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Adamis D, Coada I, Eikelenboom P, Chu CS, Finn K, Melvin V, Williams J, Meagher DJ, McCarthy G. Delirium, insulin-like growth factor I, growth hormone in older inpatients. World J Psychiatry 2020; 10:212-222. [PMID: 33014722 PMCID: PMC7515747 DOI: 10.5498/wjp.v10.i9.212] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 06/16/2020] [Accepted: 08/25/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Delirium is a common disorder in elderly medical inpatients with serious adverse outcomes and is characterized by sudden onset, disturbance in attention, awareness, consciousness and cognition, and often with behavioural disturbances. Central to understanding delirium, is understanding mechanisms by which body and brain wellbeing are linked and in particular how brain responses to bodily homeostatic stress is mediated. A number of studies have investigated the relationship between insulin-like growth factor I (IGF-I) and delirium in medically ill hospitalised patients with conflicting results. However, none have investigated growth hormone (GH) which is related to IGF-I via negative feedback.
AIM To investigate the relationship between serum levels of IGF-I and GH, and the occurrence of delirium.
METHODS Prospective, longitudinal, observational study. Consecutive elderly inpatients (aged 70+), were assessed twice weekly with Montreal cognitive assessment (MoCA), Confusion assessment method (CAM), Acute Physiology and Chronic Health Evaluation II. Delirium was defined using CAM. Previous history of dementia was evaluated with the Informant Questionnaire on Cognitive Decline in the Elderly. IGF-I and GH levels were estimated with the ELISA method. Generalized estimating equations (GEE) model was applied for the first five assessments to analyze those longitudinal data.
RESULTS The sample consisted of 198 participants (mean age 80.63 ± 6.81; range 70-97). Of these 92 (46.5%) were females. Eighty six (43.4%) were identified with a history of dementia. Incident or prevalent delirium during hospitalisation was identified with CAM in 40 participants (20.2%). Evaluation of missing values with Little's MCAR test indicated that they were missing completely at random (MCAR χ2 = 12.24, u: 9, P = 0.20). Using GEE for the analysis we found that low MoCA scores, low levels of IGF-I and high levels of GH were significantly associated with any delirium (prevalence, incident, or fluctuating , during the study period (Wald χ2 = 12.231; u: 1, P < 0.001, Wald χ2 = 7.196, u: 1, P = 0.007, Wald χ2 = 6.210; : u: 1, P = 0.013 respectively).
CONCLUSION The results show that low levels of IGF-I, high levels of GH and low scores in cognition are independently associated with the occurrence of any delirium during the hospitalisation of medically ill older people. The results of the study supports the hypothesis that deficits in the immunoreactivity of the brain (low cerebral reserve) may be associated with delirium.
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Affiliation(s)
- Dimitrios Adamis
- Department of Psychiatry, Sligo/Leitrim Mental Health Services, Sligo F91 CD34, Ireland
- Department of Psychiatry, Research and Academic Institute of Athens, Athens 11742, Greece
- Department of Psychiatry, University Hospital Limerick, Limerick V94 F858, Ireland
| | - Iulian Coada
- Department of Psychiatry, Sligo/Leitrim Mental Health Services, Sligo F91 CD34, Ireland
| | - Piet Eikelenboom
- Department of Psychiatry, GGZinGeest and VuMC, Amsterdam 1081 HV, the Netherlands
| | - Che-Sheng Chu
- Department of Psychiatry and Center for Geriatric and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan
| | - Karen Finn
- Department of Biopharmaceutical and Medical Science, School of Science and Computing, Galway-Mayo Institute of Technology, Galway H91 T8NW, Ireland
| | - Vincent Melvin
- Department of Psychiatry, Sligo/Leitrim Mental Health Services, Sligo F91 CD34, Ireland
| | - John Williams
- Department of Pathology, Sligo University Hospital, Sligo F91 H684, Ireland
| | - David James Meagher
- Department of Psychiatry, University Hospital Limerick, Limerick V94 F858, Ireland
| | - Geraldine McCarthy
- Department of Psychiatry, Sligo/Leitrim Mental Health Services, Sligo F91 CD34, Ireland
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Hall RJ, Watne LO, Cunningham E, Zetterberg H, Shenkin SD, Wyller TB, MacLullich AMJ. CSF biomarkers in delirium: a systematic review. Int J Geriatr Psychiatry 2018; 33:1479-1500. [PMID: 28585290 DOI: 10.1002/gps.4720] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/16/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In recent years, there has been a blossoming of studies examining cerebrospinal fluid (CSF) as a method of studying the pathophysiology of delirium. We systematically reviewed the literature for CSF studies in delirium and provide here a summary of the implications for our understanding of delirium pathophysiology. We also summarise the methods used for CSF analysis and discuss challenges and implications for future studies. METHODS In this systematic review, we screened MEDLINE, EMBASE, PsycINFO, Web of Science, PubMed and the Cochrane Library for articles on CSF biomarkers in delirium, published on 3 September 2016. Studies were required to use Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria for delirium or a validated tool. We excluded case reports. There were no other restrictions on study type. RESULTS We identified 3280 articles from our initial search, and 22 articles were included in this review. All studies were prospective, including over 400 patients with delirium and 700 controls. More than 70 different biomarkers were studied. Studies could not be compared with each other for meta-analysis because of their heterogeneity and varied widely in their risk of bias and quality assessments. CONCLUSIONS The 22 studies identified in this review reveal a small but growing literature, in which many of the important hypotheses in delirium pathogenesis have been examined, but from which few firm conclusions can currently be drawn. Nevertheless, the overall interpretation of the literature supports the vulnerable brain concept, that is, that biomarker evidence of, for example, Alzheimer's disease pathology and/or neuroinflammation, is associated with delirium.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Emma Cunningham
