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Geng J, Zhang Y, Chen H, Shi H, Wu Z, Chen J, Luo F. Associations between Alzheimer's disease biomarkers and postoperative delirium or cognitive dysfunction: A meta-analysis and trial sequential analysis of prospective clinical trials. Eur J Anaesthesiol 2024; 41:234-244. [PMID: 38038408 PMCID: PMC10842675 DOI: 10.1097/eja.0000000000001933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND The relationship between Alzheimer's disease biomarkers and postoperative complications, such as postoperative delirium (POD) and postoperative cognitive dysfunction (POCD), remains a subject of ongoing debate. OBJECTIVE This meta-analysis aimed to determine whether there is an association between perioperative Alzheimer's disease biomarkers and postoperative complications. DESIGN We conducted a meta-analysis of observational clinical studies that explored the correlation between Alzheimer's disease biomarkers and POD or POCD in patients who have undergone surgery, following PRISMA guidelines. The protocol was previously published (INPLASY: INPLASY202350001). DATA SOURCES A comprehensive search was conducted across PubMed, Embase, Web of Science, and Cochrane databases until March 2023. ELIGIBILITY CRITERIA Surgical patients aged at least 18 years, studies focusing on POD or POCD, research involving Alzheimer's disease biomarkers, including Aβ or tau in blood or cerebrospinal fluid (CSF), and availability of the full text. RESULTS Our meta-analysis included 15 studies: six focusing on POD and nine on POCD. The findings revealed a negative correlation between preoperative CSF β-amyloid 42 (Aβ42) levels and the onset of POD [mean difference -86.1, 95% confidence interval (CI), -114.15 to -58.05, I2 : 47%]; this association was strongly supported by trial sequential analysis (TSA). A similar negative correlation was discerned between preoperative CSF Aβ42 levels and the incidence of POCD (-165.01, 95% CI, -261.48 to -68.53, I2 : 95%). The TSA also provided robust evidence for this finding; however, the evidence remains insufficient to confirm a relationship between other Alzheimer's disease biomarkers [β-amyloid 40 (Aβ40), total tau (T-tau), phosphorylated tau (P-tau), and Aβ42/T-tau ratio] and POD or POCD. CONCLUSION The study results indicate a negative correlation between preoperative CSF Aβ42 levels and the occurrence of both POD and POCD. Future investigations are warranted to identify the predictive cutoff value of preoperative CSF Aβ42 for POD and POCD.
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Affiliation(s)
- Jun Geng
- From the Department of Anaesthesiology, Jiangyin Hospital Affiliated to Nantong University, Wuxi City, Jiangsu Province, China (JG, YZ, HC, HH, ZW, JC) and Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Gongshu District, Hangzhou City, Zhejiang Province, China (FL)
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Newman MF, Berger M, Mathew JP. Postoperative Cognitive Dysfunction and Delirium. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Hu XY, Liu H, Zhao X, Sun X, Zhou J, Gao X, Guan HL, Zhou Y, Zhao Q, Han Y, Cao JL. Automated machine learning-based model predicts postoperative delirium using readily extractable perioperative collected electronic data. CNS Neurosci Ther 2021; 28:608-618. [PMID: 34792857 PMCID: PMC8928919 DOI: 10.1111/cns.13758] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 10/13/2021] [Accepted: 10/16/2021] [Indexed: 12/19/2022] Open
Abstract
Objective Postoperative delirium (POD) is a common postoperative complication that is relevant to poor outcomes. Therefore, it is critical to find effective methods to identify patients with high risk of POD rapidly. Creating a fully automated score based on an automated machine‐learning algorithm may be a method to predict the incidence of POD quickly. Materials and methods This is the secondary analysis of an observational study, including 531 surgical patients who underwent general anesthesia. The least absolute shrinkage and selection operator (LASSO) was used to screen essential features associated with POD. Finally, eight features (age, intraoperative blood loss, anesthesia duration, extubation time, intensive care unit [ICU] admission, mini‐mental state examination score [MMSE], Charlson comorbidity index [CCI], postoperative neutrophil‐to‐lymphocyte ratio [NLR]) were used to established models. Four models, logistic regression, random forest, extreme gradient boosted trees, and support vector machines, were built in a training set (70% of participants) and evaluated in the remaining testing sample (30% of participants). Multivariate logistic regression analysis was used to explore independent risk factors for POD further. Results Model 1 (logistic regression model) was found to outperform other classifier models in testing data (area under the curve [AUC] of 80.44%, 95% confidence interval [CI] 72.24%–88.64%) and achieve the lowest Brier Score as well. These variables including age (OR = 1.054, 95%CI: 1.017~1.093), extubation time (OR = 1.027, 95%CI: 1.012~1.044), ICU admission (OR = 2.238, 95%CI: 1.313~3.793), MMSE (OR = 0.929, 95%CI: 0.876~0.984), CCI (OR = 1.197, 95%CI: 1.038~1.384), and postoperative NLR (OR = 1.029, 95%CI: 1.002~1.057) were independent risk factors for POD in this study. Conclusions We have built and validated a high‐performing algorithm to demonstrate the extent to which patient risk changes of POD during the perioperative period, thus leading to a rational therapeutic choice.
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Affiliation(s)
- Xiao-Yi Hu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - He Liu
- Department of Anesthesiology, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou Central Hospital, Zhejiang Province, Huzhou City, China
| | - Xue Zhao
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Xun Sun
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Jian Zhou
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Xing Gao
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Department of Anesthesiology, Changzhou First People's Hospital, Changzhou, Jiangsu, China
| | - Hui-Lian Guan
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Department of Anesthesiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Yang Zhou
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Qiu Zhao
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
| | - Yuan Han
- Department of Anesthesiology, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Jun-Li Cao
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Jiangsu Province, Xuzhou City, China.,Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Jiangsu Province, Xuzhou City, China
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4
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Guan HL, Liu H, Hu XY, Abdul M, Dai MS, Gao X, Chen XF, Zhou Y, Sun X, Zhou J, Li X, Zhao Q, Zhang QQ, Wang J, Han Y, Cao JL. Urinary albumin creatinine ratio associated with postoperative delirium in elderly patients undergoing elective non-cardiac surgery: A prospective observational study. CNS Neurosci Ther 2021; 28:521-530. [PMID: 34415671 PMCID: PMC8928921 DOI: 10.1111/cns.13717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction The blood‐brain barrier (BBB) disruption contributes to postoperative delirium, but cost‐effective and non‐invasive assessment of its permeability is not practicable in the clinical settings. Urine albumin to creatinine ratio (UACR), reflecting systemic vascular endothelial dysfunction, may be a prognostic and predictive factor associated with postoperative delirium. The aim was to analyze the relationship between UACR and postoperative delirium in elderly patients undergoing elective non‐cardiac surgery. Materials and methods Through stratified random sampling, a cohort of 408 individuals aged 60 years and older scheduled for elective non‐cardiac surgery were included between February and August 2019 in the single‐center, prospective, observational study. The presence of delirium was assessed using the Confusion Assessment Method (CAM) or Confusion Assessment Method for the ICU (CAM‐ICU) on the day of surgery, at 2 h after the surgery ending time and on the first 3 consecutive days with repeated twice‐daily, with at least 6‐h intervals between assessments. Urine samples were collected on one day before surgery, and 1st day and 3rd day after surgery. The primary outcome was the presence of postoperative delirium, and association of the level of UACR with postoperative delirium was evaluated with unadjusted/adjusted analyses and multivariable logistic regression. Results Postoperative delirium was observed in 26.75% (107 of 400) of patients within 3 days post‐surgery. UACR‐Pre (OR, 1.30; 95% CI, 1.14–1.49, p < 0.001), UACR‐POD1 (OR, 1.20; 95% CI, 1.13–1.27, p < 0.001), and UACR‐POD3 (OR, 1.14; 95% CI, 1.08–1.20, p < 0.001) between the delirium and non‐delirium groups show a significant difference, even after adjusting for age, education levels, and other factors. Conclusion As the marker of endothelial dysfunction, the high perioperative UACR value may be linked to the postoperative delirium in elderly patients undergoing elective non‐cardiac surgery.
