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McKay TB, Khawaja ZQ, Freedman IG, Turco I, Wiredu K, Colecchi T, Akeju O. Exploring the Pathophysiology of Delirium: An Overview of Biomarker Studies, Animal Models, and Tissue-Engineered Models. Anesth Analg 2023; 137:1186-1197. [PMID: 37851904 PMCID: PMC10840625 DOI: 10.1213/ane.0000000000006715] [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: 10/20/2023]
Abstract
Delirium is an acute brain disorder associated with disorganized thinking, difficulty focusing, and confusion that commonly follows major surgery, severe infection, and illness. Older patients are at high risk for developing delirium during hospitalization, which may contribute to increased morbidity, longer hospitalization, and increased risk of institutionalization following discharge. The pathophysiology underlying delirium remains poorly studied. This review delves into the findings from biomarker studies and animal models, and highlights the potential for tissue-engineered models of the brain in studying this condition. The aim is to bring together the existing knowledge in the field and provide insight into the future direction of delirium research.
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Affiliation(s)
- Tina B. McKay
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Zain Q. Khawaja
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Isaac G. Freedman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Isabella Turco
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Kwame Wiredu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Talia Colecchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Vasunilashorn SM, Dillon ST, Marcantonio ER, Libermann TA. Application of Multiple Omics to Understand Postoperative Delirium Pathophysiology in Humans. Gerontology 2023; 69:1369-1384. [PMID: 37722373 PMCID: PMC10711777 DOI: 10.1159/000533789] [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: 01/24/2023] [Accepted: 08/23/2023] [Indexed: 09/20/2023] Open
Abstract
Delirium, an acute change in cognition, is common, morbid, and costly, particularly among hospitalized older adults. Despite growing knowledge of its epidemiology, far less is known about delirium pathophysiology. Initial work understanding delirium pathogenesis has focused on assaying single or a limited subset of molecules or genetic loci. Recent technological advances at the forefront of biomarker and drug target discovery have facilitated application of multiple "omics" approaches aimed to provide a more complete understanding of complex disease processes such as delirium. At its basic level, "omics" involves comparison of genes (genomics, epigenomics), transcripts (transcriptomics), proteins (proteomics), metabolites (metabolomics), or lipids (lipidomics) in biological fluids or tissues obtained from patients who have a certain condition (i.e., delirium) and those who do not. Multi-omics analyses of these various types of molecules combined with machine learning and systems biology enable the discovery of biomarkers, biological pathways, and predictors of delirium, thus elucidating its pathophysiology. This review provides an overview of the most recent omics techniques, their current impact on identifying delirium biomarkers, and future potential in enhancing our understanding of delirium pathogenesis. We summarize challenges in identification of specific biomarkers of delirium and, more importantly, in discovering the mechanisms underlying delirium pathophysiology. Based on mounting evidence, we highlight a heightened inflammatory response as one common pathway in delirium risk and progression, and we suggest other promising biological mechanisms that have recently emerged. Advanced multiple omics approaches coupled with bioinformatics methodologies have great promise to yield important discoveries that will advance delirium research.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Simon T. Dillon
- Harvard Medical School, Boston, MA, USA
- Division of Interdisciplinary Medicine and Biotechnology, Department of Medicine, BIDMC, Boston, MA, USA
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, BIDMC, Boston, MA, USA
| | - Edward R. Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gerontology, Department of Medicine, BIDMC, Boston, MA, USA
| | - Towia A. Libermann
- Harvard Medical School, Boston, MA, USA
- Division of Interdisciplinary Medicine and Biotechnology, Department of Medicine, BIDMC, Boston, MA, USA
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, BIDMC, Boston, MA, USA
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Maslov GO, Zabegalov KN, Demin KA, Kolesnikova TO, Kositsyn YM, de Abreu MS, Petersen EV, Kalueff AV. Towards experimental models of delirium utilizing zebrafish. Behav Brain Res 2023; 453:114607. [PMID: 37524203 DOI: 10.1016/j.bbr.2023.114607] [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: 05/25/2023] [Revised: 07/28/2023] [Accepted: 07/29/2023] [Indexed: 08/02/2023]
Abstract
Delirium is an acute neuropsychiatric condition characterized by impaired behavior and cognition. Although the syndrome has been known for millennia, its CNS mechanisms and risk factors remain poorly understood. Experimental animal models, especially rodent-based, are commonly used to probe various pathogenetic aspects of delirium. Complementing rodents, the zebrafish (Danio rerio) emerges as a promising novel model organism to study delirium. Zebrafish demonstrate high genetic and physiological homology to mammals, easy maintenance, robust behaviors in various sensitive behavioral tests, and the potential to screen for pharmacological agents relevant to delirium. Here, we critically discuss recent developments in the field, and emphasize the developing utility of zebrafish models for translational studies of delirium and deliriant drugs. Overall, the zebrafish represents a valuable and promising aquatic model species whose use may help understand delirium etiology, as well as develop novel therapies for this severely debilitating disorder.
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Affiliation(s)
- Gleb O Maslov
- Neurobiology Program, Sirius University of Science and Technology, Sochi, Russia; Ural Federal University, Ekaterinburg, Russia
| | | | - Konstantin A Demin
- Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Tatiana O Kolesnikova
- Neurobiology Program, Sirius University of Science and Technology, Sochi, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Yuriy M Kositsyn
- Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Murilo S de Abreu
- Laboratory of Cell and Molecular Biology and Neurobiology, Moscow Institute of Physics and Technology, Moscow, Russia.
| | - Elena V Petersen
- Laboratory of Cell and Molecular Biology and Neurobiology, Moscow Institute of Physics and Technology, Moscow, Russia
| | - Allan V Kalueff
- Neurobiology Program, Sirius University of Science and Technology, Sochi, Russia; Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia; Novosibirsk State University, Novosibirsk, Russia; Laboratory of Preclinical Bioscreening, Granov Russian Research Center of Radiology and Surgical Technologies, Ministry of Healthcare of Russian Federation, Pesochny, Russia; Ural Federal University, Ekaterinburg, Russia.
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Bassi T, Rohrs E, Nicholas M, Reynolds S. Meta-analysis of serological biomarkers at hospital admission for the likelihood of developing delirium during hospitalization. Front Neurol 2023; 14:1179243. [PMID: 37360340 PMCID: PMC10288875 DOI: 10.3389/fneur.2023.1179243] [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: 03/03/2023] [Accepted: 05/11/2023] [Indexed: 06/28/2023] Open
Abstract
Importance Identifying biomarkers that, at hospital admission, predict subsequent delirium will help to focus our clinical efforts on prevention and management. Objective The study aimed to investigate biomarkers at hospital admission that may be associated with delirium during hospitalization. Data sources A librarian at the Fraser Health Authority Health Sciences Library performed searches from 28 June 2021 to 9 July 2021, using the following sources: Medline, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, and the Database of Abstracts of Reviews and Effects. Study selection The inclusion criteria were articles in English that investigated the link between serum concentration of biomarkers at hospital admission and delirium during hospitalization. Exclusion criteria were single case reports, case series, comments, editorials, letters to the editor, articles that were not relevant to the review objective, and articles concerning pediatrics. After excluding duplicates, 55 studies were included. Data extraction and synthesis This meta-analysis followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol. Independent extraction, with the consensus of multiple reviewers, was used to determine the final studies included. The weight and heterogeneity of the manuscripts were calculated using inverse covariance with a random-effects model. Main outcomes and measures Differences in mean serum concentration of biomarkers at hospital admission between patients who did and did not develop delirium during hospitalization. Results Our search found evidence that patients who developed delirium during hospitalization had, at hospital admission, significantly greater concentrations of certain inflammatory biomarkers and one blood-brain barrier leakage marker than patients who did not develop delirium during hospitalization (differences in the mean: cortisol: 3.36 ng/ml, p < 0.0001; CRP: 41.39 mg/L, p < 0.00001; IL-6: 24.05 pg/ml, p < 0.00001; S100β 0.07 ng/ml, p < 0.00001). These differences were independent of other confounding variables such as the patient's severity of illness. A significantly lower serum concentration, at hospital admission, of acetylcholinesterase (difference in the means -0.86 U/ml, p = 0.004) was also associated with an increased vulnerability to developing delirium during hospitalization. Conclusion and relevance Our meta-analysis supports the hypothesis that patients with hypothalamic-pituitary axis dysfunction, increased blood-brain barrier permeability, and chronic overload of the cholinergic system, at hospital admission, are more vulnerable to developing delirium during hospitalization.
