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Chen Z, Meng B, Li X, Lu B, Zhai X, Wang R, Chen J. Boston Naming Test as a Screening Tool for Early Postoperative Cognitive Dysfunction in Elderly Patients After Major Noncardiac Surgery. Am Surg 2024:31348241260274. [PMID: 38848748 DOI: 10.1177/00031348241260274] [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: 06/09/2024]
Abstract
PURPOSE The Boston naming test (BNT), as a simple, fast, and easily administered neuropsychological test, was demonstrated to be useful in detecting language function. In this study, BNT was investigated whether it could be a screening tool for early postoperative cognitive dysfunction (POCD). METHODS This prospective observational cohort study included 132 major noncardiac surgery patients and 81 nonsurgical controls. All participants underwent a mini-mental state examination (MMSE) and BNT 1 day before and 7 days after surgery. Early POCD was assessed by reliable change index and control group results. RESULTS Seven days after surgery, among 132 patients, POCD was detected in 30 (22.7%) patients (95% CI, 15.5%-30.0%) based on MMSE, and 45 (34.1%) patients (95% CI, 26.3%-41.9%) were found with postoperative language function decline based on BNT and MMSE. Agreement between the BNT spontaneous naming and MMSE total scoring was moderate (Kappa .523), and the sensitivity of BNT spontaneous naming for detecting early POCD was .767. Further analysis showed that areas under receiver operating characteristics curves (AUC) did not show statistically significant differences when BNT spontaneous naming (AUC .862) was compared with MMSE language functional subtests (AUC .889), or non-language functional subtests (AUC .933). CONCLUSION This study indicates the feasibility of implementing the BNT spontaneous naming test to screen early POCD in elderly patients after major noncardiac surgery.
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Affiliation(s)
- Zhang Chen
- Department of Anesthesiology, Ningbo No.2 Hospital, Haishu District, Ningbo, China
| | - Bo Meng
- Department of Anesthesiology, Ningbo No.2 Hospital, Haishu District, Ningbo, China
| | - Xiaoyu Li
- Department of Anesthesiology, Ningbo No.2 Hospital, Haishu District, Ningbo, China
| | - Bo Lu
- Department of Anesthesiology, Ningbo No.2 Hospital, Haishu District, Ningbo, China
| | - Xiaojie Zhai
- Department of Anesthesiology, Ningbo No.2 Hospital, Haishu District, Ningbo, China
| | - Ruichun Wang
- Department of Anesthesiology, Ningbo No.2 Hospital, Haishu District, Ningbo, China
| | - Junping Chen
- Department of Anesthesiology, Ningbo No.2 Hospital, Haishu District, Ningbo, China
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Abstract
Over 2.6 million adults over the age of 65 develop delirium each year in the United States (US). Delirium is associated with a significant increase in mortality and the US health care costs associated with delirium are estimated at over $164 billion annually. Despite the prevalence of the condition, the molecular pathophysiology of delirium remains unexplained, limiting the development of pharmacotherapies. Delirious patients can be identified by prominent impairments in attention and working memory (WM), two cognitive domains that localize to the dorsolateral prefrontal cortex (dlPFC). The dlPFC is also a key site for Alzheimer's disease (AD) pathology, and given the high risk of delirium in AD patients, suggests that efforts at understanding delirium might focus on the dlPFC as a final common endpoint for cognitive changes. Preclinical studies of the dlPFC reproduce many of the pharmacological observations made of delirious patients, including sensitivity to anticholinergics and an 'inverted U' pattern of dependence on monoaminergic input, with diminished performance outside a narrow range of signaling. Medications like guanfacine, which influence the dlPFC in the context of attention-deficit/hyperactivity disorder (ADHD), have emerged as therapies for delirium and motivate a detailed understanding of the influence of α-2 agonists on WM. In this review, I will discuss the neural circuitry and molecular mechanisms underlying WM and the function of the dlPFC. Localizing the cognitive deficits that are commonly seen in delirious patients may help identify new molecular targets for this highly prevalent disease.
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Affiliation(s)
- Kyle A. Lyman
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
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Arias F, Dufour AB, Jones RN, Alegria M, Fong TG, Inouye SK. Social determinants of health and incident postoperative delirium: Exploring key relationships in the SAGES study. J Am Geriatr Soc 2024; 72:369-381. [PMID: 37933703 PMCID: PMC10922227 DOI: 10.1111/jgs.18662] [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: 06/23/2023] [Revised: 09/27/2023] [Accepted: 10/01/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Examining the associations of social determinants of health (SDOH) with postoperative delirium in older adults will broaden our understanding of this potentially devastating condition. We explored the association between SDOH factors and incident postoperative delirium. METHODS A retrospective study of a prospective cohort of patients enrolled from June 18, 2010, to August 8, 2013, across two academic medical centers in Boston, Massachusetts. Overall, 560 older adults age ≥70 years undergoing major elective non-cardiac surgery were included in this analysis. Exposure variables included income, lack of private insurance, and neighborhood disadvantage. Our main outcome was incident postoperative delirium, measured using the Confusion Assessment Method long form. RESULTS Older age (odds ratio, OR: 1.01, 95% confidence interval, CI: 1.00, 1.02), income <20,000 a year (OR: 1.12, 95% CI: 1.00, 1.26), lack of private insurance (OR: 1.19, 95% CI: 1.04, 1.38), higher depressive symptomatology (OR: 1.02, 95% CI: 1.01, 1.04), and the Area Deprivation Index (OR: 1.02, 95% CI: 1.01, 1.04) were significantly associated with increased risk of postoperative delirium in bivariable analyses. In a multivariable model, explaining 27% of the variance in postoperative delirium, significant independent variables were older age (OR 1.01, 95% CI 1.00, 1.02), lack of private insurance (OR 1.18, 95% CI 1.02, 1.36), and depressive symptoms (OR 1.02, 95% CI 1.00, 1.03). Household income was no longer a significant independent predictor of delirium in the multivariable model (OR:1.02, 95% CI: 0.90, 1.15). The type of medical insurance significantly mediated the association between household income and incident delirium. CONCLUSIONS Lack of private insurance, a social determinant of health reflecting socioeconomic status, emerged as a novel and important independent risk factor for delirium. Future efforts should consider targeting SDOH factors to prevent postoperative delirium in older adults.
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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 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA 02131, USA
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL 32608, USA
| | - Alyssa B. Dufour
- Harvard Medical School, Boston, MA 02131, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02131, USA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University, Warren Alpert Medical School, Providence, RI 02912, USA
| | - Margarita Alegria
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA 02131, USA
- Department of Medicine and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02131, USA
| | - Tamara G. Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA 02131, USA
| | - Sharon K. Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA 02131, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02131, USA
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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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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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Ormseth CH, LaHue SC, Oldham MA, Josephson SA, Whitaker E, Douglas VC. Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review. JAMA Netw Open 2023; 6:e2249950. [PMID: 36607634 PMCID: PMC9856673 DOI: 10.1001/jamanetworkopen.2022.49950] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups. OBJECTIVE To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting. EVIDENCE REVIEW A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium. FINDINGS A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity. CONCLUSIONS AND RELEVANCE In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
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Affiliation(s)
- Cora H. Ormseth
- Department of Emergency Medicine, University of California, San Francisco
| | - Sara C. LaHue
- Department of Neurology, University of California, San Francisco
| | - Mark A. Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | | | - Evans Whitaker
- University of California, San Francisco, School of Medicine
| | - Vanja C. Douglas
- Department of Neurology, University of California, San Francisco
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Shiff HM, Arias F, Dufour AB, Carr D, Chen F, Gou Y, Jones R, Schmitt E, Travison TG, Kunicki ZJ, Okereke OI, Inouye SK. Paternal Occupation and Delirium Risk in Older Adults: A Potential Marker of Early-Life Exposures. Innov Aging 2022; 6:igac050. [PMID: 36128514 PMCID: PMC9478553 DOI: 10.1093/geroni/igac050] [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: 01/15/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Objectives
Delirium is a common disorder among older adults following hospitalization or major surgery. Whereas many studies examine the risk of proximate exposures and comorbidities, little is known about pathways linking childhood exposures to later-life delirium. In this study, we explored the association between paternal occupation and delirium risk.