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Affiliation(s)
- Hui-Lian Guan
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu City, China
| | - He Liu
- Department of Anesthesiology, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou Central Hospital, Huzhou City, China
| | - Xiao-Yi Hu
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Mannan Abdul
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Ming-Sheng Dai
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xing Gao
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xue-Fen Chen
- School of Public Health, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yang Zhou
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xun Sun
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Jian Zhou
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xiang Li
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Qiu Zhao
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Qian-Qian Zhang
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Jun Wang
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Yuan Han
- Department of Anesthesiology, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Jun-Li Cao
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
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Zeng W, Zhang C, Long Q, Li Y. Dexmedetomidine Alleviates LPS-Induced Neuronal Dysfunction by Modulating the AKT/GSK-3β/CRMP-2 Pathway in Hippocampal Neurons. Neuropsychiatr Dis Treat 2021; 17:671-680. [PMID: 33727816 PMCID: PMC7955869 DOI: 10.2147/ndt.s297365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/05/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Dexmedetomidine, an α2-adrenergic receptor agonist, mitigates cognitive dysfunction in elderly patients after surgery with general anesthesia. However, the underlying mechanism by which dexmedetomidine reduces cognitive dysfunction remains to be fully elucidated. The aim of this study was to investigate the effects of dexmedetomidine on lipopolysaccharide (LPS)-induced neuronal dysfunction in cultured hippocampal neurons. METHODS LPS, in the presence and absence of dexmedetomidine, was applied to cultured hippocampal neurons to mimic post-surgical inflammation. Neuronal morphology, including neurite outgrowth and synaptic transmission, was observed, and miniature excitatory postsynaptic currents were recorded by electrophysiological patch-clamp. RESULTS LPS significantly impaired neurite outgrowth in hippocampal neurons in a concentration- and time-dependent manner, which was reversed by dexmedetomidine treatment. Electrophysiological patch-clamp results showed that LPS induced synaptic transmission dysfunction, which was restored after dexmedetomidine addition. Furthermore, Western blotting assays showed that LPS suppressed the AKT/GSK-3β/CRMP-2 signaling pathway and dexmedetomidine countered the inhibitory effect of LPS by re-activating this pathway. CONCLUSION In general, dexmedetomidine protected against the effects of LPS-induced hippocampal neuron damage, including neurite outgrowth and synaptic transmission. Overall, dexmedetomidine modulated the AKT/GSK-3β/CRMP-2 signaling pathway to alleviate LPS-induced neurological dysfunction.
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Affiliation(s)
- Wei Zeng
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong, People's Republic of China.,Department of Anesthesiology, Affiliated Boai Hospital of Zhongshan, Southern Medical University, Zhongshan, 528400, Guangdong, People's Republic of China
| | - Chunyuan Zhang
- Department of Anesthesiology, Affiliated Boai Hospital of Zhongshan, Southern Medical University, Zhongshan, 528400, Guangdong, People's Republic of China
| | - Qingshan Long
- Department of Neurosurgery, Huizhou Third People's Hospital, Guangzhou Medical University, Huizhou, 516002, Guangdong, People's Republic of China
| | - Yalan Li
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong, People's Republic of China
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Kapoor MC. Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 1: The problem; nomenclature; delirium and postoperative neurocognitive disorder; and the role of cardiac surgery and anesthesia. Ann Card Anaesth 2020; 23:383-390. [PMID: 33109792 PMCID: PMC7879912 DOI: 10.4103/aca.aca_138_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The association with cardiac surgery with cognitive decline was first reported in the 1960s after the introduction of coronary artery surgery. The incidence in cognitive decline was thought to be more after cardiac surgery, especially with the use of the cardiopulmonary bypass. Anesthesia and surgery are both associated with cognitive decline but many other factors appear to contribute its genesis. On-pump surgery, microembolization during manipulation of the heart and great vessels, temperature changes, pH changes, and altered cerebral perfusion, during cardiac surgery, have all been blamed for this. Postoperative cognitive decline is associated with poor clinical outcomes and higher mortality. Several studies have been conducted in the last decade to determine the genesis of this malady. Current evidence is absolving cardiac surgery and anesthesia to be the primary causes per se of cognitive dysfunction.