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Affiliation(s)
- Thiago Bassi
- Lungpacer Medical USA Inc., Exton, PA, United States
| | - Elizabeth Rohrs
- Advancing Innovation in Medicine Institute, New Westminster, BC, Canada
- Biomedical, Physiology and Kinesiology Department, Simon Fraser University, Burnaby, BC, Canada
| | - Michelle Nicholas
- Advancing Innovation in Medicine Institute, New Westminster, BC, Canada
- Biomedical, Physiology and Kinesiology Department, Simon Fraser University, Burnaby, BC, Canada
| | - Steven Reynolds
- Advancing Innovation in Medicine Institute, New Westminster, BC, Canada
- Biomedical, Physiology and Kinesiology Department, Simon Fraser University, Burnaby, BC, Canada
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Lozano-Vicario L, García-Hermoso A, Cedeno-Veloz BA, Fernández-Irigoyen J, Santamaría E, Romero-Ortuno R, Zambom-Ferraresi F, Sáez de Asteasu ML, Muñoz-Vázquez ÁJ, Izquierdo M, Martínez-Velilla N. Biomarkers of delirium risk in older adults: a systematic review and meta-analysis. Front Aging Neurosci 2023; 15:1174644. [PMID: 37251808 PMCID: PMC10213257 DOI: 10.3389/fnagi.2023.1174644] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Delirium is a neuropsychiatric syndrome associated with increased morbidity and mortality in older patients. The aim of this study was to review predictive biomarkers of delirium in older patients to gain insights into the pathophysiology of this syndrome and provide guidance for future studies. Two authors independently and systematically searched MEDLINE, Embase, Cochrane Library, Web of Science and Scopus databases up to August 2021. A total of 32 studies were included. Only 6 studies were eligible for the meta-analysis, pooled results showed a significant increase in some serum biomarkers (C-reactive protein [CRP], tumour necrosis factor alpha [TNF-α] and interleukin-6 [IL-6]) among patients with delirium (odds ratio = 1.88, 95% CI 1.01 to 1.637; I2 = 76.75%). Although current evidence does not favour the use of any particular biomarker, serum CRP, TNF-α, and IL-6 were the most consistent biomarkers of delirium in older patients.
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Affiliation(s)
| | - Antonio García-Hermoso
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | | | - Joaquín Fernández-Irigoyen
- Proteomics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IDISNA), Pamplona, Spain
| | - Enrique Santamaría
- Proteomics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IDISNA), Pamplona, Spain
| | | | - Fabricio Zambom-Ferraresi
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Mikel L. Sáez de Asteasu
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | | | - Mikel Izquierdo
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Nicolás Martínez-Velilla
- Geriatric Unit, Hospital Universitario de Navarra (HUN), Pamplona, Spain
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
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Moppett I, Noah A. Postoperative delirium cytokine conundrum. Response to Br J Anaesth 2021. Br J Anaesth 2021; 128:e42-e43. [PMID: 34839898 DOI: 10.1016/j.bja.2021.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/12/2021] [Indexed: 11/02/2022] Open
Affiliation(s)
- Iain Moppett
- Anaesthesia and Critical Care Section, Academic Unit of Injury, Inflammation and Recovery Sciences, University of Nottingham, Nottingham, UK.
| | - Abiodun Noah
- Anaesthesia and Critical Care Section, Academic Unit of Injury, Inflammation and Recovery Sciences, University of Nottingham, Nottingham, UK
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Adembri C, Tofani L. The importance of identifying the direction of the association between preoperative inflammatory mediators and postoperative delirium. Comment on Brit J Anaesth 2021; 127: 424-434. Br J Anaesth 2021; 128:e41-e42. [PMID: 34753593 DOI: 10.1016/j.bja.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/22/2021] [Accepted: 10/08/2021] [Indexed: 12/28/2022] Open
Affiliation(s)
- Chiara Adembri
- Department of Health Sciences, Section of Anaesthesia and Intensive Care, University of Florence, Florence, Italy.
| | - Lorenzo Tofani
- Department of Statistics, Informatics, Applications, University of Florence, Florence, Italy; Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), Section of Pharmacology and Toxicology, University of Florence, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Division of Rheumatology AOUC, Florence, Italy
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Gamberale R, D'Orlando C, Brunelli S, Meneveri R, Mazzola P, Foti G, Bellani G, Zatti G, Munegato D, Volpato S, Zurlo A, Caruso G, Andreano A, Valsecchi MG, Bellelli G. Study protocol: understanding the pathophysiologic mechanisms underlying delirium in older people undergoing hip fracture surgery. BMC Geriatr 2021; 21:633. [PMID: 34736422 PMCID: PMC8567587 DOI: 10.1186/s12877-021-02584-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication of older people undergoing hip fracture surgery, which negatively affects clinical- and healthcare-related outcomes. Unfortunately, POD pathophysiology is still largely unknown, despite previous studies showing that neuroinflammation, neuroendocrine dysfunction, increased reactive oxidative stress (ROS), and endothelial dysfunctions may be involved. There is also evidence that many of the pathophysiological mechanisms which are involved in delirium are involved in sarcopenia too. This article describes the protocol of a pilot study to evaluate the feasibility of a larger one that will explore the pathophysiological mechanisms correlating POD with sarcopenia. We will analyse whether various biomarkers reflecting neuroinflammation, ROS, neuroendocrine disorders, and microvasculature lesions will be simultaneously expressed in in the blood, cerebrospinal fluid (CSF), and muscles of patients developing POD. METHODS Two centres will be involved in this study, each recruiting a convenient sample of ten older patients with hip fracture. All of them will undergo a baseline Comprehensive Geriatric Assessment, which will be used to construct a Rockwood-based Frailty Index (FI). Blood samples will be collected for each patient on the day of surgery and 1 day before. Additionally, CSF and muscle fragments will be taken and given to a biologist for subsequent analyses. The presence of POD will be assessed in each patient every morning until hospital discharge using the 4AT. Delirium subtypes and severity will be assessed using the Delirium Motor Subtype Scale-4 and the Delirium-O-Meter, respectively. We will also evaluate the patient's functional status at discharge, using the Cumulated Ambulation Score. DISCUSSION This study will be the first to correlate biomarkers of blood, CSF, and muscle in older patients with hip fracture.
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Affiliation(s)
- R Gamberale
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - C D'Orlando
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - S Brunelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - R Meneveri
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - P Mazzola
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy
| | - G Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy
| | - G Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy
| | - G Zatti
- Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy
| | - D Munegato
- Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy
| | - S Volpato
- Orthogeriatric Unit, Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - A Zurlo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - G Caruso
- Department of Biomedical and Surgical Specialist Sciences, University of Ferrara, Ferrara, Italy
| | - A Andreano
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - M G Valsecchi
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - G Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
- Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy.
