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Gaba A, Li P, Zheng X, Gao C, Cai R, Hu K, Gao L. Associations Between Depression Symptom Burden and Delirium Risk: A Prospective Cohort Study. Innov Aging 2024; 8:igae029. [PMID: 38660114 PMCID: PMC11041407 DOI: 10.1093/geroni/igae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Indexed: 04/26/2024] Open
Abstract
Background and Objectives Delirium and depression are prevalent in aging. There is considerable clinical overlap, including shared symptoms and comorbid conditions, including Alzheimer's disease, functional decline, and mortality. Despite this, the long-term relationship between depression and delirium remains unclear. This study assessed the associations of depression symptom burden and its trajectory with delirium risk in a 12-year prospective study of older hospitalized individuals. Research Design and Methods A total of 319 141 UK Biobank participants between 2006 and 2010 (mean age 58 years [range 37-74, SD = 8], 54% women) reported frequency (0-3) of 4 depressive symptoms (mood, disinterest, tenseness, or lethargy) in the preceding 2 weeks prior to initial assessment visit and aggregated into a depressive symptom burden score (0-12). New-onset delirium was obtained from hospitalization records during 12 years of median follow-up. 40 451 (mean age 57 ± 8; range 40-74 years) had repeat assessment on average 8 years after their first visit. Cox proportional hazard models examined whether depression symptom burden and trajectory predicted incident delirium. Results A total of 5 753 (15 per 1 000) newly developed delirium during follow-up. Increased risk for delirium was seen for mild (aggregated scores 1-2, hazards ratio, HR = 1.16, [95% confidence interval (CI): 1.08-1.25], p < .001), modest (scores 3-5, 1.30 [CI: 1.19-1.43], p < .001), and severe (scores ≥ 5, 1.38 [CI: 1.24-1.55], p < .001) depressive symptoms, versus none in the fully adjusted model. These findings were independent of the number of hospitalizations and consistent across settings (eg, surgical, medical, or critical care) and specialty (eg, neuropsychiatric, cardiorespiratory, or other). Worsening depression symptoms (≥1 point increase), compared to no change/improved score, were associated with an additional 39% increased risk (1.39 [1.03-1.88], p = .03) independent of baseline depression burden. The association was strongest in those over 65 years at baseline (p for interaction <.001). Discussion and Implications Depression symptom burden and worsening trajectory predicted delirium risk during hospitalization. Increased awareness of subclinical depression symptoms may aid delirium prevention.
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Affiliation(s)
- Arlen Gaba
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Peng Li
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Xi Zheng
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Chenlu Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruixue Cai
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kun Hu
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Lei Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Fislage M, Feinkohl I, Borchers F, Heinrich M, Pischon T, Veldhuijzen DS, Slooter AJ, Spies CD, Winterer G, Zacharias N. Trail making test B in postoperative delirium: a replication study. BJA OPEN 2023; 8:100239. [PMID: 37954892 PMCID: PMC10633257 DOI: 10.1016/j.bjao.2023.100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/28/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
Background The Trail Making Test B (TMT-B) is indicative of cognitive flexibility and several other cognitive domains. Previous studies suggest that it might be associated with the risk of developing postoperative delirium, but evidence is limited and conflicting. We therefore aimed to replicate the association of preoperative TMT-B results with postoperative delirium. Methods We included older adults (≥65 yr) scheduled for major surgery and without signs of dementia to participate in this binational two-centre longitudinal observational cohort study. Presurgical TMT-B scores were obtained. Delirium was assessed twice daily using validated instruments. Logistic regression was applied and the area under the receiver operating characteristic curve calculated to determine the predictive performance of TMT-B. We subsequently included covariates used in previous studies for consecutive sensitivity analyses. We further analysed the impact of outliers, missing or impaired data. Results Data from 841 patients were included and of those, 151 (18%) developed postoperative delirium. TMT-B scores were statistically significantly associated with the incidence of postoperative delirium {odds ratio per 10-s increment 1.06 (95% confidence interval [CI] 1.02-1.09), P=0.001}. The area under the receiver operating characteristic curve was 0.60 ([95% CI 0.55-0.64], P<0.001). The association persisted after removing 21 outliers (1.07 [95% CI 1.03-1.07], P<0.001). Impaired or missing TMT-B data (n=88) were also associated with postoperative delirium (odds ratio 2.74 [95% CI 1.71-4.35], P<0.001). Conclusions The TMT-B was associated with postoperative delirium, but its predictive performance as a stand-alone test was low. The TMT-B alone is not suitable to predict delirium in a clinical setting. Clinical trial registration NCT02265263. (https://clinicaltrials.gov/ct2/show/results/NCT02265263).
