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Cavallari M, Touroutoglou A, Katsumi Y, Fong TG, Schmitt E, Travison TG, Shafi MM, Libermann TA, Marcantonio ER, Alsop DC, Jones RN, Inouye SK, Dickerson BC. Relationship between cortical brain atrophy, delirium, and long-term cognitive decline in older surgical patients. Neurobiol Aging 2024; 140:130-139. [PMID: 38788524 DOI: 10.1016/j.neurobiolaging.2024.05.008] [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: 12/12/2022] [Revised: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024]
Abstract
In older patients, delirium after surgery is associated with long-term cognitive decline (LTCD). The neural substrates of this association are unclear. Neurodegenerative changes associated with dementia are possible contributors. We investigated the relationship between brain atrophy rates in Alzheimer's disease (AD) and cognitive aging signature regions from magnetic resonance imaging before and one year after surgery, LTCD assessed by the general cognitive performance (GCP) score over 6 years post-operatively, and delirium in 117 elective surgery patients without dementia (mean age = 76). The annual change in cortical thickness was 0.2(1.7) % (AD-signature p = 0.09) and 0.4(1.7) % (aging-signature p = 0.01). Greater atrophy was associated with LTCD (AD-signature: beta(CI) = 0.24(0.06-0.42) points of GCP/mm of cortical thickness; p < 0.01, aging-signature: beta(CI) = 0.55(0.07-1.03); p = 0.03). Atrophy rates were not significantly different between participants with and without delirium. We found an interaction with delirium severity in the association between atrophy and LTCD (AD-signature: beta(CI) = 0.04(0.00-0.08), p = 0.04; aging-signature: beta(CI) = 0.08(0.03-0.12), p < 0.01). The rate of cortical atrophy and severity of delirium are independent, synergistic factors determining postoperative cognitive decline in the elderly.
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Affiliation(s)
- Michele Cavallari
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra Touroutoglou
- Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yuta Katsumi
- Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA; Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eva Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Thomas G Travison
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Mouhsin M Shafi
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Towia A Libermann
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics and Systems Biology Center, Harvard Medical School, Boston, MA, USA
| | - Edward R Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David C Alsop
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard N Jones
- Departments of Psychiatry and Human Behavior and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA; Departments of Psychiatry and Human Behavior and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Bradford C Dickerson
- Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Aksnes M, Schibstad MH, Chaudhry FA, Neerland BE, Caplan G, Saltvedt I, Eldholm RS, Myrstad M, Edwin TH, Persson K, Idland AV, Pollmann CT, Olsen RB, Wyller TB, Zetterberg H, Cunningham E, Watne LO. Differences in metalloproteinases and their tissue inhibitors in the cerebrospinal fluid are associated with delirium. COMMUNICATIONS MEDICINE 2024; 4:124. [PMID: 38937571 PMCID: PMC11211460 DOI: 10.1038/s43856-024-00558-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 06/20/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND The aetiology of delirium is not known, but pre-existing cognitive impairment is a predisposing factor. Here we explore the associations between delirium and cerebrospinal fluid (CSF) levels of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs), proteins with important roles in both acute injury and chronic neurodegeneration. METHODS Using a 13-plex Discovery Assay®, we quantified CSF levels of 9 MMPs and 4 TIMPs in 280 hip fracture patients (140 with delirium), 107 cognitively unimpaired individuals, and 111 patients with Alzheimer's disease dementia. The two delirium-free control groups without acute trauma were included to unravel the effects of acute trauma (hip fracture), dementia, and delirium. RESULTS Here we show that delirium is associated with higher levels of MMP-2, MMP-3, MMP-10, TIMP-1, and TIMP-2; a trend suggests lower levels of TIMP-4 are also associated with delirium. Most delirium patients had pre-existing dementia and low TIMP-4 is the only marker associated with delirium in adjusted analyses. MMP-2, MMP-12, and TIMP-1 levels are clearly higher in the hip fracture patients than in both control groups and several other MMP/TIMPs are impacted by acute trauma or dementia status. CONCLUSIONS Several CSF MMP/TIMPs are significantly associated with delirium in hip fracture patients, but alterations in most of these MMP/TIMPs could likely be explained by acute trauma and/or pre-fracture dementia. Low levels of TIMP-4 appear to be directly associated with delirium, and the role of this marker in delirium pathophysiology should be further explored.
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Affiliation(s)
- Mari Aksnes
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | | | - Farrukh Abbas Chaudhry
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatric Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Rannveig S Eldholm
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatric Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marius Myrstad
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Trine Holt Edwin
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Karin Persson
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Vestfold Hospital Trust, Norwegian National Centre for Ageing and Health, Tønsberg, Vestfold, Norway
| | - Ane-Victoria Idland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Department of Anesthesiology, Akershus University Hospital, Lørenskog, Norway
| | | | - Roy Bjørkholt Olsen
- Department of Anesthesiology and Intensive Care, Sørlandet Hospital, Arendal, Norway
| | - Torgeir Bruun Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, the Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Emma Cunningham
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Leiv Otto Watne
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Geriatric Medicine, Akershus University Hospital, Lørenskog, Norway
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Fislage M, Winzeck S, Woodrow R, Lammers‐Lietz F, Stamatakis EA, Correia MM, Preller J, Feinkohl I, Hendrikse J, Pischon T, Spies CD, Slooter AJC, Winterer G, Menon DK, Zacharias N. Structural disconnectivity in postoperative delirium: A perioperative two-center cohort study in older patients. Alzheimers Dement 2024; 20:2861-2872. [PMID: 38451782 PMCID: PMC11032567 DOI: 10.1002/alz.13749] [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: 09/01/2023] [Revised: 11/26/2023] [Accepted: 01/21/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Structural disconnectivity was found to precede dementia. Global white matter abnormalities might also be associated with postoperative delirium (POD). METHODS We recruited older patients (≥65 years) without dementia that were scheduled for major surgery. Diffusion kurtosis imaging metrics were obtained preoperatively, after 3 and 12 months postoperatively. We calculated fractional anisotropy (FA), mean diffusivity (MD), mean kurtosis (MK), and free water (FW). A structured and validated delirium assessment was performed twice daily. RESULTS Of 325 patients, 53 patients developed POD (16.3%). Preoperative global MD (standardized beta 0.27 [95% confidence interval [CI] 0.21-0.32] p < 0.001) was higher in patients with POD. Preoperative global MK (-0.07 [95% CI -0.11 to (-0.04)] p < 0.001) and FA (0.07 [95% CI -0.10 to (-0.04)] p < 0.001) were lower. When correcting for baseline diffusion, postoperative MD was lower after 3 months (0.05 [95% CI -0.08 to (-0.03)] p < 0.001; n = 183) and higher after 12 months (0.28 [95% CI 0.20-0.35] p < 0.001; n = 45) among patients with POD. DISCUSSION Preoperative structural disconnectivity was associated with POD. POD might lead to white matter depletion 3 and 12 months after surgery.