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Adamis D, van Gool WA, Eikelenboom P. Consistent patterns in the inconsistent associations of Insulin-like growth factor 1 (IGF-1), C-Reactive Protein (C-RP) and Interleukin 6 (IL-6) levels with delirium in surgical populations. A systematic review and meta-analysis. Arch Gerontol Geriatr 2021; 97:104518. [PMID: 34536657 DOI: 10.1016/j.archger.2021.104518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biomarkers for delirium could increase diagnostic accuracy and may help to identify pathological pathways. Until now study findings concerning cytokine levels have been inconsistent. AIMS Systematic review and meta-analysis investigating the association between peripheral levels of Insulin-like Growth Factor-1 (IGF-1), C-Reactive Protein (C-RP) and Interleukin-6 (IL-6) and delirium in surgical patients, and to explore if there are distinct/specific patterns that may potentially explain inconsistent results. METHODS PubMed, Scopus, CINAHL, Cochrane, and EMBASE databases were searched. Inclusion criteria were: prospective studies, surgical populations excluding preoperative delirium, available data. The following were collected: type of operation (orthopaedic, abdominal, etc), the timing of operation (acute, elective, both), demographics, number of participants with delirium, time of preoperative blood withdrawal, and preoperative levels of each biomarker. RESULTS Low levels of IGF-1 (n = 7 studies) are significantly associated with post-operative delirium in abdominal surgical samples. High levels of C-RP (n = 9) are associated with delirium in acute orthopaedic and elective abdominal operations. IL-6 (n = 14) is a significant predictor of post-operative delirium in a variety of surgical conditions (elective or acute). DISCUSSION A common pattern exists in the otherwise conflicting reported findings. This similarity may reflect different underling mechanisms and predisposing factors like cachexia and catabolic stages. It seems that delirium in abdominal surgery is triggered by IGF-1 disturbances, while in other surgeries by an inflammatory reaction. CONCLUSIONS Despite the contradictory results concerning the association of IGF-1, C-RP and IL-6 with postoperative delirium, the present meta-analysis shows that there are certain patterns. IL-6 seems a consistent predictor for delirium in surgical samples.
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Affiliation(s)
| | - Willem A van Gool
- Department of Population and Occupational Health, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Piet Eikelenboom
- GGZinGeest, Amsterdam, the Netherlands. Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
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Urinary neopterin and total neopterin measurements allow monitoring of oxidative stress and inflammation levels of knee and hip arthroplasty patients. PLoS One 2021; 16:e0256072. [PMID: 34403444 PMCID: PMC8370602 DOI: 10.1371/journal.pone.0256072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/29/2021] [Indexed: 01/02/2023] Open
Abstract
Knee and hip arthroplasty are common surgeries within an aging population. Some data has suggested that knee arthroplasty is more traumatic to the body than hip arthroplasty due to the increased complexity and load bearing nature of the joint. Here, we compare the stress of the two surgeries by measuring urinary neopterin and total neopterin as biomarkers of oxidative stress and inflammation. Urinary neopterin and total neopterin (neopterin + 7,8-dihydroneopterin) levels were analysed in 28 knee and 22 hip arthroplasty patients pre- and post-operatively to determine oxidative stress and inflammation levels. Total neopterin was 31.1% higher with knee arthroplasty (p<0.05). Urinary neopterin was 32.8% higher in the knee arthroplasty group versus hips. The increase in neopterin and total neopterin following a post-surgical decrease in levels was significant in both groups. Levels of neopterin and total neopterin were varied between patients, but all increased following surgery and subsided by day 28. The increased levels of urinary neopterin and total neopterin from knee arthroplasty indicate that knee osteoarthritis and arthroplasty is a more significant trauma to the body than hip osteoarthritis and arthroplasty surgery. This is also shown by faster inflammatory resolution following hip arthroplasty.
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Abstract
This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.
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Dunne SS, Coffey JC, Konje S, Gasior S, Clancy CC, Gulati G, Meagher D, Dunne CP. Biomarkers in delirium: A systematic review. J Psychosom Res 2021; 147:110530. [PMID: 34098376 DOI: 10.1016/j.jpsychores.2021.110530] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delirium is a common neuropsychiatric disorder associated with prolonged hospital stays, and increased morbidity and mortality. Diagnosis is frequently missed due to varying disease presentation and lack of standardized testing. We examined biomarkers as diagnostic or prognostic indicators of delirium, and provide a rational basis for future studies. METHOD Systematic review of literature published between Jan 2000 and June 2019. Searches included: PubMed; Web of Science; CINAHL; EMBASE; COCHRANE and Medline. Additional studies were identified by searching bibliographies of eligible articles. RESULTS 2082 relevant papers were identified from all sources. Seventy-three met the inclusion criteria, all of which were observational. These assessed a range of fourteen biomarkers. All papers included were in the English language. Assessment methods varied between studies, including: DSM criteria; Confusion Assessment Method (CAM) or CAM-Intensive Care Unit (ICU). Delirium severity was measured using the Delirium Rating Scale (DRS). Delirium was secondary to post-operative dysfunction or acute medical conditions. CONCLUSION Evidence does not currently support the use of any one biomarker. However, certain markers were associated with promising results and may warrant evaluation in future studies. Heterogeneity across study methods may have contributed to inconclusive results, and more clarity may arise from standardization of methods of clinical assessment. Adjusting for comorbidities may improve understanding of the pathophysiology of delirium, in particular the role of confounders such as inflammation, cognitive disorders and surgical trauma. Future research may also benefit from inclusion of other diagnostic modalities such as EEG as well as analysis of genetic or epigenetic factors.
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Affiliation(s)
- Suzanne S Dunne
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - J Calvin Coffey
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Swiri Konje
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Sara Gasior
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Conor C Clancy
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Gautam Gulati
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - David Meagher
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland; Cognitive Impairment Research Group, School of Medicine, University of Limerick, Limerick, Ireland
| | - Colum P Dunne
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland; Cognitive Impairment Research Group, School of Medicine, University of Limerick, Limerick, Ireland.
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Noah AM, Almghairbi D, Evley R, Moppett IK. Preoperative inflammatory mediators and postoperative delirium: systematic review and meta-analysis. Br J Anaesth 2021; 127:424-434. [PMID: 34218905 DOI: 10.1016/j.bja.2021.04.033] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Postoperative delirium has eluded attempts to define its complex aetiology and describe specific risk factors. The role of neuroinflammation as a risk factor, determined by measuring blood levels of preoperative 'innate' inflammatory mediator levels, has been investigated. However, results have been conflicting. We conducted a systematic review and meta-analysis of the evidence on associations between preoperative blood levels of inflammatory mediators and postoperative delirium in the older person. Influence of type of surgery was also assessed. METHODS Original, low risk of bias studies, published in peer-reviewed journals, which fulfilled the eligibility criteria were included. Seventeen articles fulfilled study criteria. Data extraction, synthesis, and risk of bias analysis were guided by Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and quality in prognostic studies guidelines. Meta-analyses used a random-effects model. Inflammatory mediators included C-reactive protein, interleukin-6, -8, and -10, tumour necrosis factor-α, insulin-like growth factor-1, cortisol, and neopterin. Surgical groups were cardiac, noncardiac, and hip fracture. RESULTS Higher preoperative interleukin-6 was associated with postoperative delirium with a standardised mean difference (95% confidence interval) of 0.33 (0.11-0.56) and P=0.003. Higher neopterin was also associated with postoperative delirium. CONCLUSIONS The association of preoperative blood levels of inflammatory mediators with postoperative delirium may be influenced by the type of surgery and the specific mediator. The potential modulating effect of type of surgery, intrinsic brain vulnerability, and the complex interactions between inflammatory mediators and binding proteins will need to be considered in future studies. CLINICAL TRIAL REGISTRATION CRD42019159471 (PROSPERO).
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Affiliation(s)
- Abiodun M Noah
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK
| | - Dalal Almghairbi
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK
| | - Rachel Evley
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK
| | - Iain K Moppett
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK.