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Affiliation(s)
- Marinus Fislage
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Department of Neurology, National Taiwan University Hospital, Taipei, China
| | - Insa Feinkohl
- Witten/Herdecke University, Faculty of Health/School of Medicine, Witten, Germany
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research Group, Berlin, Germany
| | - Friedrich Borchers
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Maria Heinrich
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Pischon
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research Group, Berlin, Germany
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Biobank Technology Platform, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Core Facility Biobank, Berlin, Germany
| | - Dieuwke S. Veldhuijzen
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition, Leiden, the Netherlands
| | - Arjen J.C. Slooter
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Intensive Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Claudia D. Spies
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Georg Winterer
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
| | - Norman Zacharias
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
| | - BioCog Consortium
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Witten/Herdecke University, Faculty of Health/School of Medicine, Witten, Germany
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research Group, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Biobank Technology Platform, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Core Facility Biobank, Berlin, Germany
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition, Leiden, the Netherlands
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Intensive Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
- Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
- Department of Neurology, National Taiwan University Hospital, Taipei, China
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Olotu C, Lebherz L, Ascone L, Scherwath A, Kühn S, Härter M, Kiefmann R. Cognitive Deficits in Executive and Language Functions Predict Postoperative Delirium. J Cardiothorac Vasc Anesth 2023; 37:2552-2560. [PMID: 37778949 DOI: 10.1053/j.jvca.2023.08.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/18/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES Postoperative delirium (POD) remains the most common complication in older adults, with cognitive impairment being the main risk factor. Patients with mild cognitive impairment, in particular, have much to lose from delirium; despite this, their cognitive impairment might be clinically overlooked. Understanding which cognitive domains are particularly predictive in this regard may improve the sensitivity of preoperative testing and allow for a more targeted application of resource-intensive measures to prevent delirium in the perioperative period. The authors conducted this study with the aim of identifying the most indicative cognitive domains. DESIGN A secondary analysis of a randomized controlled trial. SETTING At a single center, the University Medical Centre Hamburg in Hamburg, Germany. PARTICIPANTS Patients ≥60 years without major neurocognitive disorders (dementia, Mini-Mental State Examination score ≤23) scheduled for cardiovascular surgery. MEASUREMENTS AND MAIN RESULTS Preoperative neuropsychologic testing and delirium screening were performed twice daily until postoperative day 5. A multiple logistic regression model was applied to determine the predictive ability of test performances for the development of delirium. RESULTS A total of 541 patients were included in the analysis; the delirium rate was 15.6%. After controlling for confounders, only low performance within the Trail Making Test B/A (odds ratio [OR] = 1.32; 95% CI: 1.05-1.66) and letter fluency (OR = 0.66; 95% CI: 0.45-0.96) predicted a particularly high risk for delirium development. The discriminative ability of the final multiple logistic regression model to predict POD had an area under the curve of 0.786. CONCLUSIONS Impairment in the cognitive domains of executive function and language skills associated with memory, inhibition, and access speed seem to be particularly associated with the development of delirium after surgery in adults ≥65 years of age without apparent preoperative neurocognitive impairment.