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Affiliation(s)
- Marinus Fislage
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Department of NeurologyNational Taiwan University HospitalTaipei CityTaiwan
| | - Stefan Winzeck
- Department of ComputingImperial College LondonBioMedIA GroupLondonUK
- University Division of Anaesthesia, Department of MedicineUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
| | - Rebecca Woodrow
- University Division of Anaesthesia, Department of MedicineUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
- Department of Clinical NeurosciencesUniversity of Cambridge; Addenbrooke's HospitalCambridgeUK
| | - Florian Lammers‐Lietz
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Emmanuel A. Stamatakis
- University Division of Anaesthesia, Department of MedicineUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
- Department of Clinical NeurosciencesUniversity of Cambridge; Addenbrooke's HospitalCambridgeUK
| | - Marta M. Correia
- MRC Cognition and Brain Sciences Unit, University of CambridgeCambridgeUK
| | - Jacobus Preller
- Addenbrooke's Cambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Insa Feinkohl
- Faculty of Health/School of MedicineWitten/Herdecke UniversityWittenGermany
- Max‐Delbrueck‐Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research GroupBerlinGermany
| | - Jeroen Hendrikse
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Tobias Pischon
- Max‐Delbrueck‐Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research GroupBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Max‐Delbrueck‐Center for Molecular Medicine in the Helmholtz Association (MDC), Biobank Technology PlatformBerlinGermany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Core Facility BiobankBerlinGermany
| | - Claudia D. Spies
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Arjen J. C. Slooter
- Departments of Psychiatry and Intensive Care Medicine, and UMC Utrecht Brain CenterUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Department of NeurologyUZ Brussel and Vrije Universiteit BrusselBrusselsBelgium
| | - Georg Winterer
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Pharmaimage Biomarker Solutions GmbHBerlinGermany
| | - David K. Menon
- University Division of Anaesthesia, Department of MedicineUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
| | - Norman Zacharias
- Department of Anesthesiology and Intensive Care MedicineCharité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Pharmaimage Biomarker Solutions GmbHBerlinGermany
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Ruck JM, Chu NM, Liu Y, Li Y, Chen Y, Mathur A, Carlson MC, Crews DC, Chodosh J, Segev DL, McAdams-DeMarco M. Association of Postoperative Delirium With Incident Dementia and Graft Outcomes Among Kidney Transplant Recipients. Transplantation 2024; 108:530-538. [PMID: 37643030 PMCID: PMC10840878 DOI: 10.1097/tp.0000000000004779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Kidney transplant (KT) recipients have numerous risk factors for delirium, including those shared with the general surgical population (eg, age and major surgery) and transplant-specific factors (eg, neurotoxic immunosuppression medications). Evidence has linked delirium to long-term dementia risk in older adults undergoing major surgery. We sought to characterize dementia risk associated with post-KT delirium. METHODS Using the United States Renal Data System datasets, we identified 35 800 adult first-time KT recipients ≥55 y. We evaluated risk factors for delirium using logistic regression. We evaluated the association between delirium and incident dementia (overall and by subtype: Alzheimer's, vascular, and other/mixed-type), graft loss, and death using Fine and Gray's subhazards models and Cox regression. RESULTS During the KT hospitalization, 0.9% of recipients were diagnosed with delirium. Delirium risk factors included age (OR = 1.40, 95% CI, 1.28-1.52) and diabetes (OR = 1.38, 95% CI, 1.10-1.73). Delirium was associated with higher risk of death-censored graft loss (aHR = 1.52, 95% CI, 1.12-2.05) and all-cause mortality (aHR = 1.53, 95% CI, 1.25-1.89) at 5 y post-KT. Delirium was also associated with higher risk of dementia (adjusted subhazard ratio [aSHR] = 4.59, 95% CI, 3.48-6.06), particularly vascular dementia (aSHR = 2.51, 95% CI, 1.01-6.25) and other/mixed-type dementia (aSHR = 5.58, 95% CI, 4.24-7.62) subtypes. The risk of all-type dementia associated with delirium was higher for younger recipients aged between 55 and 64 y ( Pinteraction = 0.01). CONCLUSIONS Delirium is a strong risk factor for subsequent diagnosis of dementia among KT recipients, particularly those aged between 55 and 64 y at the time of transplant. Patients experiencing posttransplant delirium might benefit from early interventions to enhance cognitive health and surveillance for cognitive impairment to enable early referral for dementia care.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yi Liu
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Yiting Li
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Yusi Chen
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Aarti Mathur
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michelle C Carlson
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Deidra C Crews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joshua Chodosh
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Medicine, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