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Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery-Review. ACTA ACUST UNITED AC 2020; 56:medicina56100493. [PMID: 32987655 PMCID: PMC7598630 DOI: 10.3390/medicina56100493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/16/2022]
Abstract
Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from hospital, with an incidence of 30 to 70% of cases, very often noticed only by close relative or friends, decreasing after six (20–30%) and twelve (15–25%) months after surgery. Perioperative cognitive disorders are associated with adverse short- and long-term effects, including increased morbidity and mortality. Due to the complexity of delirium pathomechanisms and the difficulties in the diagnosis, researchers have not yet found a clear answer to the question of which patient will be at a higher risk of developing delirium. The risk for POD and POCD in older patients with numerous comorbidities like hypertension, diabetes, and previous ischemic stroke is relatively high, and the predisposing cognitive profile for both conditions is important. The aim of this narrative review was to identify and describe biomarkers used in the diagnosis of delirium after cardiac surgery by presenting a search through studies regarding this subject, which have been published during the last ten years. The authors discussed brain-derived biomarkers, inflammation-related biomarkers, neurotransmitter-based biomarkers, and others. Work based on inflammation-related biomarkers, which are characterized by the low cost of implementation and the effectiveness of delirium diagnosis, seems to be the closest to the goal of discovering an inexpensive and effective marker. Currently, the use of a panel of tests, and not a single biomarker, brings us closer to the discovery of a test, or rather a set of tests ideal for the diagnosis of delirium after cardiac surgery.
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Oxidative stress and immune cell activation quantification in sepsis and non-sepsis critical care patients by neopterin/7,8-dihydroneopterin analysis. Pteridines 2020. [DOI: 10.1515/pteridines-2020-0015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Abstract
Introduction: Neopterin and 7,8-dihydroneopterin are used as biomarkers of oxidative stress and inflammation, but the effect of kidney function on these measurements has not been extensively explored. We examine the levels of oxidative stress, inflammation and kidney function in intensive patients and compare them to equivalent patients without sepsis.
Methods: 34 Intensive care patients were selected for the study, 14 without sepsis and 20 with. Both groups had equivalent levels of trauma, assessed by SAPS II, SOFA, and APACHE II and III scores. Plasma and urinary neopterin and total neopterin (neopterin + 7,8-dihydroneopterin) values were measured.
Results: Neopterin and total neopterin were significantly elevated in urine and plasma for multiple days in sepsis versus non-sepsis patients. Plasma neopterin and total neopterin have decreasing relationships with increased eGFR (p<0.008 and p<0.001, respectively). Plasma/urinary neopterin and total neopterin ratios demonstrate that total neopterin flux is more influenced by eGFR than neopterin, with significantce of p<0.02 and p<0.0002 respectively.
Conclusion: Sepsis patients present with greater levels of oxidative stress and immune system activation than non-sepsis patients of equal levels of trauma, as measured by neopterin and total neopterin. eGFR may need to be taken into account when accessing the level of inflammation from urinary neopterin measurements.
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Amgarth-Duff I, Hosie A, Caplan G, Agar M. A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes. BMC Psychiatry 2020; 20:182. [PMID: 32321448 PMCID: PMC7178636 DOI: 10.1186/s12888-020-02584-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 04/05/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis. METHODS A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others. RESULTS The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting. CONCLUSION There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness.
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Affiliation(s)
- Ingrid Amgarth-Duff
- University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW, Australia.
| | - Annmarie Hosie
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia
| | - Gideon Caplan
- grid.1005.40000 0004 4902 0432Prince of Wales Clinical School, University of New South Wales, Sydney, NSW Australia ,grid.415193.bDepartment of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW Australia
| | - Meera Agar
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia ,grid.1005.40000 0004 4902 0432South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales Australia ,grid.429098.eClinical Trials, Ingham Institute of Applied Medical Research, Liverpool, New South Wales Australia
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Wang J, Ji Y, Wang N, Chen W, Bao Y, Qin Q, Ma C, Xiao Q, Li S. Establishment and validation of a delirium prediction model for neurosurgery patients in intensive care. Int J Nurs Pract 2020; 26:e12818. [PMID: 32011790 DOI: 10.1111/ijn.12818] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 08/28/2019] [Accepted: 01/05/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Jun Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University Beijing China
| | - Yuanyuan Ji
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University Beijing China
| | - Ning Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University Beijing China
| | - Wenjin Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University Beijing China
| | - Yuehong Bao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University Beijing China
| | - Qinpu Qin
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University Beijing China
| | - Chunmei Ma
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University Beijing China
| | - Qian Xiao
- School of Nursing Capital Medical University Beijing China
| | - Shulan Li
- School of Nursing Capital Medical University Beijing China
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Pterins as Diagnostic Markers of Mechanical and Impact-Induced Trauma: A Systematic Review. J Clin Med 2019; 8:jcm8091383. [PMID: 31484468 PMCID: PMC6780259 DOI: 10.3390/jcm8091383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/21/2019] [Accepted: 08/27/2019] [Indexed: 12/18/2022] Open
Abstract
We performed a systematic review of the literature to evaluate pterins as biomarkers of mechanical and impact-induced trauma. MEDLINE and Scopus were searched in March 2019. We included in vivo human studies that measured a pterin in response to mechanical or impact-induced trauma with no underlying prior disease or complication. We included 40 studies with a total of 3829 subjects. Seventy-seven percent of studies measured a significant increase in a pterin, primarily neopterin or total neopterin (neopterin + 7,8-dihydroneopterin). Fifty-one percent of studies measured an increase within 24 h of trauma, while 46% measured increases beyond 48 h. Pterins also showed promise as predictors of post-trauma complications such as sepsis, multi-organ failure and mortality. Exercise-induced trauma and traumatic brain injury caused an immediate increase in neopterin or total neopterin, while patients of multiple trauma had elevated pterin levels that remained above baseline for several days. Pterin concentration changes in response to surgery were variable with patients undergoing cardiac surgery having immediate and sustained pterin increases, while gastrectomy, liver resection or hysterectomy showed no change. This review provides systematic evidence that pterins, in particular neopterin and total neopterin, increase in response to multiple forms of mechanical or impact-induced trauma.