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Affiliation(s)
- Mukul C Kapoor
- Department of Anaesthesia, Max Smart Super Specialty Hospital, Saket, Delhi, India
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7
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Hambrecht-Wiedbusch VS, LaTendresse KA, Avidan MS, Nelson AG, Phyle M, Ajluni RE, Mashour GA. General Anesthesia Does Not Have Persistent Effects on Attention in Rodents. Front Behav Neurosci 2019; 13:76. [PMID: 31057375 PMCID: PMC6478802 DOI: 10.3389/fnbeh.2019.00076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/28/2019] [Indexed: 12/30/2022] Open
Abstract
Background: Studies in animals have shown that general anesthesia can cause persistent spatial memory impairment, but the influence of anesthetics on other cognitive functions is unclear. This study tested whether exposure to general anesthesia without surgery caused a persistent deficit in attention in rodents. Methods: To evaluate whether anesthesia has persistent effects on attention, rats were randomized to three groups. Group A was exposed for 2 h to isoflurane anesthesia, and tested the following seven days for attentional deficits. Group B was used as a control and received room air before attentional testing. Since there is some evidence that a subanesthetic dose of ketamine can improve cognition and reduce disorders of attention after surgery, rats in group C were exposed to isoflurane anesthesia in combination with a ketamine injection before cognitive assessment. Attention was measured in rats using the 5-Choice Serial Reaction Time Task, for which animals were trained to respond with a nose poke on a touchscreen to a brief, unpredictable visual stimulus in one of five possible grid locations to receive a food reward. Attention was analyzed as % accuracy, % omission, and premature responses. Results: Evaluating acute attention by comparing baseline values with data from the day after intervention did not reveal any differences in attentional measurements. No significant differences were seen in % accuracy, % omission, and premature responses for the three groups tested for 7 consecutive days. Conclusion: These data in healthy rodents suggest that general anesthesia without surgery has no persistent effect on attention and the addition of ketamine does not alter the outcome.
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Affiliation(s)
- Viviane S Hambrecht-Wiedbusch
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States.,Center for Consciousness Science, University of Michigan, Ann Arbor, MI, United States
| | | | - Michael S Avidan
- Department of Anesthesiology, Washington University, St. Louis, MO, United States
| | - Amanda G Nelson
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Margaret Phyle
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Romi E Ajluni
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - George A Mashour
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States.,Center for Consciousness Science, University of Michigan, Ann Arbor, MI, United States
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Berger M, Terrando N, Smith SK, Browndyke JN, Newman MF, Mathew JP. Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology 2018; 129:829-851. [PMID: 29621031 PMCID: PMC6148379 DOI: 10.1097/aln.0000000000002194] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.