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Pendlebury ST, Luengo-Fernandez R, Seeley A, Downer MB, McColl A, Rothwell PM. Infection, delirium, and risk of dementia in patients with and without white matter disease on previous brain imaging: a population-based study. THE LANCET. HEALTHY LONGEVITY 2024; 5:e131-e140. [PMID: 38310893 DOI: 10.1016/s2666-7568(23)00266-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND The increased risk of dementia after delirium and infection might be influenced by cerebral white matter disease (WMD). In patients with transient ischaemic attack (TIA) and minor stroke, we assessed associations between hospital admissions with delirium and 5-year dementia risk and between admissions with infection and dementia risk, stratified by WMD severity (moderate or severe vs absent or mild) on baseline brain imaging. METHODS We included patients with TIA and minor stroke (National Institutes of Health Stroke Score <3) from the Oxford Vascular Study (OXVASC), a longitudinal population-based study of the incidence and outcomes of acute vascular events in a population of 94 567 individuals, with no age restrictions, attending eight general practices in Oxfordshire, UK. Hospitalisation data were obtained through linkage to the Oxford Cognitive Comorbidity, Frailty, and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR). Brain imaging was done using CT and MRI, and WMD was prospectively graded according to the age-related white matter changes (ARWMC) scale and categorised into absent, mild, moderate, or severe WMD. Delirium and infection were defined by ICD-10 coding supplemented by hand-searching of hospital records. Dementia was diagnosed using clinical or cognitive assessment, medical records, and death certificates. Associations between hospitalisation with delirium and hospitalisation with infection, and post-event dementia were assessed using time-varying Cox analysis with multivariable adjustment, and all models were stratified by WMD severity. FINDINGS From April 1, 2002, to March 31, 2012, 1369 individuals were prospectively recruited into the study. Of 1369 patients (655 with TIA and 714 with minor stroke, mean age 72 [SD 13] years, 674 female and 695 male, and 364 with moderate or severe WMD), 209 (15%) developed dementia. Hospitalisation during follow-up occurred in 891 (65%) patients of whom 103 (12%) had at least one delirium episode and 236 (26%) had at least one infection episode. Hospitalisation without delirium or infection did not predict subsequent dementia (HR 1·01, 95% CI 0·86-1·20). In contrast, hospitalisation with delirium predicted subsequent dementia independently of infection in patients with and without WMD (2·64, 1·47-4·74; p=0·0013 vs 3·41, 1·91-6·09; p<0·0001) especially in those with unimpaired baseline cognition (cognitive test score above cutoff; 4·01, 2·23-7·19 vs 3·94, 1·95-7·93; both p≤0·0001). However, hospitalisation with infection only predicted dementia in those with moderate or severe WMD (1·75, 1·04-2·94 vs 0·68, 0·39-1·20; pdiff=0·023). INTERPRETATION The increased risk of dementia after delirium is unrelated to the presence of WMD, whereas infection increases risk only in patients with WMD, suggesting differences in underlying mechanisms and in potential preventive strategies. FUNDING National Institute for Health and Care Research and Wellcome Trust.
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Affiliation(s)
- Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Departments of Acute General Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Ramon Luengo-Fernandez
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Anna Seeley
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Matthew B Downer
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Aubretia McColl
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Arias F, Chen F, Shiff H, Marcantonio ER, Jones RN, Schmitt EM, Metzger E, Fong TG, Travison TG, Inouye SK. Parental Education and Delirium Risk after Surgery in Older Adults. Clin Gerontol 2023; 46:253-266. [PMID: 36001869 PMCID: PMC9928599 DOI: 10.1080/07317115.2022.2111289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Efforts to conceptualize risk factors for postoperative delirium in older adults have focused on the time proximate to the episode, but how early-life exposures influence delirium risk is poorly understood. METHODS An observational cohort of 547 patients aged 70+undergoing major non-cardiac surgery at two academic medical centers in Boston. Demographic characteristics, cognition, parental education, health, and participation in cognitively stimulating activities were assessed prior to surgery. Delirium incidence and severity were measured daily during hospitalization. RESULTS Higher paternal education was associated with significantly lower incidence of delirium (X2(1, N =547)=8.35, p <.001; odds ratio OR=.93, 95% CI, .87 to .98) and inversely associated with delirium severity (r(545)=-.13, p <.001). Higher maternal education was associated with lower delirium incidence but did not reach statistical significance. The effect of paternal education on delirium incidence was independent of the patient's education, estimated premorbid intelligence, medical comorbidities, neighborhood disadvantage, and participation in cognitively stimulating activities (X2(2, N =547)=31.22, p <.001). CONCLUSIONS Examining early-life exposures may yield unique insights into the risks and pathogenesis of delirium. CLINICAL IMPLICATIONS Evaluating long-term factors that increase vulnerability to delirium may improve our ability to calculate risk. It may guide clinical decision-making and inform pre- and post-operative recommendations.