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19
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Cao SJ, Chen D, Yang L, Zhu T. Effects of an abnormal mini-mental state examination score on postoperative outcomes in geriatric surgical patients: a meta-analysis. BMC Anesthesiol 2019; 19:74. [PMID: 31092206 PMCID: PMC6521510 DOI: 10.1186/s12871-019-0735-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/18/2019] [Indexed: 02/05/2023] Open
Abstract
Background Perioperative cognitive impairment (CI) following surgeries is prevalent in geriatric surgical population aged 60 and older. This meta-analysis was designed to investigate whether the Mini-Mental State Examination (MMSE) has prognostic value on adverse outcomes in aged surgical patients. Methods PubMed, Cochrane, Embase and Medline through the Ovid were searched. Meta-analyses were carried out for CI versus non-cognitive impairment (NCI). Quality of evidence was assessed by the GRADE approach. Results One randomized controlled trial, two retrospective cohort trials, and 18 prospective cohort trials were included in the meta-analysis. Perioperative diagnosis of CI by the MMSE had higher rates of patients suffering from postoperative delirium (POD) [odd ratio (OR) 5.02, 95% confidence interval (CI) 3.27, 7.71, P < 0.00001], in-hospital mortality (OR 7.51, 95% CI 2.17, 26.02, P = 0.001), mortality within 1 year (OR 2.53, 95% CI 1.95,3.29, P < 0.00001). Postoperative CI patients had no extended length of stay in orthopedic [standardized mean difference (SMD) -0.10, 95% CI -0.20, 0.17, P = 0.91)] nor rehabilitation wards ((SMD, 0.04; 95% CI, − 0.23 to 0.31; P = 0.78). Conclusion Older patients with perioperative CI were more likely to suffer from POD and mortality. The MMSE showed certain value on risk stratification and prognosis evaluation in geriatric surgical population. Trial registration PROSPERO CRD42018108739. Electronic supplementary material The online version of this article (10.1186/s12871-019-0735-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shuang-Jiao Cao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Dongxu- Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Lei Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Michels M, Michelon C, Damásio D, Vitali AM, Ritter C, Dal-Pizzol F. Biomarker Predictors of Delirium in Acutely Ill Patients: A Systematic Review. J Geriatr Psychiatry Neurol 2019; 32:119-136. [PMID: 30852930 DOI: 10.1177/0891988719834346] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Delirium is a serious and common disorder that affects up to 80% of acutely ill patients, mainly the aged. In recent years, several studies pointed out possible biomarkers that could be used alone or in combination with other resources in the diagnosis and follow-up of critically ill patients who develop delirium. In this context, a systematic review was conducted to determine the predictive value of several biomarkers in acutely (critically and noncritically) ill adult patients with delirium. Studies that used the confusion assessment method (CAM) and CAM-intensive care unit as the diagnostic method were considered. The most recent search was performed in November 2017. There was no language restriction. Initially, 626 articles were screened and 39 were included in the study. A comprehensive evaluation of the abstracts resulted in the exclusion of 202 studies, leaving 39 articles as potentially relevant. Inflammatory markers, S100β and cortisol, could predict delirium occurrence in a specific subgroup population of critically ill patients.
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Affiliation(s)
- Monique Michels
- 1 Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil
| | - Cleonice Michelon
- 1 Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil
| | - Danusa Damásio
- 2 São José Hospital Research Centre, Criciúma, Santa Catarina, Brazil
| | | | - Cristiane Ritter
- 1 Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil.,2 São José Hospital Research Centre, Criciúma, Santa Catarina, Brazil
| | - Felipe Dal-Pizzol
- 1 Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil.,2 São José Hospital Research Centre, Criciúma, Santa Catarina, Brazil
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Egberts A, Osse RJ, Fekkes D, Tulen JHM, van der Cammen TJM, Mattace-Raso FUS. Differences in potential biomarkers of delirium between acutely ill medical and elective cardiac surgery patients. Clin Interv Aging 2019; 14:271-281. [PMID: 30799917 PMCID: PMC6369845 DOI: 10.2147/cia.s193605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND/AIMS The pathophysiology of delirium is poorly understood. Increasing evidence suggests that different pathways might be involved in the pathophysiology depending on the population studied. The aim of the present study was to investigate potential differences in mean plasma levels of neopterin, amino acids, amino acid ratios and homovanillic acid between two groups of patients with delirium. METHODS Data from acutely ill medical patients aged 65 years and older, and patients aged 70 years and older undergoing elective cardiac surgery, were used. Differences in biomarker levels between the groups were investigated using univariate ANOVA with adjustments for age, sex, comorbidities, C-reactive protein (CRP) and the estimated glomerular filtration rate (eGFR), where appropriate. Linear regression analysis was used to identify potential determinants of the investigated biochemical markers. RESULTS Eighty patients with delirium were included (23 acutely ill medical patients and 57 elective cardiac surgery patients). After adjustment, higher mean neopterin levels (93.1 vs 47.3 nmol/L, P=0.001) and higher phenylalanine/tyrosine ratios (1.39 vs 1.15, P=0.032) were found in acutely ill medical patients when compared to elective cardiac surgery patients. CRP levels were positively correlated with neopterin levels in acutely ill medical patients, explaining 28.4% of the variance in neopterin levels. eGFR was negatively correlated with neopterin in elective cardiac surgery patients, explaining 53.7% of the variance in neopterin levels. CONCLUSION In this study, we found differences in mean neopterin levels and phenylalanine/tyrosine ratios between acutely ill medical and elective cardiac surgery patients with delirium. Moreover, our findings may suggest that in acutely ill medical patients, neopterin levels are mainly determined by inflammation/oxidative stress whereas in elective cardiac surgery patients, neopterin levels are mainly driven by renal function/fluid status. These findings suggest that the markers and pathways that might be involved in the pathophysiology of delirium may differ between specific groups of patients.
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Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands, ;
| | - Robert J Osse
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Durk Fekkes
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Joke H M Tulen
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Tischa J M van der Cammen
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands, ;
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands, ;
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Assmann P, Kievit P, van der Wulp K, Verkroost M, Noyez L, Bor H, Schoon Y. Frailty is associated with delirium and mortality after transcatheter aortic valve implantation. Open Heart 2016; 3:e000478. [PMID: 28008356 PMCID: PMC5174802 DOI: 10.1136/openhrt-2016-000478] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/18/2016] [Accepted: 10/18/2016] [Indexed: 02/06/2023] Open
Abstract
Objective We hypothesised that frailty assessment is of additional value to predict delirium and mortality after transcatheter aortic valve implantation (TAVI). Methods Observational study in 89 consecutive patients who underwent TAVI. Inclusion from November 2012 to February 2014, follow-up until April 2014. Measurement of the association of variables from frailty assessment and cardiological assessment with delirium and mortality after TAVI, respectively. Results Incidence of delirium after TAVI: 25/89 (28%). Variables from frailty assessment protectively associated with delirium were: Mini Mental State Examination, (OR 0.79; 95% CI 0.65 to 0.96; p=0.02), Instrumental Activities of Daily Living (OR 0.79; 95% CI 0.63 to 0.99; p=0.04) and gait speed (OR 0.05; 95% CI 0.01 to 0.50; p=0.01). Timed Up and Go was predictively associated with delirium (OR 1.14; 95% CI 1.03 to 1.26; p=0.01). From cardiological assessment, pulmonary hypertension was protectively associated with delirium (OR 0.34; 95% CI 0.12 to 0.98; p=0.05). Multivariate logistic analysis: Nagelkerke R2=0.359, Mini Mental State Examination was independently associated with delirium. Incidence of mortality: 11/89 (12%). Variables predictively associated with mortality were: the summary score Frailty Index (HR 1.66, 95% CI 1.06 to 2.60; p=0.03), European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (HR 1.14, 95% CI 1.06 to 1.22; p<0.001) and complications (HR 4.81, 95% CI 1.03 to 22.38; p=0.05). Multivariate Cox proportional hazards analysis: Nagelkerke R2=0.271, Frailty Index and EuroSCORE II were independently associated with mortality. Conclusions Delirium frequently occurs after TAVI. Variables from frailty assessment are associated with delirium and mortality, independent of cardiological assessment. Thus, frailty assessment may have additional value in the prediction of delirium and mortality after TAVI.