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Affiliation(s)
- Miles Berger
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Niccolò Terrando
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - S. Kendall Smith
- Critical Care Fellow, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jeffrey N. Browndyke
- Assistant Professor, Division of Geriatric Behavioral Health, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Mark F. Newman
- Merel H. Harmel Professor of Anesthesiology, and President of the Private Diagnostic Clinic, Duke University Medical Center, Durham, NC
| | - Joseph P. Mathew
- Jerry Reves, MD Professor and Chair, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Mutch WAC, El-Gabalawy RM, Graham MR. Postoperative Delirium, Learning, and Anesthetic Neurotoxicity: Some Perspectives and Directions. Front Neurol 2018; 9:177. [PMID: 29615969 PMCID: PMC5869196 DOI: 10.3389/fneur.2018.00177] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 03/07/2018] [Indexed: 01/04/2023] Open
Abstract
Evidence of anesthetic neurotoxicity is unequivocal when studied in animal models. These findings have translated poorly to the clinical domain when equated to postoperative delirium (POD) in adults and postoperative cognitive dysfunction (POCD) in either children or the elderly. In this perspective, we examine various reasons for the differences between animal modeling of neurotoxicity and the clinical situation of POD and POCD and make suggestions as to potential directions for ongoing research. We hypothesize that the animal anesthetic neurotoxicity models are limited, in part, due to failed scaling correction of physiological time. We posit that important insights into POCD in children and adults may be gleaned from studies in adults examining alterations in perioperative management designed to limit POD. In this way, POD may be more useful as the proxy for POCD rather than neuronal dropout or behavioral abnormalities that have been used in animal models but which may not be proxies for the human condition. We argue that it is time to move beyond animal models of neurotoxicity to directly examine these problems in well-conducted clinical trials with comprehensive preoperative neuropsychometric and psychiatric testing, high fidelity intraoperative monitoring of physiological parameters during the anesthetic course and postoperative assessment of subthreshold and full classification of POD. In this manner, we can “model ourselves” to better understand these important and poorly understood conditions.
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Affiliation(s)
- W Alan C Mutch
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Renée M El-Gabalawy
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Clinical Health Psychology, University of Manitoba, Winnipeg, MB, Canada
| | - M Ruth Graham
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
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10
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Deiner S, Luo X, Lin HM, Sessler DI, Saager L, Sieber FE, Lee HB, Sano M, Jankowski C, Bergese SD, Candiotti K, Flaherty JH, Arora H, Shander A, Rock P. Intraoperative Infusion of Dexmedetomidine for Prevention of Postoperative Delirium and Cognitive Dysfunction in Elderly Patients Undergoing Major Elective Noncardiac Surgery: A Randomized Clinical Trial. JAMA Surg 2017; 152:e171505. [PMID: 28593326 DOI: 10.1001/jamasurg.2017.1505] [Citation(s) in RCA: 200] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Postoperative delirium occurs in 10% to 60% of elderly patients having major surgery and is associated with longer hospital stays, increased hospital costs, and 1-year mortality. Emerging literature suggests that dexmedetomidine sedation in critical care units is associated with reduced incidence of delirium. However, intraoperative use of dexmedetomidine for prevention of delirium has not been well studied. Objective To evaluate whether an intraoperative infusion of dexmedetomidine reduces postoperative delirium. Design, Setting, and Participants This study was a multicenter, double-blind, randomized, placebo-controlled trial that randomly assigned patients to dexmedetomidine or saline placebo infused during surgery and for 2 hours in the recovery room. Patients were assessed daily for postoperative delirium (primary outcome) and secondarily for postoperative cognitive decline. Participants were elderly (>68 years) patients undergoing major elective noncardiac surgery. The study dates were February 2008 to May 2014. Interventions Dexmedetomidine infusion (0.5 µg/kg/h) during surgery and up to 2 hours in the recovery room. Main Outcomes and Measures The primary hypothesis tested was that intraoperative dexmedetomidine administration would reduce postoperative delirium. Secondarily, the study examined the correlation between dexmedetomidine use and postoperative cognitive change. Results In total, 404 patients were randomized; 390 completed in-hospital delirium assessments (median [interquartile range] age, 74.0 [71.0-78.0] years; 51.3% [200 of 390] female). There was no difference in postoperative delirium between the dexmedetomidine and placebo groups (12.2% [23 of 189] vs 11.4% [23 of 201], P = .94). After adjustment for age and educational level, there was no difference in the postoperative cognitive performance between treatment groups at 3 months and 6 months. Adverse events were comparably distributed in the treatment groups. Conclusions and Relevance Intraoperative dexmedetomidine does not prevent postoperative delirium. The reduction in delirium previously demonstrated in numerous surgical intensive care unit studies was not observed, which underscores the importance of timing when administering the drug to prevent delirium. Trial Registration clinicaltrials.gov Identifier NCT00561678.