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Affiliation(s)
- Franchesca Arias
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, USA
- Harvard Medical School, Boston, USA
| | - Fan Chen
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, USA
| | - Haley Shiff
- Harvard T. H. Chan School of Public Health, Boston, USA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, USA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University, Warren Alpert Medical School, Providence, USA
| | - Eva M. Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, USA
| | - Eran Metzger
- Department of Medicine, Hebrew SeniorLife, Boston, USA
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, USA
| | - Tamara G. Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, USA
- Harvard Medical School, Boston, USA
| | - Thomas G. Travison
- Harvard Medical School, Boston, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, USA
- Department of Medicine and Psychiatry, Harvard Medical School, Boston, USA
| | - Sharon K. Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, USA
- Harvard Medical School, Boston, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
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7
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Kant IMJ, de Bresser J, van Montfort SJT, Witkamp TD, Walraad B, Spies CD, Hendrikse J, van Dellen E, Slooter AJC, Winterer G, Pischon T, Boraschi D, Schneider R, N#x00FC;rnberg P, Norman Zacharias MP, Morgeli R, Olbert M, Lachmann G, Borchers F, Ofosu K, Yurek F, Wolf A, Gallinat J, Hendrikse J, Slooter A, van Dellen E, Stamatakis E, Preller J, Menon D, Moreno-Lopez L, Winzeck S, Feinkohl I, Italiani P, Melillo D, Camera GD, Krause R, Heidtke K, Kuhn S, Kronabel M, Dscietzig TB, Armbruster FP, Hafen B, Ruppert J, Bocher A, Helmschrodt A, Weyer M, Hartmann K, Diehl I, Weber S, Fillmer A, Ittermann B. Postoperative delirium is associated with grey matter brain volume loss. Brain Commun 2023; 5:fcad013. [PMID: 36819940 PMCID: PMC9933897 DOI: 10.1093/braincomms/fcad013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/12/2022] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
Delirium is associated with long-term cognitive dysfunction and with increased brain atrophy. However, it is unclear whether these problems result from or predisposes to delirium. We aimed to investigate preoperative to postoperative brain changes, as well as the role of delirium in these changes over time. We investigated the effects of surgery and postoperative delirium with brain MRIs made before and 3 months after major elective surgery in 299 elderly patients, and an MRI with a 3 months follow-up MRI in 48 non-surgical control participants. To study the effects of surgery and delirium, we compared brain volumes, white matter hyperintensities and brain infarcts between baseline and follow-up MRIs, using multiple regression analyses adjusting for possible confounders. Within the patients group, 37 persons (12%) developed postoperative delirium. Surgical patients showed a greater decrease in grey matter volume than non-surgical control participants [linear regression: B (95% confidence interval) = -0.65% of intracranial volume (-1.01 to -0.29, P < 0.005)]. Within the surgery group, delirium was associated with a greater decrease in grey matter volume [B (95% confidence interval): -0.44% of intracranial volume (-0.82 to -0.06, P = 0.02)]. Furthermore, within the patients, delirium was associated with a non-significantly increased risk of a new postoperative brain infarct [logistic regression: odds ratio (95% confidence interval): 2.8 (0.7-11.1), P = 0.14]. Our study was the first to investigate the association between delirium and preoperative to postoperative brain volume changes, suggesting that delirium is associated with increased progression of grey matter volume loss.
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Affiliation(s)
- Ilse M J Kant
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands,Department of Information Technology and Digital Innovation, Leiden University Medical Center, Leiden 2333 ZA, The Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden 2333 ZA, The Netherlands
| | - Simone J T van Montfort
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Theodoor D Witkamp
- Department of Radiology and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Bob Walraad
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Claudia D Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, Berlin 10117, Germany
| | - Jeroen Hendrikse
- Department of Radiology and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Edwin van Dellen
- Department of Intensive Care Medicine and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands,Department of Psychiatry and University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands
| | - Arjen J C Slooter
- Correspondence to: Arjen Slooter Department of Intensive Care Medicine University Medical Center Utrecht Brain Center Utrecht University, Heidelberglaan 100 Utrecht 3584 CX, The Netherlands E-mail:
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8
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Barreto Chang OL, Possin KL, Maze M. Age-Related Perioperative Neurocognitive Disorders: Experimental Models and Druggable Targets. Annu Rev Pharmacol Toxicol 2023; 63:321-340. [PMID: 36100220 DOI: 10.1146/annurev-pharmtox-051921-112525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
With the worldwide increase in life span, surgical patients are becoming older and have a greater propensity for postoperative cognitive impairment, either new onset or through deterioration of an existing condition; in both conditions, knowledge of the patient's preoperative cognitive function and postoperative cognitive trajectory is imperative. We describe the clinical utility of a tablet-based technique for rapid assessment of the memory and attentiveness domains required for executive function. The pathogenic mechanisms for perioperative neurocognitive disorders have been investigated in animal models in which excessive and/or prolonged postoperative neuroinflammation has emerged as a likely contender. The cellular and molecular species involved in postoperative neuroinflammation are the putative targets for future therapeutic interventions that are efficacious and do not interfere with the surgical patient's healing process.
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Affiliation(s)
- Odmara L Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA;
| | - Katherine L Possin
- Memory and Aging Center, Department of Neurology, and Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA; .,Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
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9
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Nitchingham A, Pereira JVB, Wegner EA, Oxenham V, Close J, Caplan GA. Regional cerebral hypometabolism on 18F-FDG PET/CT scan in delirium is independent of acute illness and dementia. Alzheimers Dement 2023; 19:97-106. [PMID: 35289980 PMCID: PMC10078760 DOI: 10.1002/alz.12604] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 12/24/2021] [Accepted: 12/27/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Delirium is associated with new onset dementia and accelerated cognitive decline; however, its pathophysiology remains unknown. Cerebral glucose metabolism previously seen in delirium may have been attributable to acute illness and/or dementia. We aimed to statistically map cerebral glucose metabolism attributable to delirium. METHODS We assessed cerebral glucose metabolism using 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET) in sick, older patients with and without delirium, all without clinical dementia (N = 20). Strict exclusion criteria were adopted to minimize the effect of established confounders on FDG-PET. RESULTS Patients with delirium demonstrated hypometabolism in the bilateral thalami and right superior frontal, right posterior cingulate, right infero-lateral anterior temporal, and left superior parietal cortices. Regional hypometabolism correlated with delirium severity and performance on neuropsychological testing. DISCUSSION In patients with acute illness but without clinical dementia, delirium is accompanied by regional cerebral hypometabolism. While some hypometabolic regions may represent preclinical Alzheimer's disease (AD), thalamic hypometabolism is atypical of AD and consistent with the clinical features that are unique to delirium.
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Affiliation(s)
- Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | | | - Eva A Wegner
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.,Department of Nuclear Medicine and PET, Prince of Wales Hospital, Sydney, Australia
| | - Vincent Oxenham
- Department of Psychology, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Neurology, Royal North Shore Hospital, Sydney, Australia
| | - Jacqueline Close
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.,Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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10
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Kim N, Kim TH, Oh JK, Lim J, Lee KU, Kim SW. Analysis of the Incidence and Risk Factors of Postoperative Delirium in Patients With Degenerative Cervical Myelopathy. Neurospine 2022; 19:323-333. [PMID: 35577342 PMCID: PMC9260543 DOI: 10.14245/ns.2142778.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 04/20/2022] [Indexed: 11/19/2022] Open
Abstract
Objective The purpose of this study is to analyze various risk factors that can cause postoperative delirium (POD) in degenerative cervical myelopathy (DCM) patients, which may affect normal recovery and outcomes after surgery, and to help deal with them in advance and to take a medical approach.
