: 06/04/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate whether older adults with mild cognitive impairment (MCI) or dementia have higher rates of procedures requiring general anesthesia or intensive care unit (ICU) admissions compared with cognitively normal (CN) patients. PATIENTS AND METHODS A population-based cohort, 70 to 89 years old at enrollment, underwent clinical and longitudinal neurocognitive testing to identify those with MCI and dementia. We analyzed the effects of cognitive status (CN, MCI, or dementia) at entry into the study from October 1, 2004, through December 31, 2014, on the risk of receiving procedures requiring surgical anesthesia and ICU admission. RESULTS Of 2436 participants, 1977 (81%) were CN, 387 (16%) had MCI, and 72 (3%) had dementia. Cognitively impaired individuals were sicker. Compared with CN individuals, the likelihood of receiving a procedure requiring anesthesia was similar in participants with MCI (adjusted hazard ratio [aHR]=0.98; P=.78). Participants with dementia were less likely to receive these procedures (aHR=0.50; P=.02). Compared with CN participants, the likelihood of ICU admission for any indication was increased for those with MCI (aHR=1.24; P=.03) and dementia (aHR=1.59; P=.04). Admissions to the ICU after procedures were not different in patients with either MCI or dementia (aHR=0.96; P=.83 and aHR=1.01; P=.98, respectively). CONCLUSION Patients with MCI or dementia are not more likely to undergo surgery, and neither are they more likely to require ICU admission after procedures. An increased rate of nonsurgical ICU admissions requires vigilance to prevent deterioration of nonsurgical diseases that may lead to ICU admissions.
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Affiliation(s)
- Phillip J Schulte
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - David P Martin
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Atousa Deljou
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Moldovan Sabov
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Rosebud O Roberts
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - David S Knopman
- Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Ronald C Petersen
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | | | - Andrew C Hanson
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Darrell R Schroeder
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - David O Warner
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic, Rochester, MN.
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Schulte PJ, Roberts RO, Knopman DS, Petersen RC, Hanson AC, Schroeder DR, Weingarten TN, Martin DP, Warner DO, Sprung J. Association between exposure to anaesthesia and surgery and long-term cognitive trajectories in older adults: report from the Mayo Clinic Study of Aging. Br J Anaesth 2018; 121:398-405. [PMID: 30032878 DOI: 10.1016/j.bja.2018.05.060] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 05/04/2018] [Accepted: 05/28/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The link between exposure to general anaesthesia and surgery (exposure) and cognitive decline in older adults is debated. We hypothesised that it is associated with cognitive decline. METHODS We analysed the longitudinal cognitive function trajectory in a cohort of older adults. Models assessed the rate of change in cognition over time, and its association with exposure to anaesthesia and surgery. Analyses assessed whether exposure in the 20 yr before enrolment is associated with cognitive decline when compared with those unexposed, and whether post-enrolment exposure is associated with a change in cognition in those unexposed before enrolment. RESULTS We included 1819 subjects with median (25th and 75th percentiles) follow-up of 5.1 (2.7-7.6) yr and 4 (3-6) cognitive assessments. Exposure in the previous 20 yr was associated with a greater negative slope compared with not exposed (slope: -0.077 vs -0.059; difference: -0.018; 95% confidence interval: -0.032, -0.003; P=0.015). Post-enrolment exposure in those previously unexposed was associated with a change in slope after exposure (slope: -0.100 vs -0.059 for post-exposure vs pre-exposure, respectively; difference: -0.041; 95% confidence interval: -0.074, -0.008; P=0.016). Cognitive impairment could be attributed to declines in memory and attention/executive cognitive domains. CONCLUSIONS In older adults, exposure to general anaesthesia and surgery was associated with a subtle decline in cognitive z-scores. For an individual with no prior exposure and with exposure after enrolment, the decline in cognitive function over a 5 yr period after the exposure would be 0.2 standard deviations more than the expected decline as a result of ageing. This small cognitive decline could be meaningful for individuals with already low baseline cognition.