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Affiliation(s)
- Stacie Deiner
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Xiaodong Luo
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hung-Mo Lin
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daniel I Sessler
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio.,Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Leif Saager
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Frederick E Sieber
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Hochang B Lee
- Department of Psychiatry, Yale University, New Haven, Connecticut
| | - Mary Sano
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | | | - Christopher Jankowski
- Department of Anesthesiology and Preoperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sergio D Bergese
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Keith Candiotti
- Department of Anesthesiology, Universityof Miami, Miami, Florida
| | - Joseph H Flaherty
- Department of Internal Medicine, Geriatrics Division, St Louis University Hospital, St Louis, Missouri
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Aryeh Shander
- Department of Anesthesiology, Englewood Hospital and Medical Center, Englewood, New Jersey
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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11
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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34:192-214. [DOI: 10.1097/eja.0000000000000594] [Citation(s) in RCA: 491] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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12
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Tronson NC, Collette KM. (Putative) sex differences in neuroimmune modulation of memory. J Neurosci Res 2017; 95:472-486. [PMID: 27870428 PMCID: PMC5120654 DOI: 10.1002/jnr.23921] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 08/11/2016] [Accepted: 08/22/2016] [Indexed: 12/11/2022]
Abstract
The neuroimmune system is significantly sexually dimorphic, with sex differences evident in the number and activation states of microglia, in the activation of astrocytes, and in cytokine release and function. Neuroimmune cells and signaling are now recognized as critical for many neural functions throughout the life span, including synaptic plasticity and memory function. Here we address the question of how cytokines, astrocytes, and microglia contribute to memory, and specifically how neuroimmune modulation of memory differentially affects males and females. Understanding sex differences in both normal memory processes and dysregulation of memory in psychiatric and neurological disorders is critical for developing treatment and preventive strategies for memory disorders that are effective for both men and women. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Natalie C Tronson
- Department of Psychology, University of Michigan, Ann Arbor, Michigan
| | - Katie M Collette
- Department of Psychology, University of Michigan, Ann Arbor, Michigan
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13
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Androsova G, Krause R, Winterer G, Schneider R. Biomarkers of postoperative delirium and cognitive dysfunction. Front Aging Neurosci 2015; 7:112. [PMID: 26106326 PMCID: PMC4460425 DOI: 10.3389/fnagi.2015.00112] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/28/2015] [Indexed: 01/19/2023] Open
Abstract
Elderly surgical patients frequently experience postoperative delirium (POD) and the subsequent development of postoperative cognitive dysfunction (POCD). Clinical features include deterioration in cognition, disturbance in attention and reduced awareness of the environment and result in higher morbidity, mortality and greater utilization of social financial assistance. The aging Western societies can expect an increase in the incidence of POD and POCD. The underlying pathophysiological mechanisms have been studied on the molecular level albeit with unsatisfying small research efforts given their societal burden. Here, we review the known physiological and immunological changes and genetic risk factors, identify candidates for further studies and integrate the information into a draft network for exploration on a systems level. The pathogenesis of these postoperative cognitive impairments is multifactorial; application of integrated systems biology has the potential to reconstruct the underlying network of molecular mechanisms and help in the identification of prognostic and diagnostic biomarkers.