Research Design and Methods
A prospective observational cohort study of 528 older adults undergoing elective surgery at two academic medical centers. Paternal occupation group (white collar vs. blue collar) served as our independent variable. Delirium incidence was assessed using the Confusion Assessment Method (CAM) supplemented by medical chart review. Delirium severity was measured using the peak CAM-Severity score (CAM-S Peak), the highest value of CAM-S observed throughout the hospital stay.
Results
Blue-collar paternal occupation was significantly associated with a higher rate of incident delirium (91/234, 39%) compared with white-collar paternal occupation (84/294, 29%), adjusted odds ratio OR (95% confidence interval [CI]) = 1.6 (1.1, 2.3). All analyses were adjusted for participant age, race, gender, and Charlson Comorbidity Index. Blue-collar paternal occupation was also associated with greater delirium severity, with a mean score (SD) of 4.4 (3.3), compared with white-collar paternal occupation with a mean score (SD) of 3.5 (2.8). Among participants reporting blue-collar paternal occupation, we observed an adjusted mean difference of 0.86 (95% CI = 0.4, 1.4) additional severity units.
Discussion and Implications
Blue-collar paternal occupation is associated with greater delirium incidence and severity, after adjustment for covariates. These findings support the application of a life-course framework to evaluate the risk of later-life delirium and delirium severity. Our results also demonstrate the importance of considering childhood exposures, which may be consequential even decades later.
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Affiliation(s)
- Haley M Shiff
- Department of Epidemiology, Harvard T. H. Chan School of Public Health , Boston, Massachusetts , USA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
| | - Franchesca Arias
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
- Harvard Medical School , Boston, Massachusetts , USA
| | - Alyssa B Dufour
- Harvard Medical School , Boston, Massachusetts , USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
| | - Deborah Carr
- Department of Sociology, Boston University , Boston, Massachusetts , USA
| | - Fan Chen
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
| | - Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
| | - Richard Jones
- Department of Psychiatry and Human Behavior, Brown University, Warren Alpert Medical School , Providence, Rhode Island , USA
| | - Eva Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
| | - Thomas G Travison
- Harvard Medical School , Boston, Massachusetts , USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
| | - Zachary J Kunicki
- Department of Psychiatry and Human Behavior, Brown University, Warren Alpert Medical School , Providence, Rhode Island , USA
| | - Olivia I Okereke
- Department of Epidemiology, Harvard T. H. Chan School of Public Health , Boston, Massachusetts , USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts , USA
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Boston, Massachusetts , USA
- Harvard Medical School , Boston, Massachusetts , USA
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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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Liu H, Cheng G, Xu YL, Fang Q, Ye L, Wang CH, Liu XS. Preoperative Status of Gut Microbiota Predicts Postoperative Delirium in Patients With Gastric Cancer. Front Psychiatry 2022; 13:852269. [PMID: 35308872 PMCID: PMC8929925 DOI: 10.3389/fpsyt.2022.852269] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/09/2022] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Post-operative delirium (POD) is a serious complication which occurs after surgery, especially in the elderly undergoing abdominal surgery. Increasing evidence has revealed an association between the gut microbiota and psychological disorders involving the "brain-gut" axis. However, the association between the pathogenesis of POD after abdominal surgery in aging and composition of the gut microbiota remains unclear. METHODS Forty patients (≥65 years old) who underwent abdominal surgery were included in the study. Twenty patients had POD, whereas 20 patients did not. POD was diagnosed and assessed using the confusion assessment method (CAM) during the postoperative period. Total DNA fractions were extracted from all fecal samples of patients. 16S rRNA sequencing was performed to determine the composition of the gut microbiota. The quality of the samples was determined by calculating the α- and β-diversities. RESULTS The α- and β-diversities indicated that the samples were eligible for detection and comparison. We observed multiple differentially abundant bacteria in patients with and without POD. Generally, Proteobacteria, Enterbacteriaceae, Escherichia shigella, Klebsiella, Ruminococcus, Roseburia, Blautia, Holdemanella, Anaerostipes, Burkholderiaceae, Peptococcus, Lactobacillus, and Dorea were abundant in the POD cohort, whereas Streptococcus equinus and Blautia hominis were abundant in the control cohort. The results of receiver operating characteristic (ROC) curve analysis showed that the area under the curve (AUC) of Escherichia shigella was 0.75. Phenotype prediction showed that the gut microbiota may influence POD by altering the tolerance to oxidative stress. CONCLUSION There were significant associations between the pathogenesis of POD and composition of the gut microbiota. Escherichia shigella are promising diagnostic bacterial species for predicting POD onset after abdominal surgery in elderly people. CLINICAL TRIAL REGISTRATION http://www.chictr.org.cn/index.aspx, Chinese Clinical Trial Registry ChiCTR200030131.
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Affiliation(s)
- Hu Liu
- Department of Anesthesiology, Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Gao Cheng
- Department of Anesthesiology, Fourth Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yuan-Ling Xu
- Department of Anesthesiology, Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Qi Fang
- Department of Anesthesiology, Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Lei Ye
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chun-Hui Wang
- Department of Anesthesiology, Fourth Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xue-Sheng Liu
- Department of Anesthesiology, Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
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Ghezzi ES, Ross TJ, Sharman R, Davis D, Boord MS, Thanabalan T, Thomas J, Keage HAD. The neuropsychological profile of delirium vulnerability: A systematic review and meta-analysis. Neurosci Biobehav Rev 2021; 132:248-259. [PMID: 34863781 DOI: 10.1016/j.neubiorev.2021.11.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 12/17/2022]
Abstract
Delirium is a common neurocognitive disorder in hospitalised older adults with substantial negative consequences. Impaired global cognition is a well-established delirium risk factor. However, poor performance on attention tests and higher intra-subject variability may be more sensitive delirium risk factors, given the disorder is characterised by a fluctuating course and attentional deficits. We systematically searched databases (Embase, PsycINFO, MEDLINE) and 44 studies satisfied inclusion criteria. Random-effects meta-analysis models showed poor performance in all cognitive domains except perception was significantly associated with incident delirium. Largest effects were for orientation (g=-1.20) and construction and motor performance (g=-0.60). These effects were no longer significant in the subgroup without pre-existing cognitive impairment, where executive functions and verbal functions and language skills were associated with incident delirium. A small, non-significant association between intra-subject variability and incident delirium was found (g=0.42). Cognitive domain specific tests may be quicker and more sensitive predictors of incident delirium. This pattern of neuropsychological findings supports the proposition that vulnerability for delirium manifests as a dysfunction of whole-brain information integration.
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Affiliation(s)
- Erica S Ghezzi
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia.
| | - Tyler J Ross
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Rhianna Sharman
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing Unit at UCL, London, United Kingdom
| | - Monique S Boord
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Thivina Thanabalan
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Jessica Thomas
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
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11
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Eschweiler GW, Czornik M, Herrmann ML, Knauer YP, Forkavets O, von Arnim CAF, Denkinger M, Küster O, Conzelmann L, Metz BR, Maurer C, Kentischer F, Deeken F, Sánchez A, Wagner S, Mennig E, Thomas C, Rapp MA. Presurgical Screening Improves Risk Prediction for Delirium in Elective Surgery of Older Patients: The PAWEL RISK Study. Front Aging Neurosci 2021; 13:679933. [PMID: 34385913 PMCID: PMC8353451 DOI: 10.3389/fnagi.2021.679933] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/17/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction: The number of elective surgeries for patients who are over 70 years of age is continuously growing. At the same time, postoperative delirium (POD) is common in older patients (5–60%) depending on predisposing risk factors, such as multimorbidity, cognitive impairment, neurodegenerative disorders and other dementing disorders, and precipitating factors, such as duration of surgery. Knowledge of individual risk profiles prior to elective surgery may help to identify patients at increased risk for development of POD. In this study, clinical and cognitive risk factors for POD were investigated in patients undergoing various elective cardiac and non-cardiac surgeries. Methods: The PAWEL study is a prospective, interventional trial on delirium prevention. At baseline, 880 inpatients at five surgical centers were recruited for sub-sample PAWEL-R. Multimodal assessments included clinical renal function, medication, American Society of Anesthesiologists (ASA) Physical Status Classification System, geriatric and cognitive assessments, which comprised the Montreal Cognitive Assessment Scale (MoCA), Trail-making Test, and Digit Span backward. Delirium incidence was monitored postoperatively by the Confusion Assessment Method (CAM) and a chart review for up to a week or until discharge. Multivariate regression models and Chi-square Automatic Interaction Detectors (CHAID) analyses were performed using delirium incidence as the primary outcome. Results: Eighteen risk factors were investigated in elective cardiovascular and orthopedic or general surgery. A total of 208 out of 880 patients (24%) developed POD. A global regression model that included all risk variables predicted delirium incidence with high accuracy (AUC = 0.81; 95% CI 0.77, 0.85). A simpler model (clinical and cognitive variables; model CLIN-COG) of 10 factors that only included surgery type, multimorbidity, renal failure, polypharmacy, ASA, cut-to-suture time, and cognition (MoCA, Digit Span backward, and preexisting dementia), however, exhibited similar predictive accuracy (AUC = 0.80; 95% CI 0.76, 0.84). Conclusion: The risk of developing POD can be estimated by preoperative assessments, such as ASA classification, expected cut-to-suture time, and short cognitive screenings. This rather efficient approach predicted POD risk over all types of surgery. Thus, a basic risk assessment including a cognitive screen can help to stratify patients at low, medium, or high POD risk to provide targeted prevention and/or management strategies for patients at risk.