Methods A total of 148 patients aged 60 years or older who underwent laminoplasty or anterior cervical discectomy and fusion (ACDF) for DCM from 2008 to 2015 were included in this study. Incidence and multiple risk factors for development of POD were analyzed.
Results POD occurred in 24 patients (16.2%). Among the 148 patients, 78 received laminoplasty, of whom 19 patients (24%) experienced delirium; the other 70 patients underwent ACDF, of whom 5 patients (7.1%) experienced delirium. History of Parkinson disease (odds ratio [OR], 178.242; p = 0.015), potassium level (OR, 3.764; p = 0.031), and surgical approach of laminoplasty over ACDF (OR, 8.538; p = 0.008) were found to be significant risk factors in a multivariate analysis. Age (OR, 1.056; p = 0.04) and potassium level (OR, 3.217; p = 0.04) were significant risk factors in the laminoplasty group.
Conclusion The findings of this study suggest that the incidence and risk factors for POD may vary in patients with DCM. It is necessary to understand multiple factors that affect the development of POD.
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Affiliation(s)
- Namhoo Kim
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Tae-Hwan Kim
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jae Keun Oh
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jeongsup Lim
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kang Uk Lee
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Seok Woo Kim
- Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
- Corresponding Author Seok Woo Kim Spine Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22 Gwanpyeong-ro 170beon-gil, Dongann-gu, Anyang 14068, Korea
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11
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Huang HW, Zhang XK, Li HY, Wang YG, Jing B, Chen Y, Patel MB, Ely EW, Liu YO, Zhou JX, Lin S, Zhang GB. Higher Grade Glioma Increases the Risk of Postoperative Delirium: Deficient Brain Compensation Might Be a Potential Mechanism of Postoperative Delirium. Front Aging Neurosci 2022; 14:822984. [PMID: 35493935 PMCID: PMC9045131 DOI: 10.3389/fnagi.2022.822984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The brain compensation mechanism in postoperative delirium (POD) has not been reported. We uncovered the mechanism by exploring the association between POD and glioma grades, and the relationship between preoperative brain structural and functional compensation with POD in patients with frontal glioma. Methods A total of 335 adult patients with glioma were included. The multivariable analysis examined the association between tumor grade and POD. Then, 20 patients with left frontal lobe glioma who had presurgical structural and functional MRI data and Montreal Cognitive Assessment (MoCA) in this cohort were analyzed. We measured the gray matter volume (GMV) and functional connectivity (FC) in patients with (n = 8) and without (n = 12) POD and healthy controls (HCs, n = 29) to detect the correlation between the structural and functional alteration and POD. Results The incidence of POD was 37.3%. Multivariable regression revealed that high-grade glioma had approximately six times the odds of POD. Neuroimaging data showed that compared with HC, the patients with left frontal lobe glioma showed significantly increased GMV of the right dorsal lateral prefrontal cortex (DLPFC) in the non-POD group and decreased GMV of right DLPFC in the POD group, and the POD group exhibited significantly decreased FC of right DLPFC, and the non-POD group showed the increasing tendency. Partial correlation analysis showed that GMV in contralesional DLPFC were positively correlated with preoperative neurocognition, and the GMV and FC in contralesional DLPFC were negatively correlated with POD. Conclusions Our findings suggested that insufficient compensation for injured brain regions involving cognition might be more vulnerable to suffering from POD.
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Affiliation(s)
- Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiao-Kang Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Hao-Yi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Yong-Gang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Bin Jing
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - You Chen
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, United States
- Department of Electrical Engineering & Computer Science, Vanderbilt University, Nashville, TN, United States
| | - Mayur B. Patel
- Section of Surgical Sciences, Department of Surgery and Neurosurgery, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
- Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ya-Ou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Jian-Xin Zhou,
| | - Song Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
- *Correspondence: Jian-Xin Zhou,
| | - Guo-Bin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, Center of Brain Tumor, China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
- *Correspondence: Jian-Xin Zhou,
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12
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Post-Operative Cognitive Impairment: A Cognitive Epidemiology Perspective. J Intell 2022; 10:jintelligence10010018. [PMID: 35324574 PMCID: PMC8949407 DOI: 10.3390/jintelligence10010018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
Cognitive epidemiology investigates cognitive predictors of health and disease outcomes. Post-operative cognitive impairment is a common complication of surgery but has been neglected as a health outcome in cognitive epidemiology research. This is despite the fact that knowledge of cognitive predictors of post-operative cognitive impairment can be utilized for risk stratification, informed decision-making (in elective surgery), and personalized care of patients during the postoperative period. In this narrative review, the current literature on cognitive predictors of post-operative cognitive impairment and gaps therein are summarized.