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Affiliation(s)
- Ganna Androsova
- Bioinformatics core, Luxembourg Centre for Systems Biomedicine (LCSB), University of LuxembourgBelvaux, Luxembourg
| | - Roland Krause
- Bioinformatics core, Luxembourg Centre for Systems Biomedicine (LCSB), University of LuxembourgBelvaux, Luxembourg
| | - Georg Winterer
- Experimental and Clinical Research Center (ECRC), Department of Anesthesiology and Operative Intensive Care Medicine, Charité University Medicine BerlinBerlin, Germany
| | - Reinhard Schneider
- Bioinformatics core, Luxembourg Centre for Systems Biomedicine (LCSB), University of LuxembourgBelvaux, Luxembourg
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14
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Hudetz JA, Patterson KM, Iqbal Z, Gandhi SD, Pagel PS. Remote Ischemic Preconditioning Prevents Deterioration of Short-Term Postoperative Cognitive Function After Cardiac Surgery Using Cardiopulmonary Bypass: Results of a Pilot Investigation. J Cardiothorac Vasc Anesth 2015; 29:382-8. [DOI: 10.1053/j.jvca.2014.07.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Indexed: 11/11/2022]
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15
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[Potential cognitive alterations after treatment of benign prostate syndrome. Investigations on transurethral electroresection and 180 W GreenLight XPS laser therapy]. Z Gerontol Geriatr 2014; 48:446-51. [PMID: 25287677 DOI: 10.1007/s00391-014-0819-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/05/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The study was carried out to detect possible changes in cognition after transurethral resection of the prostate (TURP) and 180 W GreenLight-XPS laser treatment of the prostate. METHODS Cognitive capacity was assessed by the mini-mental state examination (MMSE) and the clock test preoperatively and on postoperative day 2 in addition to documentation of clinical parameters, such as patient age, prostate size, duration of surgery, comorbidities, co-medications and alterations in hemoglobin (Hb) and sodium concentrations. RESULTS Patients treated with TURP (n = 88) and 180 W GreenLight-XPS laser treatment of the prostate (n = 114) were comparable regarding age, prostate size and duration of surgery. Baseline characteristics of the patients treated by laser showed an increased potential for postoperative cognitive changes with an average of 3.8 comorbidities (TURP 3.11, p = 0.005) and were using an average of 6.79 multiple medications (TURP 5.24, p < 0.001); however, neither the MMSE nor the clock test demonstrated a decrease in the average postoperative score (difference between postoperative and preoperative MMSE + 0.6 ± 1.6 for 180 W GreenLight-XPS laser treatment and + 0.6 ± 1.6 for TURP, p = 0.944; difference postoperative and preoperative clock test + 0.43 ± 1.44 for 180 W GreenLight-XPS laser treatment and 0.13 ± 1.17 for TURP, p = 0.097). Neither postoperative hemoglobin nor sodium concentrations, as safety relevant parameters, demonstrated clinically relevant changes. The differences between the surgical procedures were not statistically significant. DISCUSSION Neither 180 W GreenLight-XPS laser treatment of the prostate nor TURP demonstrated changes in cognition by comparing the preoperative MMSE and the clock test scores. In this study, the baseline characteristics of laser-treated patients showed a higher number of comorbidities and a higher use of medications, particular those with anticholinergic potency; therefore, 180 W GreenLight-XPS laser treatment of the prostate appears particularly safe for elderly patients.
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16
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Nadelson M, Sanders R, Avidan M. Perioperative cognitive trajectory in adults. Br J Anaesth 2014; 112:440-51. [DOI: 10.1093/bja/aet420] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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17
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Ettema R, Harten DV, Hoogerduijn J, Hoekstra T, Schuurmans M. Nurses Opinions Regarding Delirium Care in the Older General Hospital Population and in Older Cardiac Surgery Patients Specifically: A Multicentre Survey among Dutch Nurses. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ijcm.2014.521173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Krenk L, Rasmussen LS, Kehlet H. Delirium in the fast-track surgery setting. Best Pract Res Clin Anaesthesiol 2013; 26:345-53. [PMID: 23040285 DOI: 10.1016/j.bpa.2012.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 07/25/2012] [Indexed: 12/12/2022]
Abstract
Postoperative delirium (PD) and postoperative cognitive dysfunction (POCD) are two separate syndromes of cognitive decline after major surgery, especially in the elderly. Pathogenesis is multifactorial with some common risk factors, and to reduce the risk, a multimodal approach is necessary. The fast-track methodology is becoming a well-established perioperative care regime with possible preventive effects for postoperative cognitive decline, including reduced pain and use of opioids, and early mobilisation with early discharge (≤3 days) to preoperative environment after total hip/knee arthroplasty (THA/TKA). The fast-track set-up seems to be associated with a lower frequency of PD and early POCD after THA/TKA. Thus, in a series of 225 patients ≥60 years, no cases of PD were seen and the incidence of POCD was reduced by more than 50% at 1 week postoperatively compared to previous studies. In conclusion, the fast-track methodology may reduce the incidence of postoperative cognitive decline after surgery.