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Affiliation(s)
- Gerhard W Eschweiler
- Geriatric Center, Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Manuel Czornik
- Geriatric Center, Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Matthias L Herrmann
- Geriatric Center, Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany.,Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Freiburg, Germany
| | - Yvonne P Knauer
- Geriatric Center, Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Oksana Forkavets
- Geriatric Center, Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Christine A F von Arnim
- Department of Neurology, University Hospital of Ulm, Ulm, Germany.,Division of Geriatrics, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Denkinger
- Institute for Geriatric Research, Agaplesion Bethesda Ulm and Ulm University, Ulm, Germany
| | - Olivia Küster
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
| | | | - Brigitte R Metz
- Geriatric Center and Department of Geriatric Medicine, ViDia Christian Clinics Karlsruhe, Karlsruhe, Germany
| | - Christoph Maurer
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Freiburg, Germany
| | - Felix Kentischer
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Freiburg, Germany
| | - Friederike Deeken
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Alba Sánchez
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Sören Wagner
- Department of Anesthesiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Eva Mennig
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Christine Thomas
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael A Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
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12
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Racine AM, Touroutoglou A, Abrantes T, Wong B, Fong TG, Cavallari M, Travison TG, Gou Y, Marcantonio ER, Alsop DC, Jones RN, Inouye SK, Dickerson BC. Older Patients with Alzheimer's Disease-Related Cortical Atrophy Who Develop Post-Operative Delirium May Be at Increased Risk of Long-Term Cognitive Decline After Surgery. J Alzheimers Dis 2021; 75:187-199. [PMID: 32250290 DOI: 10.3233/jad-190380] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Older surgical patients with Alzheimer's disease (AD) dementia and delirium are at increased risk for accelerated long-term cognitive decline. OBJECTIVE Investigate associations between a probabilistic marker of preclinical AD, delirium, and long-term cognitive decline. METHODS The Successful Aging after Elective Surgery cohort includes older adults (≥70 years) without dementia who underwent elective surgery. 140 patients underwent preoperative magnetic resonance imaging and had≥6 months cognitive follow-up. Cortical thickness was measured in 'AD-Signature' regions. Delirium was evaluated each postoperative day by the Confusion Assessment Method. Cognitive performance was assessed using a detailed neuropsychological battery at baseline; months 1, 2, and 6; and every 6 months thereafter until 36 months. Using either a General Cognitive Performance composite (GCP) or individual test scores as outcomes, we performed linear mixed effects models to examine main effects of AD-signature atrophy and the interaction of AD-signature atrophy and delirium on slopes of cognitive change from post-operative months 2-36. RESULTS Reduced baseline AD-signature cortical thickness was associated with greater 36-month cognitive decline in GCP (standardized beta coefficient, β = -0.030, 95% confidence interval [-0.060, -0.001]). Patients who developed delirium who also had thinner AD signature cortex showed greater decline on a verbal learning test (β = -0.100 [-0.192, -0.007]). CONCLUSION Patients with the greatest baseline AD-related cortical atrophy who develop delirium after elective surgery appear to experience the greatest long-term cognitive decline. Thus, atrophy suggestive of preclinical AD and the development of delirium may be high-risk indicators for long-term cognitive decline following surgery.
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Affiliation(s)
- Annie M Racine
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Alexandra Touroutoglou
- Harvard Medical School, Boston, MA, USA.,Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Tatiana Abrantes
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Bonnie Wong
- Harvard Medical School, Boston, MA, USA.,Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Tamara G Fong
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michele Cavallari
- Harvard Medical School, Boston, MA, USA.,Department of Radiology, Center for Neurological Imaging, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas G Travison
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Yun Gou
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Edward R Marcantonio
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David C Alsop
- Harvard Medical School, Boston, MA, USA.,Department of Radiology, Beth Israel Deaconess Medical Center, 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, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Bradford C Dickerson
- Harvard Medical School, Boston, MA, USA.,Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA, USA
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13
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Krishnan S, Brovman EY, Urman RD. Preoperative Cognitive Impairment as a Perioperative Risk Factor in Patients Undergoing Total Knee Arthroplasty. Geriatr Orthop Surg Rehabil 2021; 12:21514593211004533. [PMID: 35186420 PMCID: PMC8848037 DOI: 10.1177/21514593211004533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/02/2021] [Indexed: 12/21/2022] Open
Abstract
Background: The study assessed whether pre-existing cognitive impairment (CI) prior to elective total knee arthroplasty (TKA) is associated with worse postoperative outcomes such as delirium, in-hospital medical complications, 30-day mortality, hospital length of stay and non-home discharge. Methods: A retrospective database analysis from the NSQIP Geriatric Surgery Pilot Project was used. There was an initial cohort of 6350 patients undergoing elective TKA, 104 patients with CI were propensity score matched to 104 patients without CI. Results: Analysis demonstrated a significantly increased incidence of post-operative delirium (POD) in the cohort with pre-op CI (p = < .001), a worsened functional status (p = < .001) and increased nonhome discharge postoperatively compared to the group without CI (p = 0.029). Other post-operative outcomes included 30-day mortality of 0% in both groups, and low rate of complications such as infection (2.88% vs 0.96%), pneumonia (1.92% vs 0%), failure to wean (0.96% vs 0%), and reintubation (0.96% vs 0%). Some other differences between the CI group and non-CI group, although not statistically significant, included increased rate of transfusion (10.58% vs 6.73%), and sepsis (1.92% vs 0%). The length of stay was increased in the non-CI group (4.28% vs 2.32%, p = 0.122). Conclusion: CI in patients undergoing TKA is associated with an increased risk of POD, worsened postoperative functional status, and discharge to non-home facility.
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Affiliation(s)
- Sindhu Krishnan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ethan Y. Brovman
- Center for Perioperative Research, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Center for Perioperative Research, Brigham and Women’s Hospital, Boston, MA, USA
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14
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Susano MJ, Dias M, Seixas FS, Vide S, Grasfield R, Abelha FJ, Crosby G, Culley DJ, Amorim P. Association Among Preoperative Cognitive Performance, Regional Cerebral Oxygen Saturation, and Postoperative Delirium in Older Portuguese Patients. Anesth Analg 2021; 132:846-855. [PMID: 33002925 DOI: 10.1213/ane.0000000000005159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative delirium is common among older patients and preoperative identification of high-risk patients is widely recommended. The aim of this study was to assess whether preoperative cognitive performance using brief screening tools or regional cerebral oxygen saturation (Scto2) was associated with the development of postoperative delirium in older Portuguese patients undergoing elective surgery. METHODS Prospective observational cohort study where preoperative cognitive screening tools (Mini-Cog, Mini-Mental State Examination, verbal fluency) and Scto2 (INVOS 5100C; Medtronic, Ireland) were assessed in 238 patients ≥65 years old undergoing elective surgery between July 2017 and May 2019 at a tertiary academic center in Portugal. The primary outcome was postoperative delirium detected by the 3D-Confusion Assessment Method. Data were analyzed by univariate analysis and multivariable logistic regression. RESULTS Delirium was identified in 53 patients (22%); 162 patients (68%) had completed only 4 years of education. On multivariable analysis, probable cognitive impairment tested by the Mini-Cog (odds ratio [OR] = 1.57; 95% confidence interval [CI], 0.70-3.53; corrected P value >.999), by the Mini-Mental State Examination (OR = 2.75; 95% CI, 1.23-6.13; corrected P value = .052), and by the animal verbal fluency test (OR = 1.24; 95% CI, 0.49-3.16; corrected P value >.999) were not significantly associated with the development of postoperative delirium. In contrast, lower preoperative Scto2 (OR = 1.08; 95% CI, 1.02-1.14; corrected P value = .024 for each point decrease in Scto2) was associated with postoperative delirium. CONCLUSIONS We did not find enough evidence to suggest that poor preoperative cognitive performance was significantly associated with the development of postoperative delirium in an older Portuguese surgical population with an overall low level of formal education, but rather that preoperative Scto2 may be helpful in identifying patients at risk for delirium.