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Affiliation(s)
- Patricia Assmann
- Department of Primary and Elderly Care, Radboud University Medical Centre Nijmegen, The Netherlands; ZZG Care Group, Nijmegen, The Netherlands
| | - Peter Kievit
- Department of Cardiology , Radboud University Medical Centre Nijmegen , The Netherlands
| | - Kees van der Wulp
- Department of Cardiology , Radboud University Medical Centre Nijmegen , The Netherlands
| | - Michel Verkroost
- Department of Cardio-Thoracic Surgery , Radboud University Medical Centre Nijmegen , The Netherlands
| | - Luc Noyez
- Department of Cardio-Thoracic Surgery , Radboud University Medical Centre Nijmegen , The Netherlands
| | - Hans Bor
- Department of Primary and Elderly Care , Radboud University Medical Centre Nijmegen , The Netherlands
| | - Yvonne Schoon
- Department of Geriatrics , Radboud University Medical Centre Nijmegen , The Netherlands
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Watne LO, Idland AV, Fekkes D, Raeder J, Frihagen F, Ranhoff AH, Chaudhry FA, Engedal K, Wyller TB, Hassel B. Increased CSF levels of aromatic amino acids in hip fracture patients with delirium suggests higher monoaminergic activity. BMC Geriatr 2016; 16:149. [PMID: 27484129 PMCID: PMC4970288 DOI: 10.1186/s12877-016-0324-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/28/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To examine whether delirium in hip fracture patients was associated with changes in the levels of amino acids and/or monoamine metabolites in cerebrospinal fluid (CSF) and serum. METHODS In this prospective cohort study, 77 patients admitted with an acute hip fracture to Oslo University Hospital, Norway, were studied. The concentrations of amino acids in CSF and serum were determined by high performance liquid chromatography. The patients were assessed daily for delirium by the Confusion Assessment Method (pre-operatively and post-operative day 1-5 (all) or until discharge (delirious patients)). Pre-fracture dementia status was decided by an expert panel. Serum was collected pre-operatively and CSF immediately before spinal anesthesia. RESULTS Fifty-three (71 %) hip fracture patients developed delirium. In hip fracture patients without dementia (n = 39), those with delirium had significantly higher CSF levels of tryptophan (40 % higher), tyrosine (60 % higher), phenylalanine (59 % higher) and the monoamine metabolite 5-hydroxyindoleacetate (23 % higher) compared to those without delirium. The same amino acids were also higher in CSF in delirious patients with dementia (n = 38). The correlations between serum and CSF amino acid levels were poor. CONCLUSION Higher CSF levels of monoamine precursors in hip fracture patients with delirium suggest a higher monoaminergic activity in the central nervous system during delirium in this patient group.
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Affiliation(s)
- Leiv Otto Watne
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway. .,Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO BOX 4950, Nydalen, N-0424, Oslo, Norway. .,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway. .,Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, Scotland, UK.
| | - Ane-Victoria Idland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO BOX 4950, Nydalen, N-0424, Oslo, Norway
| | - Durk Fekkes
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Johan Raeder
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Anette Hylen Ranhoff
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Knut Engedal
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Norwegian National Advisory Unit on Ageing and Health, Vestfold Health Trust, Tønsberg, Norway
| | - Torgeir Bruun Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO BOX 4950, Nydalen, N-0424, Oslo, Norway
| | - Bjørnar Hassel
- Department of Complex Neurology and Neurohabilitation, Oslo University Hospital, N-0027, Oslo, Norway. .,Norwegian Defense Research Establishment (FFI), Kjeller, Norway.
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24
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Hall RJ, Watne LO, Idland AV, Raeder J, Frihagen F, MacLullich AMJ, Staff AC, Wyller TB, Fekkes D. Cerebrospinal fluid levels of neopterin are elevated in delirium after hip fracture. J Neuroinflammation 2016; 13:170. [PMID: 27357281 PMCID: PMC4928278 DOI: 10.1186/s12974-016-0636-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 06/21/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The inflammatory cell product neopterin is elevated in serum before and during delirium. This suggests a role for disordered cell-mediated immunity or oxidative stress. Cerebrospinal fluid (CSF) neopterin levels reflect brain neopterin levels more closely than serum levels. Here we hypothesized that CSF neopterin levels would be higher in delirium. METHODS In this prospective cohort study, 139 elderly patients with acute hip fracture were recruited in Oslo and Edinburgh. Delirium was diagnosed with the confusion assessment method performed daily pre-operatively and on the first 5 days post-operatively. Paired CSF and blood samples were collected at the onset of spinal anaesthesia. Neopterin levels were measured using high-performance liquid chromatography. RESULTS Sixty-four (46 %) of 139 hip fracture patients developed delirium perioperatively. CSF neopterin levels were higher in delirium compared to controls (median 29.6 vs 24.7 nmol/mL, p = 0.003), with highest levels in patients who developed delirium post-operatively. Serum neopterin levels were also higher in delirium (median 37.0 vs 27.1 nmol/mL, p = 0.003). CSF neopterin remained significantly associated with delirium after controlling for relevant risk factors. Higher neopterin levels were associated with poorer outcomes (death or new institutionalization) 1 year after surgery (p = 0.02 for CSF and p = 0.03 for serum). CONCLUSIONS This study is the first to examine neopterin in CSF from patients with delirium. Our findings suggest potential roles for activation of cell-mediated immune responses or oxidative stress in the delirium process. High levels of serum or CSF neopterin in hip fracture patients may also be useful in predicting poor outcomes.
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Affiliation(s)
- Roanna J. Hall
- />Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
- />Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Ane-Victoria Idland
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Johan Raeder
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- />Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Frede Frihagen
- />Department of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Alasdair M. J. MacLullich
- />Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland
- />Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Anne Cathrine Staff
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- />Department of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Torgeir Bruun Wyller
- />Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PB 4950 Nydalen, N-0424 Oslo, Norway
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Durk Fekkes
- />Department of Anaesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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O'Neal JB, Shaw AD. Predicting, preventing, and identifying delirium after cardiac surgery. Perioper Med (Lond) 2016; 5:7. [PMID: 27119013 PMCID: PMC4845390 DOI: 10.1186/s13741-016-0032-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/29/2016] [Indexed: 02/07/2023] Open
Abstract
Delirium after cardiac surgery is a major problem. The exact mechanisms behind delirium are not understood. Potential pathways of delirium include neurotransmitter interference, global cognitive disorder, and neuroinflammation. Several predisposing and precipitating risk factors have been identified for postoperative delirium. The development of delirium following cardiac surgery is associated with worse outcomes in the perioperative period. Multiple interventions are being explored for the prevention and treatment of delirium. Studies investigating the potential roles of biomarkers in delirium as well as pharmacological interventions to reduce the incidence and duration of delirium are necessary to mitigate this negative outcome.
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Affiliation(s)
- Jason B O'Neal
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
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Egberts A, Fekkes D, Wijnbeld EHA, van der Ploeg MA, van Saase JLCM, Ziere G, van der Cammen TJM, Mattace-Raso FUS. Disturbed Serotonergic Neurotransmission and Oxidative Stress in Elderly Patients with Delirium. Dement Geriatr Cogn Dis Extra 2015; 5:450-8. [PMID: 26955379 PMCID: PMC4777943 DOI: 10.1159/000440696] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Oxidative stress and disturbances in serotonergic and dopaminergic neurotransmission may play a role in the pathophysiology of delirium. Aims In this study, we investigated levels of amino acids, amino acid ratios and levels of homovanillic acid (HVA) as indicators for oxidative stress and disturbances in neurotransmission. Methods Plasma levels of amino acids, amino acid ratios and HVA were determined in acutely ill patients aged ≥65 years admitted to the wards of Internal Medicine and Geriatrics of the Erasmus University Medical Center and the ward of Geriatrics of the Havenziekenhuis, Rotterdam, The Netherlands. Differences in the biochemical parameters between patients with and without delirium were investigated by analysis of variance in models adjusted for age, gender and comorbidities. Results Of the 86 patients included, 23 had delirium. In adjusted models, higher mean phenylalanine/tyrosine ratios (1.34 vs. 1.14, p = 0.028), lower mean tryptophan/large neutral amino acids ratios (4.90 vs. 6.12, p = 0.021) and lower mean arginine levels (34.8 vs. 45.2 µmol/l, p = 0.022) were found in patients with delirium when compared to those without. No differences were found in HVA levels between patients with and without delirium. Conclusion The findings of this study suggest disturbed serotonergic neurotransmission and an increased status of oxidative stress in patients with delirium.