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Affiliation(s)
- P J Schulte
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - R O Roberts
- Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - D S Knopman
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - R C Petersen
- Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - A C Hanson
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - D R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - T N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - D P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - D O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - J Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
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Hughes CG, Patel MB, Brummel NE, Thompson JL, McNeil JB, Pandharipande PP, Jackson JC, Chandrasekhar R, Ware LB, Ely EW, Girard TD. Relationships between markers of neurologic and endothelial injury during critical illness and long-term cognitive impairment and disability. Intensive Care Med 2018; 44:345-355. [PMID: 29523900 PMCID: PMC5870884 DOI: 10.1007/s00134-018-5120-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/28/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE Neurologic and endothelial injury biomarkers are associated with prolonged delirium during critical illness and may reflect injury pathways that lead to poor long-term outcomes. We hypothesized that blood-brain barrier (BBB), neuronal, and endothelial injury biomarkers measured during critical illness are associated with cognitive impairment and disability after discharge. METHODS We enrolled adults with respiratory failure and/or shock and measured plasma concentrations of BBB (S100B), neuronal (UCHL1, BDNF), and endothelial (E-selectin, PAI-1) injury markers within 72 h of ICU admission. At 3 and 12 months post-discharge, we assessed participants' global cognition, executive function, and activities of daily living (ADL). We used multivariable regression to determine whether biomarkers were associated with outcomes after adjusting for relevant demographic and acute illness covariates. RESULTS Our study included 419 survivors of critical illness with median age 59 years and APACHE II score 25. Higher S100B was associated with worse global cognition at 3 and 12 months (P = 0.008; P = 0.01). UCHL1 was nonlinearly associated with global cognition at 3 months (P = 0.02). Higher E-selectin was associated with worse global cognition (P = 0.006 at 3 months; P = 0.06 at 12 months). BDNF and PAI-1 were not associated with global cognition. No biomarkers were associated with executive function. Higher S100B (P = 0.05) and E-selectin (P = 0.02) were associated with increased disability in ADLs at 3 months. CONCLUSIONS S100B, a marker of BBB and/or astrocyte injury, and E-selectin, an adhesion molecule and marker of endothelial injury, are associated with long-term cognitive impairment after critical illness, findings that may reflect mechanisms of critical illness brain injury.
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Affiliation(s)
- Christopher G Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Nashville, USA.
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, USA.
| | - Mayur B Patel
- Section of Surgical Sciences, Departments of Surgery, Neurosurgery and Hearing and Speech Sciences, Division of Trauma and Surgical Critical Care, Vanderbilt Brain Institute, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, USA
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, USA
| | - Nathan E Brummel
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Jennifer L Thompson
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA
| | - J Brennan McNeil
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Pratik P Pandharipande
- Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, USA
| | - James C Jackson
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Nashville, USA
- Research Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, USA
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - E Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Nashville, USA
- Geriatric Research, Education and Clinical Center Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, USA
| | - Timothy D Girard
- Department of Critical Care Medicine and Clinical Research, Investigation and Systems Modeling of Acute Illnesses Center, University of Pittsburgh, Pittsburgh, USA
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Stollings JL, Thompson JL, Ferrell BA, Scheinin M, Wilkinson GR, Hughes CG, Shintani AK, Ely EW, Girard TD, Pandharipande PP, Patel MB. Sedative Plasma Concentrations and Delirium Risk in Critical Illness. Ann Pharmacother 2018; 52:513-521. [PMID: 29363356 DOI: 10.1177/1060028017753480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The relationship between plasma concentration of sedatives and delirium is unknown. OBJECTIVE We hypothesized that higher plasma concentrations of lorazepam are associated with increased delirium risk, whereas higher plasma concentrations of dexmedetomidine are associated with reduced delirium risk. METHODS This prospective cohort study was embedded in a double-blind randomized clinical trial, where ventilated patients received infusions of lorazepam and dexmedetomidine. Plasma concentrations of these drugs and delirium assessments were measured at least daily. A multivariable logistic regression model accounting for repeated measures was used to analyze associations between same-day plasma concentrations of lorazepam and dexmedetomidine (exposures) and the likelihood of next-day delirium (outcome), adjusting for same-day mental status (delirium, coma, or normal) and same-day fentanyl doses. RESULTS This critically ill cohort (n = 103) had a median age of 60 years (IQR: 48-66) with APACHE II score of 28 (interquartile range [IQR] = 24-32), where randomization resulted in assignment to lorazepam (n = 51) or dexmedetomidine (n = 52). After adjusting for same-day fentanyl dose and mental status, higher plasma concentrations of lorazepam were associated with increased probability of next-day delirium (comparing 500 vs 0 ng/mL; odds ratio [OR] = 13.2; 95% CI = 1.4-120.1; P = 0.02). Plasma concentrations of dexmedetomidine were not associated with next-day delirium (comparing 1 vs 0 ng/mL; OR = 1.1; 95% CI = 0.9-1.3; P = 0.45). CONCLUSIONS In critically ill patients, higher lorazepam plasma concentrations were associated with delirium, whereas dexmedetomidine plasma concentrations were not. This implies that the reduced delirium risk seen in patients sedated with dexmedetomidine may be a result of avoidance of benzodiazepines, rather than a dose-dependent protective effect of dexmedetomidine.