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Affiliation(s)
- Maria J Susano
- From the Centre for Clinical Research in Anesthesia, Department of Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Surgical Centre, Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Mariana Dias
- Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - Francisco S Seixas
- Department of Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Sérgio Vide
- Surgical Centre, Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal.,Department of Anaesthesia, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Rachel Grasfield
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Boston, Massachusetts
| | - Fernando J Abelha
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Anesthesiology, Surgery and Physiology, Centro Hospitalar de São João, Porto, Portugal
| | - Gregory Crosby
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro Amorim
- From the Centre for Clinical Research in Anesthesia, Department of Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Department of Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
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15
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Oldham MA, Lin IH, Hawkins KA, Li FY, Yuh DD, Lee HB. Depression predicts cognitive and functional decline one month after coronary artery bypass graft surgery (Neuropsychiatric Outcomes After Heart Surgery study). Int J Geriatr Psychiatry 2021; 36:452-460. [PMID: 33022808 PMCID: PMC9326959 DOI: 10.1002/gps.5443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 09/17/2020] [Accepted: 10/02/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Prior research on cognitive and functional outcomes after coronary artery bypass graft (CABG) surgery has largely explored these two domains in isolation. In this study, we assess baseline depression and cognition as risk factors for decline in the Clinical Dementia Rating Sum-of-Boxes (CDR-SB) 1 month post-CABG surgery, which a combined measure of cognition and function. DESIGN The Neuropsychiatric Outcomes After Heart Surgery study is a prospective observational cohort study. SETTING A tertiary care, academic center. PARTICIPANTS Of a total study sample of 148 patients undergoing CABG surgery, 124 (83.8%) completed 1-month follow-up assessment. Mean age was 66.3, 32 (25.8%) female and 112 (90.3%) White. MEASUREMENTS Cognition, function, and depression were assessed on semi-structured clinical interviews. Cognitive and functional status were defined using CDR-SB; mild or major depression was defined by the Hamilton Depression Rating Scale. Additionally, neuropsychological battery was performed at baseline. RESULTS CDR-SB decline occurred in 18 (14.5%) subjects. Older age, depression, baseline CDR-SB, and postoperative delirium were associated with 1-month decline on univariate analysis. Older age (OR 1.1 [1.0-1.2]) and depression (OR 6.2 [1.1-35.0]) remained significant on multivariate regression. In separate models, baseline performance on visual Wechsler memory scale (delayed), Hopkins verbal learning test (immediate and delayed), controlled oral word fluency test, and Trails B predicted CDR-SB decline. CONCLUSION Roughly one in seven patients experienced CDR-SB decline 1 month after CABG surgery. Also, preoperative depression deserves recognition for being a predictor of CDR-SB decline one month post-CABG.
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Affiliation(s)
- Mark A. Oldham
- University of Rochester Medical Center,Corresponding author: , @MarkOldhamMD
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16
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Arias F, Chen F, Fong TG, Shiff H, Alegria M, Marcantonio ER, Gou Y, Jones RN, Travison TG, Schmitt EM, Kind AJ, Inouye SK. Neighborhood-Level Social Disadvantage and Risk of Delirium Following Major Surgery. J Am Geriatr Soc 2020; 68:2863-2871. [PMID: 32865254 PMCID: PMC7744425 DOI: 10.1111/jgs.16782] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/13/2020] [Accepted: 07/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND/OBJECTIVES Delirium is a common postoperative complication associated with prolonged length of stay, hospital readmission, and premature mortality. We explored the association between neighborhood-level characteristics and delirium incidence and severity, and compared neighborhood- with individual-level indicators of socioeconomic status in predicting delirium incidence. DESIGN A prospective observational cohort of patients enrolled between June 18, 2010, and August 8, 2013. Baseline interviews were conducted before surgery, and delirium/delirium severity was evaluated daily during hospitalization. Research staff evaluating delirium were blinded to baseline cognitive status. SETTING Two academic medical centers in Boston, MA. PARTICIPANTS A total of 560 older adults, aged 70 years or older, undergoing major noncardiac surgery. INTERVENTION The Area Deprivation Index (ADI) was used to characterize each neighborhood's socioeconomic disadvantage. MEASUREMENTS Delirium was assessed using the Confusion Assessment Method (CAM) long form. Delirium severity was calculated using the highest value of CAM Severity score (CAM-S) occurring during daily hospital assessments (CAM-S Peak). RESULTS Residing in the most disadvantaged neighborhoods (ADI > 44) was associated with a higher risk of incident delirium (12/26; 46%), compared with the least disadvantaged neighborhoods (122/534; 23%) (risk ratio (RR) (95% confidence interval (CI)) = 2.0 (1.3-3.1). The CAM-S Peak score was significantly associated with ADI (Spearman rank correlation, ρ = 0.11; P = .009). Mean CAM-S Peak scores generally rose from 3.7 to 5.3 across levels of increasing neighborhood disadvantage. The RR (95% CI) values associated with individual-level markers of socioeconomic status and cultural background were: 1.2 (0.9-1.7) for education of 12 years or less; 1.3 (0.8-2.1) for non-White race; and 1.7 (1.1-2.6) for annual household income of less than $20,000. None of these individual-level markers exceeded the ADI in terms of effect size or significance for prediction of delirium risk. CONCLUSIONS Neighborhood-level makers of social disadvantage are associated with delirium incidence and severity, and demonstrated an exposure-response relationship. Future studies should consider contextual-level metrics, such as the ADI, as risk markers of social disadvantage that can help to guide delirium treatment and prevention.