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13
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Pendlebury ST, Thomson RJ, Welch SJV, Kuker W, Rothwell PM. Utility of white matter disease and atrophy on routinely acquired brain imaging for prediction of long-term delirium risk: population-based cohort study. Age Ageing 2022; 51:6427231. [PMID: 34793588 PMCID: PMC8753040 DOI: 10.1093/ageing/afab200] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/04/2021] [Indexed: 12/15/2022] Open
Abstract
Background brain imaging done as part of standard care may have clinical utility beyond its immediate indication. Using delirium as an exemplar, we determined the predictive value of baseline brain imaging variables [white matter changes (WMC) and atrophy] for delirium risk on long-term follow-up after transient ischemic attack (TIA)/stroke in a population-based cohort study. Methods surviving TIA/stroke participants in the Oxford Vascular Study (OXVASC) were assessed prospectively for delirium during all hospitalisations over 6 months (2013–14). Using logistic regression, independent associations were determined between baseline OXVASC computed tomography or magnetic resonance brain imaging measures of WMC and cerebral atrophy (none/mild versus moderate/severe) and delirium adjusted for age, sex, baseline stroke severity, depression, illness severity and pre-admission cognition. Results among 1,565 TIA/stroke survivors with 194 hospital admissions (158 patients, mean/standard deviation age at admission = 79.2/11.5 years), delirium occurred in 59 (37%). WMC and atrophy on baseline imaging were associated with delirium [odds ratio (OR) = 3.41, 1.21–5.85, P = 0.001 and OR = 2.50, 1.23–5.08, P = 0.01 (unadjusted) and OR = 2.67, 1.21–5.85, P = 0.02 and OR = 2.18, 1.00–4.73, P = 0.05 (adjusted age and sex)]. Associations were strengthened when analyses were restricted to patients hospitalised within 5 years of baseline brain imaging [OR = 6.04, 2.39–15.24, P < 0.0001 and OR = 4.64, 1.46–14.82, P = 0.009 (unadjusted)] but only WMC remained significant after adjustment for all covariates including pre-admission cognition (OR = 4.83, 1.29–18.13, P = 0.02 for Mini-Mental State Examination and OR = 5.15, 1.26–21.09, P = 0.02 for Montreal Cognitive Assessment). Conclusions WMC and atrophy on brain imaging done up to 5 years earlier predicted delirium and may have clinical utility in risk stratification. Associations with WMC but not atrophy were independent of pre-admission cognitive impairment.
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Affiliation(s)
- Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Departments of General (Internal) Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ross J Thomson
- Department of Cardiology, Royal Free Hospital, London, UK
| | - Sarah J V Welch
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
| | - Wilhelm Kuker
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
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14
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Arias F, Alegria M, Kind AJ, Jones RN, Travison TG, Marcantonio ER, Schmitt EM, Fong TG, Inouye SK. A framework of social determinants of health for delirium tailored to older adults. J Am Geriatr Soc 2022; 70:235-242. [PMID: 34693992 PMCID: PMC8742772 DOI: 10.1111/jgs.17465] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/15/2021] [Accepted: 08/21/2021] [Indexed: 01/03/2023]
Abstract
Delirium is a debilitating medical condition that disproportionately affects hospitalized older adults and is associated with adverse health outcomes, increased mortality, and high medical costs. Efforts to understand delirium risk in hospitalized older adults have focused on examining medical comorbidities, pre-existing cognitive deficits, and other clinical and demographic factors present in the period proximate to the hospitalization. The contribution of social determinants of health (SDOH), including social circumstances, environmental characteristics, and early-life exposures, referred as the social exposome, to delirium risk is poorly understood. Increased knowledge about the influence of SDOH will offer a more comprehensive understanding of factors that may increase vulnerability to delirium and poor outcomes. Clinically, these efforts can guide the development and implementation of holistic preventive strategies to improve clinical outcomes. We propose a SDOH framework for delirium adapted for older adults. We provide the definition, description, and rationale for the domains and variables in our proposed model.
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Affiliation(s)
- Franchesca Arias
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA,Harvard Medical School, Boston, MA
| | - Margarita Alegria
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA,Department of Medicine and Psychiatry, Harvard Medical School, Boston, MA
| | - Amy J. Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI,Madison VA Geriatrics Research Education and Clinical Center (GRECC), Middleton VA Hospital, Madison, WI
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University, Warren Alpert Medical School, Providence, RI
| | - Thomas G. Travison
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA,Harvard Medical School, Boston, MA,Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA,Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eva M. Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA
| | - Tamara G. Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA,Harvard Medical School, Boston, MA
| | - Sharon K. Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA,Harvard Medical School, Boston, MA,Department of Medicine and Psychiatry, Harvard Medical School, Boston, MA
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15
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Abstract
An aging-related reduction in the brain's functional reserve may explain why delirium is more frequent in the elderly than in younger people insofar as the reserve becomes inadequate to cover the metabolic requirements that are critically increased by stressors. The aim of this paper is to review the normal aging-related changes that theoretically compromise complex mental activities, neuronal and synaptic densities, and the neurocomputational flexibility of the functional reserve. A pivotal factor is diminished connectivity, which is substantially due to the loss of synapses and should specifically affect association systems and cholinergic fibres in delirious patients. However, micro-angiopathy with impaired blood flow autoregulation, increased blood/brain barrier permeability, changes in cerebrospinal fluid dynamics, weakened mitochondrial performance, and a pro-inflammatory involution of the immune system may also jointly affect neurons and their synaptic assets, and even cause the progression of delirium to dementia regardless of the presence of co-existing plaques, tangles, or other pathological markers. On the other hand, the developmental growth in functional reserve during childhood and adolescence makes the brain increasingly resistant to delirium, and residual reserve can allow the elderly to recover. These data support the view that functional reserve is the variable that confronts stressors and governs the risk and intensity of and recovery from delirium. Although people of any age are at risk of delirium, the elderly are at greater risk because aging and age-dependent structural changes inevitably affect the brain's functional reserve.