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Affiliation(s)
- Cynthia Olotu
- Department of Anaesthesiology, University Medical Center Hamburg, Hamburg, Germany.
| | - Lisa Lebherz
- Institute of Medical Psychology, University Medical Center Hamburg, Hamburg, Germany
| | - Leonie Ascone
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg, Hamburg, Germany
| | - Angela Scherwath
- Institute of Medical Psychology, University Medical Center Hamburg, Hamburg, Germany; Department of Stem Cell Transplantation, University Medical Center Hamburg, Hamburg, Germany
| | - Simone Kühn
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg, Hamburg, Germany
| | - Martin Härter
- Institute of Medical Psychology, University Medical Center Hamburg, Hamburg, Germany
| | - Rainer Kiefmann
- Department of Anaesthesiology, University Medical Center Hamburg, Hamburg, Germany; Anesthesia Department, Rotkreuzklinikum Munich, Munich, Germany
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Li J, Wang J, Yang M, Wang G, Xu P. The relationship between major depression and delirium: A two-sample Mendelian randomization analysis. J Affect Disord 2023; 338:69-73. [PMID: 37244544 DOI: 10.1016/j.jad.2023.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/08/2023] [Accepted: 05/15/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Major depression (MD) is a well-recognized risk factor for delirium. However, observational studies cannot provide direct evidence of causality between MD and delirium. METHODS This study explored the genetic causal association between MD and delirium using two-sample Mendelian randomization (MR). Genome-wide association study (GWAS) summary data for MD were obtained from the UK Biobank. GWAS summary data for delirium were obtained from the FinnGen Consortium. Inverse-variance weighted (IVW), MR Egger, weighted median, simple mode, and weighted mode were used to perform the MR analysis. In addition, the Cochrane's Q test was used to detect heterogeneity in the MR results. Horizontal pleiotropy was detected using the MR-Egger intercept test and MR pleiotropy residual sum and outliers (MR-PRESSO) test. Leave-one-out analysis was used to investigate the sensitivity of this association. RESULTS The IVW method showed that MD was an independent risk factor for delirium (P = 0.013). Horizontal pleiotropy was unlikely to bias causality (P > 0.05), and no evidence of heterogeneity was found between the genetic variants (P > 0.05). Finally, a leave-one-out test showed that this association was stable and robust. LIMITATIONS All participants included in the GWAS were of European ancestry. Due to database limitations, the MR analysis did not conduct stratified analyses for different countries, ethnicities, or age groups. CONCLUSION We conducted a two-sample MR analysis and found the evidence of genetic causal association between MD and delirium.
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Affiliation(s)
- Jing Li
- Department of Anesthesiology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710054, China
| | - Jiachen Wang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710054, China
| | - Mingyi Yang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710054, China
| | - Gang Wang
- Institute of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi 710054, China
| | - Peng Xu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710054, China.
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Cipriani MC, Pais C, Savoia V, Falsiroli C, Bellieni A, Cingolani A, Fantoni M, Chieffo DPR, Sani G, Landi F, Landi G, Liperoti R. Association between Older Age and Psychiatric Symptoms in a Population of Hospitalized Patients with COVID-19. J Pers Med 2023; 13:973. [PMID: 37373962 DOI: 10.3390/jpm13060973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Increased rates of anxiety and depression have been reported for older adults during the COVID-19 pandemic. However, little is known regarding the onset of mental health morbidity during the acute phase of the disease and the role of age as potential independent risk factor for psychiatric symptoms. The cross-sectional association between older age and psychiatric symptoms has been estimated in a sample of 130 patients hospitalized for COVID-19 during the first and second wave of the pandemic. Compared to younger patients, those who were 70 years of age or older resulted at a higher risk of psychiatric symptoms measured on the Brief Psychiatric Symptoms Rating Scale (BPRS) (adjusted (adj.) odds ratio (OR) 2.36, 95% confidence interval (CI) 1.05-5.30) and delirium (adj. OR 5.24, 95% CI 1.63-16.8)). No association was found between older age and depressive symptoms or anxiety. Age was associated with psychiatric symptoms independently of gender, marital status, history of psychiatric illness, severity of disease and cardiovascular morbidity. Older adults appear at high risk of developing psychiatric symptoms related to COVID-19 disease during hospital stay. Multidisciplinary preventive and therapeutic interventions should be implemented to reduce the risk of psychiatric morbidity and related adverse health care outcomes among older hospital inpatients with COVID-19.