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Affiliation(s)
| | | | - Benjamin A Ferrell
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,3 University of Tennessee School of Medicine, Nashville, TN, USA
| | - Mika Scheinin
- 4 University of Turku, Turku, Finland.,5 Turku University Hospital, Turku, Finland
| | - Grant R Wilkinson
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christopher G Hughes
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Ayumi K Shintani
- 2 Vanderbilt University School of Medicine, Nashville, TN, USA.,6 Osaka University, Suita, Japan
| | - E Wesley Ely
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA.,7 Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, USA
| | | | - Pratik P Pandharipande
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA.,7 Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, USA
| | - Mayur B Patel
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA.,7 Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, USA
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Marra A, Pandharipande PP, Patel MB. Intensive Care Unit Delirium and Intensive Care Unit-Related Posttraumatic Stress Disorder. Surg Clin North Am 2017; 97:1215-1235. [PMID: 29132506 PMCID: PMC5747308 DOI: 10.1016/j.suc.2017.07.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Delirium is one of the most common behavioral manifestations of acute brain dysfunction in the intensive care unit (ICU) and is a strong predictor of worse outcome. Routine monitoring for delirium is recommended for all ICU patients using validated tools. In delirious patients, a search for all reversible precipitants is the first line of action and pharmacologic treatment should be considered when all causes have been ruled out, and it is not contraindicated. Long-term morbidity has significant consequences for survivors of critical illness and for their caregivers. ICU patients may develop posttraumatic stress disorder related to their critical illness experience.
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Affiliation(s)
- Annachiara Marra
- Doctoral Candidate, University of Naples Federico II, Visiting Research Fellow, Center for Health Services Research, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, 1215 21st Avenue South, Medical Center East, Suite 6100, Nashville, TN 37232-8300
| | - Pratik P. Pandharipande
- Professor of Anesthesiology and Surgery, Chief, Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Center for Health Services Research, Vanderbilt University Medical Center, 1211 21st Avenue South, Medical Arts Building, Suite 526, Nashville, TN 37212
| | - Mayur B. Patel
- Assistant Professor of Surgery, Neurosurgery, Hearing & Speech Sciences, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Section of Surgical Sciences, Center for Health Services Research, Vanderbilt Brain Institute, Vanderbilt University Medical Center, 1211 21st Avenue South, Medical Arts Building, Suite 404, Nashville, TN 37212
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Fodale V, Tripodi VF, Penna O, Famà F, Squadrito F, Mondello E, David A. An update on anesthetics and impact on the brain. Expert Opin Drug Saf 2017; 16:997-1008. [PMID: 28697315 DOI: 10.1080/14740338.2017.1351539] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION While anesthetics are indispensable clinical tools and generally considered safe and effective, a growing concern over the potential neurotoxicity of anesthesia or specific anesthetic agents has called into question the safety of general anesthetics, especially when administered at extremes of age. Areas covered: This article reviews and updates research findings on the safety of anesthesia and anesthetics in terms of long-term neurotoxicity, with particular focus on postoperative cognitive dysfunctions, Alzheimer's disease and dementias, developing brain, post-operative depression and autism spectrum disorder. Expert opinion: Exposure to general anesthetics is potentially harmful to the human brain, and the consequent long-term cognitive deficits should be classified as an iatrogenic pathology, and considered a public health problem. The fact that in laboratory and clinical research only certain anesthetic agents and techniques, but not others, appear to be involved, raises the problem on what is the safest and the least safe anesthetic to maximize anesthesia efficiency, avoid occurrence of adverse events, and ensure patient safety. New trends in research are moving toward the theory that neuroinflammation could be the hallmark of, or could have a pivotal role in, several neurological disorders.