- Centre for Public Health, Queen's University of Belfast, Belfast, Ireland
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Susan D Shenkin
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland
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Hall RJ, Shenkin SD, Maclullich AMJ. A systematic literature review of cerebrospinal fluid biomarkers in delirium. Dement Geriatr Cogn Disord 2012; 32:79-93. [PMID: 21876357 DOI: 10.1159/000330757] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2011] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) analysis has great potential to advance understanding of delirium pathophysiology. METHODS A systematic literature review of CSF studies of DSM or ICD delirium was performed. RESULTS In 8 studies of 235 patients, delirium was associated with: elevated serotonin metabolites, interleukin-8, cortisol, lactate and protein, and reduced somatostatin, β-endorphin and neuron-specific enolase. Elevated acetylcholinesterase predicted poor outcome after delirium and higher dopamine metabolites were associated with psychotic features. CONCLUSIONS No clear conclusions emerged, but the current literature suggests multiple areas for further investigation with more detailed studies.
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Affiliation(s)
- Roanna J Hall
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences and Community Health, UK. roanna.hall @ ed.ac.uk
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Adamis D, Meagher D. Insulin-like growth factor I and the pathogenesis of delirium: a review of current evidence. J Aging Res 2011; 2011:951403. [PMID: 21766035 PMCID: PMC3134253 DOI: 10.4061/2011/951403] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 04/26/2011] [Accepted: 05/12/2011] [Indexed: 01/28/2023] Open
Abstract
Delirium is a frequent complication in medically ill elderly patients that is associated with serious adverse outcomes including increased mortality. Delirium risk is linked to older age, dementia, and illness that involves activation of inflammatory responses. IGF-I is increasingly postulated as a key link between environmental influences on body metabolism with a range of neuronal activities and has been described as the master regulator of the connection between brain and bodily well-being. The relationships between IGF-I and ageing, cognitive impairment and inflammatory illness further support a possible role in delirium pathogenesis. Five studies of IGF-I in delirium were identified by a systematic review. These conflicting findings, with three of the five studies indicating an association between IGF-1 and delirium occurrence, may relate to the considerable methodological differences in these studies. The relevance of IGF-I and related factors to delirium pathogenesis can be clarified by future studies which account for these issues and other confounding factors. Such work can inform therapeutic trials of IGF-I and/or growth hormone administration.
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Affiliation(s)
- Dimitrios Adamis
- Research and Academic Institute of Athens, 27 Themistokleous Street and Akadimias, 10677 Athens, Greece
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Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin 2008; 24:789-856, ix. [PMID: 18929943 DOI: 10.1016/j.ccc.2008.06.004] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Delirium is the most common complication found in the general hospital setting. Yet, we know relatively little about its actual pathophysiology. This article contains a summary of what we know to date and how different proposed intrinsic and external factors may work together or by themselves to elicit the cascade of neurochemical events that leads to the development delirium. Given how devastating delirium can be, it is imperative that we better understand the causes and underlying pathophysiology. Elaborating a pathoetiology-based cohesive model to better grasp the basic mechanisms that mediate this syndrome will serve clinicians well in aspiring to find ways to correct these cascades, instituting rational treatment modalities, and developing effective preventive techniques.
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Broadhurst C, Wilson KCM, Kinirons MT, Wagg A, Dhesi JK. Clinical pharmacology of old age syndromes. Br J Clin Pharmacol 2003; 56:261-72. [PMID: 12919174 PMCID: PMC1884351 DOI: 10.1046/j.0306-5251.2003.01877.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2002] [Accepted: 03/28/2003] [Indexed: 11/20/2022] Open
Abstract
Several syndromes occur in old age. They are often associated with increased mortality and in all there is a paucity of basic and clinical research. The recent developments in the clinical pharmacology of three common syndromes of old age (delirium, urinary incontinence, and falls) are discussed along with directions for future research.