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16
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Nitchingham A, Caplan GA. Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia. Neuropsychiatr Dis Treat 2021; 17:1341-1352. [PMID: 33981143 PMCID: PMC8107052 DOI: 10.2147/ndt.s247957] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/18/2021] [Indexed: 12/18/2022] Open
Abstract
Delirium occurring in a patient with preexisting dementia is referred to as delirium superimposed on dementia (DSD). DSD commonly occurs in older hospitalized patients and is associated with worse outcomes, including higher rates of mortality and institutionalization, compared to inpatients with delirium or dementia alone. This narrative review summarizes the screening, diagnosis, management, and pathophysiology of DSD and concludes by highlighting opportunities for future research. Studies were identified via Medline and PsycINFO keyword search, and handsearching reference lists. Conceptually, DSD could be considered an "acute exacerbation" of dementia precipitated by a noxious insult akin to an acute exacerbation of heart failure or acute on chronic renal failure. However, unlike other organ systems, there are no established biomarkers for delirium, so DSD is diagnosed and monitored clinically. Because cognitive dysfunction is common to both delirium and dementia, the diagnosis of DSD can be challenging. Inattention, altered levels of arousal, and motor dysfunction may help distinguish DSD from dementia alone. An informant history suggestive of an acute change in cognition or alertness should be investigated and managed as delirium until proven otherwise. The key management principles include prevention, identifying and treating the underlying precipitant(s), implementing multicomponent interventions to create an ideal environment for brain recovery, preventing complications, managing distress, and monitoring for resolution. Informing and involving family members or caregivers throughout the patient journey are essential because there is significant prognostic uncertainty, including the risk of persistent cognitive and functional decline following DSD and relapse. Furthermore, informal carers can provide significant assistance in management. Emerging evidence demonstrates that increased exposure to delirium is associated with neuronal injury and worse cognitive outcomes although the mechanisms through which this occurs remain unclear. Given the clinical overlap between delirium and dementia, studying shared pathophysiological pathways may uncover diagnostic tests and is an essential step in therapeutic innovation.
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Affiliation(s)
- Anita Nitchingham
- The Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Aged Care, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Gideon A Caplan
- The Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Aged Care, Prince of Wales Hospital, Sydney, NSW, Australia
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17
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Kant IMJ, de Bresser J, van Montfort SJT, Mutsaerts HJMM, Witkamp TD, Buijsrogge M, Spies C, Hendrikse J, Slooter AJC. Preoperative brain MRI features and occurrence of postoperative delirium. J Psychosom Res 2021; 140:110301. [PMID: 33260072 DOI: 10.1016/j.jpsychores.2020.110301] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 10/18/2020] [Accepted: 11/12/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Delirium is a frequent complication after surgery with important negative outcomes for affected patients and society. However, it is still largely unknown why some patients have a predisposition for delirium and others not. To increase our understanding of the neural substrate of postoperative delirium, we studied the association between preoperative brain MRI features and the occurrence of delirium after major surgery. METHODS A group of 413 patients without dementia (Mean 72 years, SD: 5) was included in a prospective observational two-center study design. The study was conducted at Charité Universitätsmedizin (Berlin, Germany) and the University Medical Center Utrecht (Utrecht, The Netherlands). We measured preoperative brain volumes (total brain, gray matter, white matter), white matter hyperintensity volume and shape, brain infarcts and cerebral perfusion, and used logistic regression analysis adjusted for age, sex, intracranial volume, study center and type of surgery. RESULTS Postoperative delirium was present in a total of 70 patients (17%). Preoperative cortical brain infarcts increased the risk of postoperative delirium, although this did not reach statistical significance (OR (95%CI): 1.63 (0.84-3.18). Furthermore, we found a trend for an association of a more complex shape of white matter hyperintensities with occurrence of postoperative delirium (OR (95%CI): 0.97 (0.95-1.00)). Preoperative brain volumes, white matter hyperintensity volume, and cerebral perfusion were not associated with occurrence of postoperative delirium. CONCLUSION Our study suggests that patients with preoperative cortical brain infarcts and those with a more complex white matter hyperintensity shape may have a predisposition for developing delirium after major surgery.
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Affiliation(s)
- Ilse M J Kant
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands; Department of Radiology and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Simone J T van Montfort
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
| | - Henri J M M Mutsaerts
- Department of Radiology and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
| | - Theo D Witkamp
- Department of Radiology and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands
| | - Marc Buijsrogge
- Department of Cardiothoracic Surgery, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM,CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Jeroen Hendrikse
- Department of Radiology and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, UMC Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, the Netherlands.
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Rosgen BK, Krewulak KD, Stelfox HT, Ely EW, Davidson JE, Fiest KM. The association of delirium severity with patient and health system outcomes in hospitalised patients: a systematic review. Age Ageing 2020; 49:549-557. [PMID: 32342978 PMCID: PMC7331098 DOI: 10.1093/ageing/afaa053] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 01/23/2020] [Accepted: 03/13/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND delirium is an acute state of confusion that affects >20% of hospitalised patients. Recent literature indicates that more severe delirium may lead to worse patient outcomes and health system outcomes, such as increased mortality, cognitive impairment and length of stay (LOS). METHODS using systematic review methodology, we summarised associations between delirium severity and patient or health system outcomes in hospitalised adults. We searched MEDLINE, EMBASE, PsycINFO, CINAHL and Scopus databases with no restrictions, from inception to 25 October 2018. We included original observational research conducted in hospitalised adults that reported on associations between delirium severity and patient or health system outcomes. Quality of included articles was assessed using the Newcastle-Ottawa Scale. The level of evidence was quantified based on the consistency of findings and quality of studies reporting on each outcome. RESULTS we included 20 articles evaluating associations that reported: mortality (n = 11), cognitive ability (n = 3), functional ability (n = 3), patient distress (n = 1), quality of life (n = 1), hospital LOS (n = 4), intensive care unit (ICU) LOS (n = 2) and discharge home (n = 2). There was strong-level evidence that delirium severity was associated with increased ICU LOS and a lower proportion of patients discharged home. There was inconclusive evidence for associations between delirium severity and mortality, hospital LOS, functional ability, cognitive ability, patient distress and quality of life. CONCLUSION delirium severity is associated with increased ICU LOS and a lower proportion of patients discharged home. Delirium severity may be a useful adjunct to existing delirium screening to determine the burden to health care system resources.