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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 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Fan Chen
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA 02131, USA
| | - Tamara G. Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Haley Shiff
- Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Margarita Alegria
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Medicine and Psychiatry, Harvard Medical School, Boston, MA 02115
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA 02115, USA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA 02131, USA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University, Warren Alpert Medical School, Providence, RI 02912, USA
| | - Thomas G. Travison
- Harvard Medical School, Boston, MA 02115, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew Senior Life, Boston, MA 02131, USA
| | - Eva M. Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
| | - Amy J.H. Kind
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison WI 53705, USA
- Madison VA Geriatrics Research Education and Clinical Center (GRECC), Middleton VA Hospital, Madison WI 53705, USA
| | - Sharon K. Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Harvard Medical School, Boston, MA 02115, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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17
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Susano MJ, Grasfield RH, Friese M, Rosner B, Crosby G, Bader AM, Kang JD, Smith TR, Lu Y, Groff MW, Chi JH, Grodstein F, Culley DJ. Brief Preoperative Screening for Frailty and Cognitive Impairment Predicts Delirium after Spine Surgery. Anesthesiology 2020; 133:1184-1191. [PMID: 32898243 PMCID: PMC7657972 DOI: 10.1097/aln.0000000000003523] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Frailty and cognitive impairment are associated with postoperative delirium, but are rarely assessed preoperatively. The study was designed to test the hypothesis that preoperative screening for frailty or cognitive impairment identifies patients at risk for postoperative delirium (primary outcome). METHODS In this prospective cohort study, the authors administered frailty and cognitive screening instruments to 229 patients greater than or equal to 70 yr old presenting for elective spine surgery. Screening for frailty (five-item FRAIL scale [measuring fatigue, resistance, ambulation, illness, and weight loss]) and cognition (Mini-Cog, Animal Verbal Fluency) were performed at the time of the preoperative evaluation. Demographic data, perioperative variables, and postoperative outcomes were gathered. Delirium was the primary outcome detected by either the Confusion Assessment Method, assessed daily from postoperative day 1 to 3 or until discharge, if patient was discharged sooner, or comprehensive chart review. Secondary outcomes were all other-cause complications, discharge not to home, and hospital length of stay. RESULTS The cohort was 75 [73 to 79 yr] years of age, 124 of 219 (57%) were male. Many scored positive for prefrailty (117 of 218; 54%), frailty (53 of 218; 24%), and cognitive impairment (50 to 82 of 219; 23 to 37%). Fifty-five patients (25%) developed delirium postoperatively. On multivariable analysis, frailty (scores 3 to 5 [odds ratio, 6.6; 95% CI, 1.96 to 21.9; P = 0.002]) versus robust (score 0) on the FRAIL scale, lower animal fluency scores (odds ratio, 1.08; 95% CI, 1.01 to 1.51; P = 0.036) for each point decrease in the number of animals named, and more invasive surgical procedures (odds ratio, 2.69; 95% CI, 1.31 to 5.50; P = 0.007) versus less invasive procedures were associated with postoperative delirium. CONCLUSIONS Screening for frailty and cognitive impairment preoperatively using the FRAIL scale and the Animal Verbal Fluency test in older elective spine surgery patients identifies those at high risk for the development of postoperative delirium. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Maria J. Susano
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA.; Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Rachel H. Grasfield
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Matthew Friese
- Translational Medicine and Clinical Pharmacology, Sanofi, Cambridge, MA
| | - Bernard Rosner
- Bio-Statistician, Harvard Medical School; Brigham and Women’s Hospital, Boston, MA
| | - Gregory Crosby
- Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Angela M. Bader
- Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
| | - James D. Kang
- Harvard Medical School; Chairman, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Timothy R. Smith
- Harvard Medical School; Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA
| | - Yi Lu
- Harvard Medical School; Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA
| | - Michael W. Groff
- Harvard Medical School; Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA
| | - John H. Chi
- Harvard Medical School; Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA
| | | | - Deborah J. Culley
- Harvard Medical School; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Boston, MA
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18
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Katsumi Y, Racine AM, Torrado-Carvajal A, Loggia ML, Hooker JM, Greve DN, Hightower BG, Catana C, Cavallari M, Arnold SE, Fong TG, Vasunilashorn SM, Marcantonio ER, Schmitt EM, Xu G, Libermann TA, Barrett LF, Inouye SK, Dickerson BC, Touroutoglou A, Collins JA. The Role of Inflammation after Surgery for Elders (RISE) study: Examination of [ 11C]PBR28 binding and exploration of its link to post-operative delirium. Neuroimage Clin 2020; 27:102346. [PMID: 32712451 PMCID: PMC7390821 DOI: 10.1016/j.nicl.2020.102346] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/11/2020] [Accepted: 07/10/2020] [Indexed: 12/11/2022]
Abstract
Major surgery is associated with a systemic inflammatory cascade that is thought, in some cases, to contribute to transient and/or sustained cognitive decline, possibly through neuroinflammatory mechanisms. However, the relationship between surgery, peripheral and central nervous system inflammation, and post-operative cognitive outcomes remains unclear in humans, primarily owing to limitations of in vivo biomarkers of neuroinflammation which vary in sensitivity, specificity, validity, and reliability. In the present study, [11C]PBR28 positron emission tomography, cerebrospinal fluid (CSF), and blood plasma biomarkers of inflammation were assessed pre-operatively and 1-month post-operatively in a cohort of patients (N = 36; 30 females; ≥70 years old) undergoing major orthopedic surgery under spinal anesthesia. Delirium incidence and severity were evaluated daily during hospitalization. Whole-brain voxel-wise and regions-of-interest analyses were performed to determine the magnitude and spatial extent of changes in [11C]PBR28 uptake following surgery. Results demonstrated that, compared with pre-operative baseline, [11C]PBR28 binding in the brain was globally downregulated at 1 month following major orthopedic surgery, possibly suggesting downregulation of the immune system of the brain. No significant relationship was identified between post-operative delirium and [11C]PBR28 binding, possibly due to a small number (n = 6) of delirium cases in the sample. Additionally, no significant relationships were identified between [11C]PBR28 binding and CSF/plasma biomarkers of inflammation. Collectively, these results contribute to the literature by demonstrating in a sizeable sample the effect of major surgery on neuroimmune activation and preliminary evidence identifying no apparent associations between [11C]PBR28 binding and fluid inflammatory markers or post-operative delirium.
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Affiliation(s)
- Yuta Katsumi
- Department of Psychology, Northeastern University, Boston, MA, United States; Japan Society for the Promotion of Science, Tokyo, Japan; Harvard Medical School, Boston, MA, United States
| | - Annie M Racine
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | - Angel Torrado-Carvajal
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States; Medical Image Analysis and Biometry Laboratory, Universidad Rey Juan Carlos, Madrid, Spain
| | - Marco L Loggia
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Jacob M Hooker
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Douglas N Greve
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Baileigh G Hightower
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Ciprian Catana
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Michele Cavallari
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States
| | - Steven E Arnold
- Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Tamara G Fong
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States; Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Sarinnapha M Vasunilashorn
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Edward R Marcantonio
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Eva M Schmitt
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | - Guoquan Xu
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | - Towia A Libermann
- Harvard Medical School, Boston, MA, United States; Genomics, Proteomics, Bioinformatics and Systems Biology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Lisa Feldman Barrett
- Department of Psychology, Northeastern University, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Sharon K Inouye
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Bradford C Dickerson
- Harvard Medical School, Boston, MA, United States; Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Alexandra Touroutoglou
- Harvard Medical School, Boston, MA, United States; Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Jessica A Collins
- Harvard Medical School, Boston, MA, United States; Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
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van Zuylen ML, Hermanides J, ten Hoope W, Preckel B, van de Beek D, van Gool WA, Schoenmaker N. Registration of attentional function as a predictor of incident delirium (the RAPID study). ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12031. [PMID: 32551358 PMCID: PMC7297189 DOI: 10.1002/trc2.12031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/06/2020] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Older adults undergoing elective surgery have a high risk of developing postoperative delirium (POD). Validated models predicting POD are scarce. This study investigated whether preoperative impairment of attentional function predicts POD in older adults without previously diagnosed cognitive impairment. METHODS In this prospective cohort study we recruited patients aged ≥70 years preceding major elective surgery. Preoperatively a visual vigilance test was administered to determine intra-individual reaction-time variability. Postoperatively, presence of delirium was screened daily. RESULTS We recruited 152 patients, 25 (16.4%) developed POD. Intra-individual reaction-time variability was not significantly different between patients with or without POD (0.18 ± 0.08 ms vs 0.22 ± 0.11 ms; P = 0.087). Receiver operating characteristic analyses indicated a poor accuracy for POD (area under the curve 0.609 ± 0.63). Except for surgery duration, no clinically significant between-group differences were found for secondary outcome parameters. DISCUSSION Preoperative intra-individual reaction time variability does not predict the incidence of POD in older patients undergoing major elective surgery.
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Affiliation(s)
- Mark L. van Zuylen
- Department of AnesthesiologyAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Jeroen Hermanides
- Department of AnesthesiologyAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Werner ten Hoope
- Department of AnesthesiologyAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Department of AnesthesiologyRijnstate HospitalArnhemthe Netherlands
| | - Benedikt Preckel
- Department of AnesthesiologyAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Diederik van de Beek
- Department of NeurologyAmsterdam UMCUniversity of AmsterdamAmsterdam NeuroscienceAmsterdamthe Netherlands
| | - Willem A. van Gool
- Department of NeurologyAmsterdam UMCUniversity of AmsterdamAmsterdam NeuroscienceAmsterdamthe Netherlands
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20
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Lee SJ, Jung SH, Lee SU, Lim JY, Yoon KS, Lee SY. Postoperative delirium after hip surgery is a potential risk factor for incident dementia: A systematic review and meta-analysis of prospective studies. Arch Gerontol Geriatr 2019; 87:103977. [PMID: 31751902 DOI: 10.1016/j.archger.2019.103977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although a few trials have explored the relationship between postoperative delirium (POD) and incident dementia in patients with hip surgery, the numbers of participants in each study are relatively small. Thus, we performed a meta-analysis to examine whether POD after hip surgery is a risk factor for incident dementia. METHODS Six prospective cohort studies investigating the development of incident dementia in patients with POD after hip surgery were retrieved from PubMed, Embase, and the Cochrane Library. We performed a pairwise meta-analysis using fixed- and random- effect models. RESULTS POD significantly increased the risk of incident dementia and cognitive decline (overall odds ratio [ORs] = 8.957; 95 % confidence interval [CI], 5.444-14.737; P < 0.001 in fixed-effects model; overall ORs = 8.962; 95 % CI, 5.344-15.029; P < 0.001 in random-effects model). A publication bias was not evident in this study. CONCLUSIONS Our meta-analysis revealed that POD after hip surgery is a risk factor for incident dementia. Early identification of cognitive function should be needed after surgery and appropriate prevention and treatment for dementia will be required, especially in cases with POD.