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Affiliation(s)
- C Broadhurst
- EMI Academic Unit, St Catherine's Hospital, Birkenhead, Merseyside CH42 0LQ, UK.
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Uchino K, Billheimer D, Cramer SC. Entry criteria and baseline characteristics predict outcome in acute stroke trials. Stroke 2001; 32:909-16. [PMID: 11283391 DOI: 10.1161/01.str.32.4.909] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED Background and Purpose-We sought to study the range of entry criteria and baseline characteristics in acute stroke trials and to understand their effects on patient outcomes. METHODS -Randomized, placebo-controlled therapeutic trials in patients with acute ischemic stroke were identified. Entry criteria, baseline clinical characteristics, and outcome were extracted for the placebo group of each trial. The relationship between key variables was then determined. RESULTS -Across 90 placebo groups identified, there was great variation in entry criteria and outcome measures. This was associated with divergent outcomes; for example, in some studies most placebo group patients died, while in other studies nearly all had no disability. Entry criteria were significantly correlated with outcome; for example, higher age cutoff for study entry correlated with 3-month mortality. Entry criteria also predicted baseline clinical characteristics; for example, wider time window for study entry correlated directly with time to treatment and inversely with stroke severity (initial National Institutes of Health Stroke Scale score). Baseline characteristics predicted outcome. Greater stroke severity predicted higher 3-month mortality rate; despite this, successful thrombolytic trials have enrolled more severe strokes than most trials. The mean age of enrollees also predicted 3-month mortality and was inversely related to percentage of patients with 3-month Barthel Index score >/=95. The strongest predictors of 3-month mortality were obtained with multivariate models. CONCLUSIONS -Acute stroke studies vary widely in entry criteria and outcome measures. Across multiple studies, differences in entry criteria, and the baseline clinical characteristics they predict, influence patient outcomes along a continuum. In some studies, enrolling a specific subset of patients may have improved the chances of identifying a treatment-related effect, while in others, such chances may have been reduced. These findings may be useful in the design of future stroke therapeutic trials.
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Affiliation(s)
- K Uchino
- Department of Neurology and Statistics, University of Washington, Seattle, WA, USA
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Camus V, Gonthier R, Dubos G, Schwed P, Simeone I. Etiologic and outcome profiles in hypoactive and hyperactive subtypes of delirium. J Geriatr Psychiatry Neurol 2001; 13:38-42. [PMID: 10753006 DOI: 10.1177/089198870001300106] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The existence of hyperactive, hypoactive, or mixed clinical subtypes of delirium is widely accepted. But relationships between these motor profiles and etiology or outcome remain unclear. The aim of this study was to compare etiologic and outcome profiles in a case series of 183 elderly patients (mean age = 84.1 years, SD = 5.9) consecutively admitted into the geriatric wards of two French university hospitals or referred to a geriatric psychiatry consultation-liaison unit within a Swiss university hospital. All patients met DSM-III-R criteria for delirium and were classified into clinical subtypes according to the results of a previous factor analysis of scores on a 19-item checklist rating a wide range of delirium symptoms. The hyperactive subtype was more frequent (n = 85, 46.5%) than the unspecified (n = 50, 27.3%) and hypoactive subtypes (n = 48, 26.2%). There was no significant difference in terms of etiologic or outcome profile between clinical subtype groups. The presence of acute metabolic disorders, cardiovascular disease, and hyperthermia as etiologic factors was significantly associated with full recovery of the episode at 3 weeks follow-up, whereas probable preexisting dementia was significantly associated with partial recovery or failure to recover.
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Affiliation(s)
- V Camus
- Geriatric Psychiatry Department, University of Lausanne School of Medicine, Switzerland
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Meagher DJ, Trzepacz PT. Delirium phenomenology illuminates pathophysiology, management, and course. J Geriatr Psychiatry Neurol 1999; 11:150-6; discussion 157-8. [PMID: 9894734 DOI: 10.1177/089198879801100306] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The phenomenology of delirium has received little standardized longitudinal study but offers the prospect of valuable insights regarding clinical subtypes, differentiation from other neuropsychiatric disorders, identification of underlying pathophysiologies, management, and course. This review examines current approaches to the investigation of delirium phenomenology and how the findings to date illuminate our understanding of delirium. It concludes with recommendations for future investigations.
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Affiliation(s)
- D J Meagher
- St. Ita's Hospital, Portrane, County Dublin, Republic of Ireland
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