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Affiliation(s)
- Vincenzo Fodale
- a Department of Human Pathology of Adult and Evolutive Age , Section of Anesthesiology, University of Messina , Messina , Italy
| | - Vincenzo F Tripodi
- b Department of Cardiac Surgery, Unit of Cardioanesthesia , Metropolitan Hospital "Bianchi Melacrino Morelli" , Reggio Calabria , Italy
| | - Olivia Penna
- a Department of Human Pathology of Adult and Evolutive Age , Section of Anesthesiology, University of Messina , Messina , Italy
| | - Fausto Famà
- a Department of Human Pathology of Adult and Evolutive Age , Section of Anesthesiology, University of Messina , Messina , Italy
| | - Francesco Squadrito
- c Department of Clinical and Experimental Medicine , University of Messina , Messina , Italy
| | - Epifanio Mondello
- a Department of Human Pathology of Adult and Evolutive Age , Section of Anesthesiology, University of Messina , Messina , Italy
| | - Antonio David
- a Department of Human Pathology of Adult and Evolutive Age , Section of Anesthesiology, University of Messina , Messina , Italy
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Sprung J, Roberts RO, Knopman DS, Price LL, Schulz HP, Tatsuyama CL, Weingarten TN, Schroeder DR, Hanson AC, Petersen RC, Warner DO. Mild Cognitive Impairment and Exposure to General Anesthesia for Surgeries and Procedures: A Population-Based Case-Control Study. Anesth Analg 2017; 124:1277-1290. [PMID: 28291057 PMCID: PMC5359052 DOI: 10.1213/ane.0000000000001725] [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: 01/12/2023]
Abstract
BACKGROUND To examine whether exposure to general anesthesia for procedures at age ≥40 years is associated with prevalent mild cognitive impairment (MCI) in the elderly. METHODS A case-control study nested within a population-based cohort. Olmsted County, Minnesota, residents, aged 70-91 years, underwent baseline evaluations that included the Clinical Dementia Rating scale, a neurologic evaluation, and neuropsychologic testing. Individuals identified with MCI (cases) at enrollment were matched 1:2 on age, sex, education, and apolipoprotein genotype with participants who were cognitively normal at the time of the index visit. Medical records from age 40 years until the index visit were reviewed to determine exposures to general anesthesia. Conditional logistic regression, taking into account the matched set study design and adjusting for MCI risk factors, was used to assess whether exposure to anesthesia after the age of 40 years was associated with prevalent MCI. RESULTS A total of 387 Mayo Clinic Study of Aging participants (219 males, 168 females) were diagnosed with MCI at enrollment with mean age of 81 ± 5 years. Exposure to general anesthesia after the age of 40 years was not significantly associated with prevalent MCI when analyzed as a dichotomous variable (any versus none, adjusted odds ratio, 0.97 [95% confidence interval, 0.68-1.40]) or the number of exposures (odds ratio, 1.13 [0.74-1.72], 0.81 [0.53-1.22], and 1.03 [0.67-1.58] for 1, 2-3, and ≥4 exposures, respectively, with no exposure as the reference). Similar results were obtained for exposure to anesthesia after the age of 60 years and during 5, 10, and 20 years before the first visit. CONCLUSIONS Exposure to general anesthesia for procedures at age ≥40 years was not associated with prevalent MCI in the elderly.
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Affiliation(s)
- Juraj Sprung
- From the Departments of *Anesthesiology; †Health Sciences Research, Division of Epidemiology; ‡Neurology; and §Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
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