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Affiliation(s)
- Soong Joon Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Se Hee Jung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Shi-Uk Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kang-Sup Yoon
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Sang Yoon Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.
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21
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Lindroth H, Bratzke L, Twadell S, Rowley P, Kildow J, Danner M, Turner L, Hernandez B, Brown R, Sanders RD. Predicting postoperative delirium severity in older adults: The role of surgical risk and executive function. Int J Geriatr Psychiatry 2019; 34:1018-1028. [PMID: 30907449 PMCID: PMC6579704 DOI: 10.1002/gps.5104] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/20/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Delirium is an important postoperative complication, yet predictive risk factors for postoperative delirium severity remain elusive. We hypothesized that the NSQIP risk calculation for serious complications (NSQIP-SC) or risk of death (NSQIP-D), and cognitive tests of executive function (Trail Making Tests A and B [TMTA and TMTB]), would be predictive of postoperative delirium severity. Further, we demonstrate how advanced statistical techniques can be used to identify candidate predictors. METHODS/DESIGN Data from an ongoing perioperative prospective cohort study of 100 adults (65 y old or older) undergoing noncardiac surgery were analyzed. In addition to NSQIP-SC, NSQIP-D, TMTA, and TMTB, participant age, sex, American Society of Anesthesiologists (ASA) score, tobacco use, surgery type, depression, Framingham risk score, and preoperative blood pressure were collected. The Delirium Rating Scale-R-98 (DRS) measured delirium severity; the Confusion Assessment Method (CAM) identified delirium. LASSO and best subsets linear regression were employed to identify predictive risk factors. RESULTS Ninety-seven participants with a mean age of 71.68 ± 4.55, 55% male (31/97 CAM+, 32%), and a mean peak DRS of 21.5 ± 6.40 were analyzed. LASSO and best subsets regression identified NSQIP-SC and TMTB to predict postoperative delirium severity (P < 00.001, adjusted R2 : 0.30). NSQIP-SC and TMTB were also selected as predictors for postoperative delirium incidence (AUROC 0.81, 95% CI, 0.72-0.90). CONCLUSIONS In this cohort, we identified NSQIP risk score for serious complications and a measure of executive function, TMT-B, to predict postoperative delirium severity using advanced modeling techniques. Future studies should investigate the utility of these variables in a formal delirium severity prediction model.
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Affiliation(s)
- Heidi Lindroth
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI,School of Nursing, University of Wisconsin-Madison, Madison, WI,School of Medicine-Center for Aging Research, Department of Medicine, Indiana University, Indianapolis, IN @minipixie26
| | - Lisa Bratzke
- School of Nursing, University of Wisconsin-Madison, Madison, WI
| | - Sara Twadell
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI,Charles E. Schmidt College of Medicine, Florida Atlantic University
| | - Paul Rowley
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Janie Kildow
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI,School of Medicine, Indiana University, Indianapolis, IN
| | - Mara Danner
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Lily Turner
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Brandon Hernandez
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Roger Brown
- School of Nursing, University of Wisconsin-Madison, Madison, WI
| | - Robert D. Sanders
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI,Corresponding author: Robert D. Sanders, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC Madison, WI 53792-3272 Telephone: 608-263-8100 Fax: 608-263-0575 Madison, USA.
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22
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Zhang J, Bi JJ, Guo GJ, Yang L, Zhu B, Zhan GF, Li S, Huang NN, Hashimoto K, Yang C, Luo AL. Abnormal composition of gut microbiota contributes to delirium-like behaviors after abdominal surgery in mice. CNS Neurosci Ther 2019; 25:685-696. [PMID: 30680947 PMCID: PMC6515708 DOI: 10.1111/cns.13103] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/02/2018] [Accepted: 12/22/2018] [Indexed: 01/12/2023] Open
Abstract
Aims Anesthesia and surgery can cause delirium‐like symptoms postoperatively. Increasing evidence suggests that gut microbiota is a physiological regulator of the brain. Herein, we investigated whether gut microbiota plays a role in postoperative delirium (POD). Methods Mice were separated into non‐POD and POD phenotypes after abdominal surgery by applying hierarchical clustering analysis to behavioral tests. Fecal samples were collected, and 16S ribosomal RNA gene sequencing was performed to detect differences in gut microbiota composition among sham, non‐POD, and POD mice. Fecal bacteria from non‐POD and POD mice were transplanted into antibiotics‐induced pseudo‐germ‐free mice to investigate the effects on behaviors. Results α‐diversity and β‐diversity indicated differences in gut microbiota composition between the non‐POD and POD mice. At the phylum level, the non‐POD mice had significantly higher levels of Tenericutes, which were not detected in the POD mice. At the class level, levels of Gammaproteobacteria were higher in the POD mice, whereas the non‐POD mice had significantly higher levels of Mollicutes, which were not detected in the POD mice. A total of 20 gut bacteria differed significantly between the POD and non‐POD mice. Interestingly, the pseudo‐germ‐free mice showed abnormal behaviors prior to transplant. The pseudo‐germ‐free mice that received fecal bacteria transplants from non‐POD mice but not from POD mice showed improvements in behaviors. Conclusions Abnormal gut microbiota composition after abdominal surgery may contribute to the development of POD. A therapeutic strategy that targets gut microbiota could provide a novel alterative for POD treatment.
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Affiliation(s)
- Jie Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiang-Jiang Bi
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guo-Jun Guo
- Department of Hand Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Yang
- Department of Cardiology and Critical Care Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Bin Zhu
- Department of Cardiology and Critical Care Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Gao-Feng Zhan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shan Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nian-Nian Huang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, Japan
| | - Chun Yang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ai-Lin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Budėnas A, Tamašauskas Š, Šliaužys A, Navickaitė I, Sidaraitė M, Pranckevičienė A, Deltuva VP, Tamašauskas A, Bunevičius A. Incidence and clinical significance of postoperative delirium after brain tumor surgery. Acta Neurochir (Wien) 2018; 160:2327-2337. [PMID: 30406871 DOI: 10.1007/s00701-018-3718-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 10/27/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Delirium is an acute and reversible deterioration of mental state. Postoperative delirium (POD) can develop after surgical procedures and is associated with impaired health status and worse recovery. So far, there is little data about postoperative delirium after brain surgery. The aim of this study was to evaluate frequency, risk factors, and prognostic value of POD in predicting short-term postoperative outcomes after brain tumor surgery. METHODS Five-hundred and twenty-two patients who underwent elective brain tumor surgery in 2010-2017 were included in this prospective study. Patients were monitored for POD using the Confusion Assessment Method for the ICU (CAM-ICU) for 2 to 7 days after the surgery. At hospital discharge, outcomes were evaluated using the Glasgow Outcome Scale (GOS). RESULTS POD was diagnosed in 22 (4.2%) patients. Risk factors of POD were low level of hemoglobin, poor functional status at time of admission, low education level and older age (65 years and older). POD incidence was not associated with brain tumor laterality, location, extent of resection, histological diagnosis, or affected brain lobe. POD was associated with greater risk for unfavorable outcomes at hospital discharge (OR = 5.3; 95% CI [2.1-13.4], p = 0.001). CONCLUSIONS POD is not a common complication after elective brain tumor surgery. Older age, poor functional status, low education level and anemia are associated with greater POD risk. Extent of surgical intervention and brain tumor location are not associated with POD risk. POD is associated with worse outcome at hospital discharge.