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Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Durk Fekkes
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eline H A Wijnbeld
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Milly A van der Ploeg
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan L C M van Saase
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gijsbertus Ziere
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tischa J M van der Cammen
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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Hollinger A, Siegemund M, Goettel N, Steiner LA. Postoperative Delirium in Cardiac Surgery: An Unavoidable Menace? J Cardiothorac Vasc Anesth 2015; 29:1677-87. [DOI: 10.1053/j.jvca.2014.08.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Indexed: 01/20/2023]
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Gosselt AN, Slooter AJ, Boere PR, Zaal IJ. Risk factors for delirium after on-pump cardiac surgery: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:346. [PMID: 26395253 PMCID: PMC4579578 DOI: 10.1186/s13054-015-1060-0] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 09/04/2015] [Indexed: 12/13/2022]
Abstract
Introduction As evidence-based effective treatment protocols for delirium after cardiac surgery are lacking, efforts should be made to identify risk factors for preventive interventions. Moreover, knowledge of these risk factors could increase validity of etiological studies in which adjustments need to be made for confounding variables. This review aims to systematically identify risk factors for delirium after cardiac surgery and to grade the evidence supporting these associations. Method A prior registered systematic review was performed using EMBASE, CINAHL, MEDLINE and Cochrane from 1990 till January 2015 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007371). All studies evaluating patients for delirium after cardiac surgery with cardiopulmonary bypass (CPB) using either randomization or multivariable data analyses were included. Data was extracted and quality was scored in duplicate. Heterogeneity impaired pooling of the data; instead a semi-quantitative approach was used in which the strength of the evidence was graded based on the number of investigations, the quality of studies, and the consistency of the association reported across studies. Results In total 1462 unique references were screened and 34 were included in this review, of which 16 (47 %) were graded as high quality. A strong level of evidence for an association with the occurrence of postoperative delirium was found for age, previous psychiatric conditions, cerebrovascular disease, pre-existent cognitive impairment, type of surgery, peri-operative blood product transfusion, administration of risperidone, postoperative atrial fibrillation and mechanical ventilation time. Postoperative oxygen saturation and renal insufficiency were supported by a moderate level of evidence, and there is no evidence that gender, education, CPB duration, pre-existent cardiac disease or heart failure are risk factors. Conclusion Of many potential risk factors for delirium after cardiac surgery, for only 11 there is a strong or moderate level of evidence. These risk factors should be taken in consideration when designing future delirium prevention strategies trials or when controlling for confounding in future etiological studies. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1060-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alex Nc Gosselt
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Arjen Jc Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Pascal Rq Boere
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Irene J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Egberts A, Wijnbeld EHA, Fekkes D, van der Ploeg MA, Ziere G, Hooijkaas H, van der Cammen TJM, Mattace-Raso FUS. Neopterin: a potential biomarker for delirium in elderly patients. Dement Geriatr Cogn Disord 2015; 39:116-24. [PMID: 25413160 DOI: 10.1159/000366410] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND/AIMS The diagnosis of delirium is not supported by specific biomarkers. In a previous study, high neopterin levels were found in patients with a postoperative delirium. In the present study, we investigated levels of neopterin, interleukin-6 (IL-6) and insulin-like growth factor-1 (IGF-1) in acutely ill admitted elderly patients with and without a delirium. METHODS Plasma/serum levels of neopterin, IL-6 and IGF-1 were determined in patients aged ≥65 years admitted to the wards of Internal Medicine and Geriatrics. Differences in biomarker levels between patients with and without a delirium were investigated by the analysis of variance in models adjusted for age, gender, comorbidities and eGFR (when appropriate). RESULTS Eighty-six patients were included; 23 of them with a delirium. In adjusted models, higher mean levels of neopterin (70.5 vs. 45.9 nmol/l, p = 0.009) and IL-6 (43.1 vs. 18.5 pg/ml, p = 0.034) and lower mean levels of IGF-1 (6.3 vs. 9.3 nmol/l, p = 0.007) were found in patients with a delirium compared to those without. CONCLUSIONS The findings of this study suggest that neopterin might be a potential biomarker for delirium which, through oxidative stress and activation of the immune system, may play a role in the pathophysiology of delirium.
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Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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Melatonin treatment in the prevention of postoperative delirium in cardiac surgery patients. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 12:126-33. [PMID: 26336494 PMCID: PMC4550034 DOI: 10.5114/kitp.2015.52853] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 05/22/2015] [Accepted: 05/25/2015] [Indexed: 12/17/2022]
Abstract
Introduction Post-cardiac surgery delirium is a severe complication. The circadian rhythm of melatonin secretion has been shown to be altered postoperatively. Aim of the study It was hypothesized that restoring normal sleeping patterns with a substance that is capable of resynchronizing circadian rhythm such as exogenous administration of melatonin may possibly reduce the incidence of postoperative delirium. Material and methods This paper represents a prospective clinical observational study. Two consecutive groups of 250 consecutive patients took part in the study. Group A was the control group and group B was the melatonin group. In group B, the patients received prophylactic melatonin treatment. The main objectives were to observe the incidence of delirium, to identify any predictors of delirium, and to compare the two groups based on the delirium incidence. Results The incidence of delirium was 8.4% in the melatonin group vs. 20.8% in the control group (p = 0.001). Predictors of delirium in the melatonin group were age (p = 0.001) and higher EuroSCORE II value (p = 0.001). In multivariate analysis, age and EuroSCORE II value (p = 0.014) were predictors of postoperative delirium. Comparing the groups, the main predictors of delirium were age (p = 0.001), EuroSCORE II value (p = 0.001), cardio-pulmonary bypass (CPB) time (p = 0.001), aortic cross-clamping (ACC) time (p = 0.008), sufentanil dose (p = 0.001) and mechanical ventilation (p = 0.033). Conclusions Administration of melatonin significantly decreases the incidence of postoperative delirium after cardiac surgery. Prophylactic treatment with melatonin should be considered in every patient scheduled for cardiac surgery.
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Sabol F, Bilý B, Artemiou P, Kolesár A, Török P, Bilecová-Rabajdová M, Kolarčík P, Luczy J. Incidence and risk factors of delirium in patients after cardiac surgery: Modifiable and non-modifiable factors. COR ET VASA 2015. [DOI: 10.1016/j.crvasa.2015.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Schenning KJ, Deiner SG. Postoperative Delirium: A Review of Risk Factors and Tools of Prediction. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0086-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Neerland BE, Hov KR, Bruun Wyller V, Qvigstad E, Skovlund E, MacLullich AMJ, Bruun Wyller T. The protocol of the Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID: a randomised placebo-controlled trial. BMC Geriatr 2015; 15:7. [PMID: 25887557 PMCID: PMC4336683 DOI: 10.1186/s12877-015-0006-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 01/23/2015] [Indexed: 12/11/2022] Open
Abstract
Background Delirium affects 15% of hospitalised patients and is linked with poor outcomes, yet few pharmacological treatment options exist. One hypothesis is that delirium may in part result from exaggerated and/or prolonged stress responses. Dexmedetomidine, a parenterally-administered alpha2-adrenergic receptor agonist which attenuates sympathetic nervous system activity, shows promise as treatment in ICU delirium. Clonidine exhibits similar pharmacodynamic properties and can be administered orally. We therefore wish to explore possible effects of clonidine upon the duration and severity of delirium in general medical inpatients. Methods/Design The Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is a randomised, placebo-controlled, double-blinded, parallel group study with 4-month prospective follow-up. We will recruit 100 older medical inpatients with delirium or subsyndromal delirium in the acute geriatric ward. Participants will be randomised to oral clonidine or placebo until delirium free for 2 days (Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria), or after a maximum of 7 days treatment. Assessment of haemodynamics (blood pressure, heart rate and electrocardiogram) and delirium will be performed daily until discharge or a maximum of 7 days after end of treatment. The primary endpoint is the trajectory of delirium over time (measured by Memorial Delirium Assessment Scale). Secondary endpoints include the duration of delirium, use of rescue medication for delirium, pharmacokinetics and pharmacodynamics of clonidine, cognitive function after 4 months, length of hospital stay and need for institutionalisation. Discussion LUCID will explore the efficacy and safety of clonidine for delirium in older medical inpatients. Trial registration ClinicalTrials.gov NCT01956604. EudraCT Number: 2013-000815-26
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Affiliation(s)
- Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, University of Oslo, Pb 4956, N-0424, Oslo, Norway.
| | - Karen Roksund Hov
- Oslo Delirium Research Group, Department of Geriatric Medicine, University of Oslo, Pb 4956, N-0424, Oslo, Norway. .,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.
| | - Vegard Bruun Wyller
- Department of Pediatrics, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Eirik Qvigstad
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.
| | - Eva Skovlund
- School of Pharmacy, University of Oslo, Oslo, Norway.