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Affiliation(s)
- Brianna K Rosgen
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - E Wesley Ely
- Department of Internal Medicine, Center for Health Services Research and Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, and the Tennessee Valley VA GRECC, Nashville, TN, USA
| | | | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
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19
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Scicutella A. The pharmacotherapeutic management of postoperative delirium: an expert update. Expert Opin Pharmacother 2020; 21:905-916. [PMID: 32156151 DOI: 10.1080/14656566.2020.1738388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Postoperative delirium is a common sequela in older adults in the peri-operative period leading to poor outcomes with a complex pathophysiology which has led to a variety of different pharmacologic agents employed in attempts to prevent and treat this syndrome. No pharmacologic agent has been approved to treat this disorder, but this review discusses the pharmacologic strategies which have been tried based on the hypotheses of the causation of the syndrome including neurotransmitter imbalance, inflammation, and oxidative stress. AREAS COVERED Systematic reviews and meta-analyses of randomized clinical trials (RCTs) were included via search of electronic databases specifically for the terms postoperative delirium and pharmacologic treatments. With this approach, the recurrent topics of analgesia and sedation, antipsychotics, acetylcholinesterase inhibitors (AchE-Is), inflammation, and melatonin were emphasized and provided the outline for this review. EXPERT OPINION Research evidence does not support any particular agent in any of the pharmacologic classes reviewed. However, there is some potential benefit with dexmedetomidine, melatonin, and the monitoring of anesthetic agents all of which need further clinical trials to validate these conclusions. Exploration of ways to improve studies and the application of novel pharmacologic agents may offer future benefit.
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Affiliation(s)
- Angela Scicutella
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell , Hempstead, NY, USA.,Psychiatry, SUNY Health Science Center at Brooklyn - Behavioral Health , Brooklyn, NY, USA
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20
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Kapoor MC. Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 2: Cognitive dysfunction after critical illness; potential contributors in surgery and intensive care; pathogenesis; and therapies to prevent/treat perioperative neurological dysfunction. Ann Card Anaesth 2020; 23:391-400. [PMID: 33109793 PMCID: PMC7879886 DOI: 10.4103/aca.aca_139_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Severe cognitive decline and cognitive dysfunction has been attributed to patient's stay in the cardiovascular intensive care unit. Prolonged mechanical ventilation, long duration of stay, sedation protocols, and sleep deprivation contribute to patients developing neurocognitive disorder after intensive care admission and it is associated with poor clinical outcomes. Trauma of surgery, stress of critical care, and administration of anaesthesia evoke a systemic inflammatory response and trigger neuroinflammation and oxidative stress. Anaesthetic agents modulate the function of the GABA receptors. The persistence of these effects in the postoperative period promotes development of cognitive dysfunction. A number of drugs are under investigation to restrict or prevent this cognitive decline.
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Affiliation(s)
- Mukul C Kapoor
- Department of Anaesthesia, Max Smart Super Specialty Hospital, Saket, Delhi, India
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21
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Rengel KF, Hayhurst CJ, Pandharipande PP, Hughes CG. Long-term Cognitive and Functional Impairments After Critical Illness. Anesth Analg 2019; 128:772-780. [DOI: 10.1213/ane.0000000000004066] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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22
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Abstract
Cognitive complications are common after surgery in the elderly, and with an increased number of elderly patients undergoing surgery, a potential impact of anaesthesia and surgery on long term cognition, and especially dementia would be concerning. The question whether anaesthesia and surgery in itself induce structural changes in the brain and thereby cognitive deterioration, or reveal a preexisting cognitive impairment remains unresolved. Several studies show an increased risk of reversible cognitive impairment after surgery in the elderly, but the risk of inducing dementia remains speculative. Further studies are needed to elucidate this potential association. Meanwhile, elderly frail patients need to be closely followed including preoperative cognitive screening, since they are at increased risk of cognitive deterioration after surgery and discharge.
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Affiliation(s)
- Jacob Steinmetz
- University of Copenhagen, Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark.
| | - Lars Simon Rasmussen
- University of Copenhagen, Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
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23
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24
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Huang C, Mårtensson J, Gögenur I, Asghar MS. Exploring Postoperative Cognitive Dysfunction and Delirium in Noncardiac Surgery Using MRI: A Systematic Review. Neural Plast 2018; 2018:1281657. [PMID: 29743884 PMCID: PMC5878869 DOI: 10.1155/2018/1281657] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/09/2018] [Indexed: 12/25/2022] Open
Abstract
Surgical patients are at high risk of developing postoperative cognitive dysfunction (POCD) and postoperative delirium (POD). POCD and POD are associated with increased morbidity and mortality and worsening functional outcomes leading to severe socioeconomic consequences for the patient and the society in general. Magnetic resonance imaging (MRI) offers a unique opportunity to study the anatomy and function of the brain. MRI thus plays an important role in elucidating the neuronal component of POCD and POD. Our aim has been to systematically gather MRI findings that are related to POCD and POD. Systematic searches were conducted in PubMed, EMBASE, and PsycINFO: MRI studies investigating patients with POCD as identified by perioperative cognitive testing or patients with delirium identified postoperatively by the Confusion Assessment Method. A total of ten eligible papers were included with a total of 269 surgical patients, 36 patient controls, and 55 healthy controls who all underwent MRI examination. These studies suggested that reduction of thalamic and hippocampal volumes and reduction of cerebral blood flow may be associated with POCD, while presurgery/preexisting and postoperative white matter pathology may be associated with POD. However, the evidence from these studies is rather weak. Future MRI studies are warranted to verify the current findings.
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Affiliation(s)
- Chenxi Huang
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Copenhagen University Hospital, Køge, Denmark
| | | | - Ismail Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Copenhagen University Hospital, Køge, Denmark
| | - Mohammad Sohail Asghar
- Department of Neuroanaesthesia and Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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25
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Latronico N, Minelli C, Eikermann M. Prediction of long-term outcome subtypes in ARDS: first steps towards personalised medicine in critical care. Thorax 2017; 72:1067-1068. [PMID: 28988218 DOI: 10.1136/thoraxjnl-2017-210775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Department of Anesthesia, Critical Care and Emergency, Brescia University Hospital, Brescia, Italy
| | - Cosetta Minelli
- Population Health and Occupational Disease, National Heart and Lung Institute, Imperial College London, London, UK
| | - Matthias Eikermann
- Department of Anesthesia, Critical and Pain Medicine, Beth Israel Deconness Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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