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Affiliation(s)
- Antanas Budėnas
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Šarūnas Tamašauskas
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Albertas Šliaužys
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | | | - Aistė Pranckevičienė
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania
- Neuroscience Institute, Lithuanian University of Health Sciences, Eiveniu str 2, LT-50009, Kaunas, Lithuania
| | - Vytenis Pranas Deltuva
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania
- Neuroscience Institute, Lithuanian University of Health Sciences, Eiveniu str 2, LT-50009, Kaunas, Lithuania
| | - Arimantas Tamašauskas
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania
- Neuroscience Institute, Lithuanian University of Health Sciences, Eiveniu str 2, LT-50009, Kaunas, Lithuania
| | - Adomas Bunevičius
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania.
- Neuroscience Institute, Lithuanian University of Health Sciences, Eiveniu str 2, LT-50009, Kaunas, Lithuania.
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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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: 140] [Impact Index Per Article: 23.3] [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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25
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Lindroth H, Bratzke L, Purvis S, Brown R, Coburn M, Mrkobrada M, Chan MTV, Davis DHJ, Pandharipande P, Carlsson CM, Sanders RD. Systematic review of prediction models for delirium in the older adult inpatient. BMJ Open 2018; 8:e019223. [PMID: 29705752 PMCID: PMC5931306 DOI: 10.1136/bmjopen-2017-019223] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To identify existing prognostic delirium prediction models and evaluate their validity and statistical methodology in the older adult (≥60 years) acute hospital population. DESIGN Systematic review. DATA SOURCES AND METHODS PubMed, CINAHL, PsychINFO, SocINFO, Cochrane, Web of Science and Embase were searched from 1 January 1990 to 31 December 2016. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses and CHARMS Statement guided protocol development. INCLUSION CRITERIA age >60 years, inpatient, developed/validated a prognostic delirium prediction model. EXCLUSION CRITERIA alcohol-related delirium, sample size ≤50. The primary performance measures were calibration and discrimination statistics. Two authors independently conducted search and extracted data. The synthesis of data was done by the first author. Disagreement was resolved by the mentoring author. RESULTS The initial search resulted in 7,502 studies. Following full-text review of 192 studies, 33 were excluded based on age criteria (<60 years) and 27 met the defined criteria. Twenty-three delirium prediction models were identified, 14 were externally validated and 3 were internally validated. The following populations were represented: 11 medical, 3 medical/surgical and 13 surgical. The assessment of delirium was often non-systematic, resulting in varied incidence. Fourteen models were externally validated with an area under the receiver operating curve range from 0.52 to 0.94. Limitations in design, data collection methods and model metric reporting statistics were identified. CONCLUSIONS Delirium prediction models for older adults show variable and typically inadequate predictive capabilities. Our review highlights the need for development of robust models to predict delirium in older inpatients. We provide recommendations for the development of such models.
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Affiliation(s)
- Heidi Lindroth
- Department of Anesthesiology, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- School of Nursing, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Lisa Bratzke
- School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Suzanne Purvis
- Department of Nursing, University Hospital, Madison, Wisconsin, USA
| | - Roger Brown
- School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Mark Coburn
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marko Mrkobrada
- Department of Medicine, Western University, London, Ontario, Canada
| | - Matthew T V Chan
- Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Pratik Pandharipande
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Cynthia M Carlsson
- Department of Anesthesiology, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Medicine, Division of Geriatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Geriatric Research, Education, and Clinical Center (GRECC), William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
- Wisconsin Alzheimer's Disease Research Center, Madison, Wisconsin, USA
- Wisconsin Alzheimer's Institute, Madison, Wisconsin, USA
| | - Robert D Sanders
- Department of Anesthesiology, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Haugen CE, Mountford A, Warsame F, Berkowitz R, Bae S, Thomas A, Brown CH, Brennan DC, Neufeld KJ, Carlson MC, Segev DL, McAdams-DeMarco M. Incidence, Risk Factors, and Sequelae of Post-kidney Transplant Delirium. J Am Soc Nephrol 2018; 29:1752-1759. [PMID: 29685884 DOI: 10.1681/asn.2018010064] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/30/2018] [Indexed: 01/20/2023] Open
Abstract
Background Frail kidney transplant (KT) recipients may be particularly vulnerable to surgical stressors, resulting in delirium and subsequent adverse outcomes. We sought to identify the incidence, risk factors, and sequelae of post-KT delirium.Methods We studied 125,304 adult KT recipients (1999-2014) to estimate delirium incidence in national registry claims. Additionally, we used a validated chart abstraction algorithm to identify post-KT delirium in 893 adult recipients (2009-2017) from a cohort study of frailty. Delirium sequelae were identified using adjusted logistic regression (length of stay ≥2 weeks and institutional discharge [skilled nursing or rehabilitation facility]) and adjusted Cox regression (death-censored graft loss and mortality).Results Only 0.8% of KT recipients had a delirium claim. In the cohort study, delirium incidence increased with age (18-49 years old: 2.0%; 50-64 years old: 4.6%; 65-75 years old: 9.2%; and ≥75 years old: 13.8%) and frailty (9.0% versus 3.9%); 20.0% of frail recipients aged ≥75 years old experienced delirium. Frailty was independently associated with delirium (odds ratio [OR], 2.05; 95% confidence interval [95% CI], 1.02 to 4.13; P=0.04), but premorbid global cognitive function was not. Recipients with delirium had increased risks of ≥2-week length of stay (OR, 5.42; 95% CI, 2.76 to 10.66; P<0.001), institutional discharge (OR, 22.41; 95% CI, 7.85 to 63.98; P<0.001), graft loss (hazard ratio [HR], 2.73; 95% CI, 1.14 to 6.53; P=0.03), and mortality (HR, 3.12; 95% CI, 1.76 to 5.54; P<0.001).Conclusions Post-KT delirium is a strong risk factor for subsequent adverse outcomes, yet it is a clinical entity that is often missed.
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Affiliation(s)
| | | | | | | | - Sunjae Bae
- Departments of Surgery.,Departments of Epidemiology and
| | | | | | | | - Karin J Neufeld
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle C Carlson
- Mental Health, Johns Hopkins School of Public Health, Baltimore, Maryland; and.,Johns Hopkins University Center on Aging and Health, Baltimore, Maryland
| | - Dorry L Segev
- Departments of Surgery.,Departments of Epidemiology and
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Magny E, Le Petitcorps H, Pociumban M, Bouksani-Kacher Z, Pautas É, Belmin J, Bastuji-Garin S, Lafuente-Lafuente C. Predisposing and precipitating factors for delirium in community-dwelling older adults admitted to hospital with this condition: A prospective case series. PLoS One 2018; 13:e0193034. [PMID: 29474380 PMCID: PMC5825033 DOI: 10.1371/journal.pone.0193034] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/03/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Factors associated with delirium among community-dwelling older adults have been poorly studied. Our aim was to describe the prevalence of predisposing and precipitating factors for delirium among patients admitted for delirium and to assess whether these factors were appropriately recognized at the first patient assessment at hospital. METHODS Consecutive community-dwelling individuals admitted to three geriatric acute care units with a confirmed initial diagnosis of delirium were prospectively included. An independent investigator recorded, using a predefined form, any acute medical condition considered by the attending geriatrician to be a precipitating factor, at the first patient assessment and at the end of his stay in acute care. RESULTS A total of 208 patients were included, 80.0% had a pre-existing cognitive or neurological disorder, or both. The most frequent precipitating factor found were infections (49.0% of all patients, mainly lung and urinary tract infections), followed by drugs (30.8%), dehydration (26.4%) and electrolytic disturbances (18.7%, mostly hyponatremia). 91% of patients had a cerebral imagery, but acute neurological conditions were found in only 18.3%. Fewer precipitating factors were found at first than at final assessment (1.4 (95%CI 1.3-1.6) versus 1.9 (95%CI 1.8-2.0) respectively, p<0.001). This difference was significant for all main categories of precipitating factors. CONCLUSIONS Infections, followed by drugs and hydro-electrolytic disorders seem to be the most frequent precipitating factors for delirium in community-dwelling elderly individuals. Early diagnostic and management of precipitating factors in these patients should be improved, as a significant number of them are missed at the initial assessment.