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Affiliation(s)
- Lene Krenk
- Rigshospitalet, Section of Surgical Pathophysiology, The Lundbeck Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen O, Denmark.
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19
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Saczynski JS, Marcantonio ER, Quach L, Fong TG, Gross A, Inouye SK, Jones RN. Cognitive trajectories after postoperative delirium. N Engl J Med 2012; 367:30-9. [PMID: 22762316 PMCID: PMC3433229 DOI: 10.1056/nejmoa1112923] [Citation(s) in RCA: 757] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is common after cardiac surgery and may be associated with long-term changes in cognitive function. We examined postoperative delirium and the cognitive trajectory during the first year after cardiac surgery. METHODS We enrolled 225 patients 60 years of age or older who were planning to undergo coronary-artery bypass grafting or valve replacement. Patients were assessed preoperatively, daily during hospitalization beginning on postoperative day 2, and at 1, 6, and 12 months after surgery. Cognitive function was assessed with the use of the Mini-Mental State Examination (MMSE; score range, 0 to 30, with lower scores indicating poorer performance). Delirium was diagnosed with the use of the Confusion Assessment Method. We examined performance on the MMSE in the first year after surgery, controlling for demographic characteristics, coexisting conditions, hospital, and surgery type. RESULTS The 103 participants (46%) in whom delirium developed postoperatively had lower preoperative mean MMSE scores than those in whom delirium did not develop (25.8 vs. 26.9, P<0.001). In adjusted models, those with delirium had a larger drop in cognitive function (as measured by the MMSE score) 2 days after surgery than did those without delirium (7.7 points vs. 2.1, P<0.001) and had significantly lower postoperative cognitive function than those without delirium, both at 1 month (mean MMSE score, 24.1 vs. 27.4; P<0.001) and at 1 year (25.2 vs. 27.2, P<0.001) after surgery. With adjustment for baseline differences, the between-group difference in mean MMSE scores was significant 30 days after surgery (P<0.001) but not at 6 or 12 months (P=0.056 for both). A higher percentage of patients with delirium than those without delirium had not returned to their preoperative baseline level at 6 months (40% vs. 24%, P=0.01), but the difference was not significant at 12 months (31% vs. 20%, P=0.055). CONCLUSIONS Delirium is associated with a significant decline in cognitive ability during the first year after cardiac surgery, with a trajectory characterized by an initial decline and prolonged impairment. (Funded by the Harvard Older Americans Independence Center and others.).
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Affiliation(s)
- Jane S Saczynski
- Division of Geriatric Medicine and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA 01605, USA.
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Hudetz JA, Iqbal Z, Gandhi SD, Patterson KM, Byrne AJ, Pagel PS. Postoperative Delirium and Short-term Cognitive Dysfunction Occur More Frequently in Patients Undergoing Valve Surgery With or Without Coronary Artery Bypass Graft Surgery Compared With Coronary Artery Bypass Graft Surgery Alone: Results of a Pilot Study. J Cardiothorac Vasc Anesth 2011; 25:811-6. [DOI: 10.1053/j.jvca.2010.05.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Indexed: 12/13/2022]
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Forrest CM, Mackay GM, Oxford L, Millar K, Darlington LG, Higgins MJ, Stone TW. Kynurenine metabolism predicts cognitive function in patients following cardiac bypass and thoracic surgery. J Neurochem 2011; 119:136-52. [DOI: 10.1111/j.1471-4159.2011.07414.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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