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Room F1424, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, University of Oslo, Pb 4956, N-0424, Oslo, Norway. .,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.
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van Meenen LCC, van Meenen DMP, de Rooij SE, ter Riet G. Risk Prediction Models for Postoperative Delirium: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2014; 62:2383-90. [DOI: 10.1111/jgs.13138] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Sophia E. de Rooij
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Gerben ter Riet
- Department of General Practice; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
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McDonagh DL, Berger M, Mathew JP, Graffagnino C, Milano CA, Newman MF. Neurological complications of cardiac surgery. Lancet Neurol 2014; 13:490-502. [PMID: 24703207 PMCID: PMC5928518 DOI: 10.1016/s1474-4422(14)70004-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As increasing numbers of elderly people undergo cardiac surgery, neurologists are frequently called upon to assess patients with neurological complications from the procedure. Some complications mandate acute intervention, whereas others need longer term observation and management. A large amount of published literature exists about these complications and guidance on best practice is constantly changing. Similarly, despite technological advances in surgical intervention and modifications in surgical technique to make cardiac procedures safer, these advances often create new avenues for neurological injury. Accordingly, rapid and precise neurological assessment and therapeutic intervention rests on a solid understanding of the evidence base and procedural variables.
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Affiliation(s)
- David L McDonagh
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Department of Neurology, Duke University Medical Center, Durham, NC, USA.
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | | | - Carmelo A Milano
- Department of Surgery (Division of Cardiovascular and Thoracic Surgery), Duke University Medical Center, Durham, NC, USA
| | - Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Maldonado JR. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. Am J Geriatr Psychiatry 2013; 21:1190-222. [PMID: 24206937 DOI: 10.1016/j.jagp.2013.09.005] [Citation(s) in RCA: 406] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/10/2013] [Accepted: 09/13/2013] [Indexed: 12/20/2022]
Abstract
Delirium is a neurobehavioral syndrome caused by dysregulation of neuronal activity secondary to systemic disturbances. Over time, a number of theories have been proposed in an attempt to explain the processes leading to the development of delirium. Each proposed theory has focused on a specific mechanism or pathologic process (e.g., dopamine excess or acetylcholine deficiency theories), observational and experiential evidence (e.g., sleep deprivation, aging), or empirical data (e.g., specific pharmacologic agents' association with postoperative delirium, intraoperative hypoxia). This article represents a review of published literature and summarizes the top seven proposed theories and their interrelation. This review includes the "neuroinflammatory," "neuronal aging," "oxidative stress," "neurotransmitter deficiency," "neuroendocrine," "diurnal dysregulation," and "network disconnectivity" hypotheses. Most of these theories are complementary, rather than competing, with many areas of intersection and reciprocal influence. The literature suggests that many factors or mechanisms included in these theories lead to a final common outcome associated with an alteration in neurotransmitter synthesis, function, and/or availability that mediates the complex behavioral and cognitive changes observed in delirium. In general, the most commonly described neurotransmitter changes associated with delirium include deficiencies in acetylcholine and/or melatonin availability; excess in dopamine, norepinephrine, and/or glutamate release; and variable alterations (e.g., either a decreased or increased activity, depending on delirium presentation and cause) in serotonin, histamine, and/or γ-aminobutyric acid. In the end, it is unlikely that any one of these theories is fully capable of explaining the etiology or phenomenologic manifestations of delirium but rather that two or more of these, if not all, act together to lead to the biochemical derangement and, ultimately, to the complex cognitive and behavioral changes characteristic of delirium.
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Affiliation(s)
- José R Maldonado
- Departments of Psychiatry, Internal Medicine & Surgery and the Psychosomatic Medicine Service, Stanford University School of Medicine, and Board of Directors, American Delirium Society, Stanford, CA.
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Wijnia JW, Oudman E. Biomarkers of delirium as a clue to diagnosis and pathogenesis of Wernicke-Korsakoff syndrome. Eur J Neurol 2013; 20:1531-8. [PMID: 23790077 DOI: 10.1111/ene.12217] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 05/16/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Wernicke's encephalopathy (WE) and Korsakoff's syndrome are considered to be different stages of the same disorder due to thiamine deficiency, which is called Wernicke-Korsakoff syndrome (WKS). The earliest biochemical change is the decrease of α-ketoglutarate-dehydrogenase activity in astrocytes. According to autopsy-based series, mental status changes are present in 82% of WE cases. The objective of the present review is to identify possible underlying mechanisms relating the occurrence of delirium to WKS. METHODS Studies involving delirium in WKS, however, are rare. Therefore, first, a search was done for candidate biomarkers of delirium irrespective of the clinical setting. Secondly, the results were focused on identification of these biomarkers in reports on WKS. RESULTS In various settings, 10 biochemical and/or genetic biomarkers showed strong associations with the occurrence of delirium. For WKS three of these candidate biomarkers were identified, namely brain tissue cell counts of CD68 positive cells as a marker of microglial activation, high cerebrospinal fluid lactate levels, and MHPG, a metabolite of norepinephrine. Based on current literature, markers of microglial activation may present an interesting patho-etiological relationship between thiamine deficiency and delirium in WKS. CONCLUSIONS In WKS cases, changes in astroglia and microglial proliferation were reported. The possible loss-of-function mechanisms following thiamine deficiency in WKS are proposed to come from microglial activation, resulting in a delirium in the initial phase of WKS.
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Affiliation(s)
- J W Wijnia
- Lelie Care Group, Slingedael Korsakoff Centre, Rotterdam, The Netherlands
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Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital settings. Best Pract Res Clin Anaesthesiol 2012; 26:277-87. [PMID: 23040281 PMCID: PMC3580997 DOI: 10.1016/j.bpa.2012.07.003] [Citation(s) in RCA: 208] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 07/25/2012] [Indexed: 10/27/2022]
Abstract
Delirium is one of the most common causes of acute end-organ dysfunction across hospital settings, occurring in as high as 80% of critically ill patients that require intensive care unit (ICU) care. The implications of this acute form of brain injury are profound. Across many hospital settings (emergency department, general medical ward, postoperative and ICU), a patient who experiences delirium is more likely to experience increased short- and long-term mortality, decreases in long-term cognitive function, increases in hospital length of stay and increased complications of hospital care. With the development of reliable setting-specific delirium-screening instruments, researchers have been able to highlight the predisposing and potentially modifiable risk factors that place patients at highest risk. Among the large number of risk factors discovered, administration of potent sedative medications, most notably benzodiazepines, is most consistently and strongly associated with an increased burden of delirium. Alternatively, in both the hospital and ICU, delirium can be prevented with the application of protocols that include early mobility/exercise. Future studies must work to understand the epidemiology across settings and focus upon modifiable risk factors that can be integrated into existing delirium prevention and treatment protocols.
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Affiliation(s)
- Eduard E Vasilevskis
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, USA.
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