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Affiliation(s)
- Maria Camilla Cipriani
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
- School of Medicine, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Cristina Pais
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
| | - Vezio Savoia
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
| | - Cinzia Falsiroli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
| | - Andrea Bellieni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
| | - Antonella Cingolani
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
- School of Medicine, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Massimo Fantoni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
- School of Medicine, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Daniela Pia Rosaria Chieffo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
- School of Medicine, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Gabriele Sani
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
- School of Medicine, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Francesco Landi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
- School of Medicine, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Giovanni Landi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
| | - Rosa Liperoti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo F. Vito 1, 00168 Rome, Italy
- School of Medicine, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
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Fernández-Jiménez E, Muñoz-Sanjose A, Mediavilla R, Martínez-Alés G, Louzao II, Andreo J, Cebolla S, Bravo-Ortiz MF, Bayón C. Prospective Analysis Between Neutrophil-to-Lymphocyte Ratio on Admission and Development of Delirium Among Older Hospitalized Patients With COVID-19. Front Aging Neurosci 2021; 13:764334. [PMID: 34887744 PMCID: PMC8650500 DOI: 10.3389/fnagi.2021.764334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022] Open
Abstract
Objective: To examine any prospective association between neutrophil-to-lymphocyte ratio (NLR) at hospital admission and subsequent delirium in older COVID-19 hospitalized patients comparing by sex and age groups. Methods: The sample consisted of 1,785 COVID-19 adult inpatients (minimum sample size required of 635 participants) admitted to a public general hospital in Madrid (Spain) between March 16th and April 15th, 2020. Variables were obtained from electronic health records. Binary logistic regression models were performed between baseline NLR and delirium adjusting for age, sex, medical comorbidity, current illness severity, serious mental illness history and use of chloroquine and dexamethasone. An NLR cut-off was identified, and stratified analyses were performed by age and sex. Also, another biomarker was tested as an exposure (the systemic immune-inflammation index -SII). Results: 55.3% of the patients were men, with a mean age of 66.8 years. Roughly 13% of the patients had delirium during hospitalization. NLR on admission predicted subsequent delirium development (adjusted OR = 1.02, 95 percent CI: 1.00-1.04, p = 0.024). Patients between 69 and 80 years with NLR values > 6.3 presented a twofold increased risk for delirium (p = 0.004). There were no sex differences in the association between baseline NLR and delirium (p > 0.05) nor SII predicted delirium development (p = 0.341). Conclusion: NLR is a good predictor of delirium during hospitalization, especially among older adults, independently of medical comorbidity, illness severity, and other covariates. Routine blood tests on admission might provide valuable information to guide the decision-making process to be followed with these especially vulnerable patients.
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Affiliation(s)
- Eduardo Fernández-Jiménez
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Ainoa Muñoz-Sanjose
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Roberto Mediavilla
- Department of Psychiatry, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBERSAM), Madrid, Spain
| | - Gonzalo Martínez-Alés
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBERSAM), Madrid, Spain.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Iker I Louzao
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain
| | - Jorge Andreo
- Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Susana Cebolla
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - María-Fe Bravo-Ortiz
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Psychiatry, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBERSAM), Madrid, Spain
| | - Carmen Bayón
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Psychiatry, Universidad Autónoma de Madrid (UAM), Madrid, Spain
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