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Affiliation(s)
- Emmanuelle Magny
- Service de Gériatrie à orientation Cardiologique et Neurologique, Hôpital Charles Foix, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, APHP, Paris, France
| | - Hélène Le Petitcorps
- Service de Gériatrie aiguë, Hôpital Charles Foix, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, APHP, Paris, France
| | - Maria Pociumban
- Plateforme de Recherche Clinique en Gériatrie, Hôpital Charles Foix, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, APHP, Paris, France
| | - Zineb Bouksani-Kacher
- Plateforme de Recherche Clinique en Gériatrie, Hôpital Charles Foix, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, APHP, Paris, France
| | - Éric Pautas
- Service de Gériatrie aiguë, Hôpital Charles Foix, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, APHP, Paris, France
- DHU FAST, Sorbonne Universités, Université Paris 6 Pierre et Marie Curie (UPMC), Paris, France
| | - Joël Belmin
- Service de Gériatrie à orientation Cardiologique et Neurologique, Hôpital Charles Foix, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, APHP, Paris, France
- Plateforme de Recherche Clinique en Gériatrie, Hôpital Charles Foix, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, APHP, Paris, France
- DHU FAST, Sorbonne Universités, Université Paris 6 Pierre et Marie Curie (UPMC), Paris, France
| | - Sylvie Bastuji-Garin
- Université Paris Est Créteil (UPEC), IMRB, A-TVB DHU, CEpiA EA 4393, (Clinical Epidemiology and Ageing Unit, APHP, Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Carmelo Lafuente-Lafuente
- Service de Gériatrie à orientation Cardiologique et Neurologique, Hôpital Charles Foix, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, APHP, Paris, France
- Plateforme de Recherche Clinique en Gériatrie, Hôpital Charles Foix, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, APHP, Paris, France
- DHU FAST, Sorbonne Universités, Université Paris 6 Pierre et Marie Curie (UPMC), Paris, France
- * E-mail:
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28
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Functional impairment prior to major non-cardiac surgery is associated with mortality within one year in elderly patients with gastrointestinal, gynaecological and urogenital cancer: A prospective observational cohort study. J Geriatr Oncol 2017; 9:53-59. [PMID: 28888555 DOI: 10.1016/j.jgo.2017.07.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 06/21/2017] [Accepted: 07/27/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the prognostic value of elements of the Geriatric Assessment, in particular the Timed Up and Go (TUG) Test and the Barthel Index of Activities of Daily Living (ADL) for one-year post-operative mortality in elderly patients with cancer. MATERIALS AND METHODS This prospective cohort study included patients 65years of age or older undergoing elective major surgery for cancer between June 2008 and June 2010. Preoperative functional status was measured by the TUG Test and the Barthel Index of ADL Cognitive state was assessed by the Mini Mental State Examination (MMSE). Complications were recorded prospectively. The degree of resection was noted. RESULTS Data from 131 patients (56% women; median age, 71years) were analysed at 1year of follow-up. Mortality after 1year was 28.2%. Twenty-nine patients (22.3%) were dependent in ADLs, and 43 (35.2%) impaired in TUG. Thirteen patients (10.7%) were both, dependent in ADLs and impaired in TUG. Short-term complications after surgery occurred in 66% of patients, and major complications occurred in 29%. Patients who were dependent in ADLs and impaired in TUG had significantly higher 1-year mortality (OR, 4.5; 95% CI, 1.21-18.25; p=0.034). Lower scores on the MMSE (OR, 0.64; 95% CI, 0.43-0.95; p=0.048) and incomplete surgical resection (OR, 3.25; 95% CI, 1.15-9.20; p=0.026) were independently associated with higher 1-year mortality. CONCLUSION Functional assessments, such as ADL and TUG scores, as well as mild cognitive impairment, are predictors of long-term outcome in elderly cancer patients. TRIAL REGISTRATION German Clinical Trials Register (DRKS 00005150).
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29
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Cunningham EL, Mawhinney T, Beverland D, O'Brien S, McAuley DF, Cairns R, Passmore P, McGuinness B. Observational cohort study examining apolipoprotein E status and preoperative neuropsychological performance as predictors of post-operative delirium in an older elective arthroplasty population. Age Ageing 2017; 46:779-786. [PMID: 28383643 DOI: 10.1093/ageing/afx042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 03/08/2017] [Indexed: 01/19/2023] Open
Abstract
Introduction delirium following surgery is common and is associated with negative outcomes. Preoperative cognitive impairment has been shown to be a risk factor for post-operative delirium. Often the cognitive tests used are cumbersome. This study tests the hypothesis that the quantification of brain vulnerability, using Apolipoprotein E (ApoE) status and neuropsychological tests, both traditional and more easily administered, can quantify the risk of post-operative delirium following elective primary arthroplasty surgery. Methods this observational cohort study recruited participants aged 65 years or older admitted prior to elective primary hip or knee arthroplasty. Baseline data was collected and participants underwent neuropsychological testing and had blood taken for ApoE genotyping preoperatively. Post-operatively participants were assessed daily for delirium using the Confusion Assessment Method (CAM) and charts were reviewed where possible for reports of delirium. Univariate and multivariate analyses of preoperative factors were undertaken to identify independent predictors of delirium. Results between March 2012 and October 2014, 315 participants completed the study with an overall incidence of post-operative delirium of 40/315 (12.7%). Of these 18 fulfilled the CAM criteria for delirium and 22 were deemed delirious by consensus decision based on chart review. ApoE genotype was not associated with post-operative delirium in this cohort. Time taken to complete Colour Trails 2, errors in mini mental state examination and level of pain preoperatively were independent predictors of post-operative delirium. Conclusions this study challenges the assertion that ApoE4 genotype predicts post-operative delirium. It replicates previous work suggesting cognitive impairment predicts post-operative delirium and shows for the 1st time that simple cognitive tests can be as effective as more detailed tests.
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Affiliation(s)
- Emma Louise Cunningham
- Centre for Public Health, Institute of Clinical Sciences, Block B, Queens University Belfast, Royal Victoria Hospital, Belfast BT12 6BA, UK
| | | | | | | | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - Peter Passmore
- Centre for Public Health, Institute of Clinical Sciences, Block B, Queens University Belfast, Royal Victoria Hospital, Belfast BT12 6BA, UK
| | - Bernadette McGuinness
- Centre for Public Health, Institute of Clinical Sciences, Block B, Queens University Belfast, Royal Victoria Hospital, Belfast BT12 6BA, UK
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30
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Hshieh TT, Dai W, Cavallari M, Guttmann CR, Meier DS, Schmitt EM, Dickerson BC, Press DZ, Marcantonio ER, Jones RN, Gou YR, Travison TG, Fong TG, Ngo L, Inouye SK, Alsop DC. Cerebral blood flow MRI in the nondemented elderly is not predictive of post-operative delirium but is correlated with cognitive performance. J Cereb Blood Flow Metab 2017; 37:1386-1397. [PMID: 27401806 PMCID: PMC5453459 DOI: 10.1177/0271678x16656014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Three-dimensional Arterial Spin Labeling (ASL) MRI was performed before surgery in a cohort of 146 prospectively enrolled subjects ≥ 70 years old scheduled to undergo elective surgery. We investigated the prospective association between ASL-derived measures of cerebral blood flow (CBF) before surgery with postoperative delirium incidence and severity using whole-brain and globally normalized voxel-wise analysis. We also investigated the cross-sectional association of CBF with patients' baseline performance on specific neuropsychological tests, and with a composite general cognitive performance measure (GCP). Out of 146 subjects, 32 (22%) developed delirium. We found no significant association between global and voxel-wise CBF with delirium incidence or severity. We found the most significant positive associations between CBF of the posterior cingulate and precuneus and the Hopkins Verbal Learning Test - Revised total score, Visual Search and Attention Test (VSAT) score and the GCP composite. VSAT score was also strongly associated with right parietal lobe CBF. ASL can be employed in a large, well-characterized older cohort to examine associations between CBF and age-related cognitive performance. Although ASL CBF measures in regions previously associated with preclinical Alzheimer's Disease were correlated with cognition, they were not found to be indicators of baseline pathology that may increase risk for delirium.
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Affiliation(s)
- Tammy T Hshieh
- 1 Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Weiying Dai
- 3 Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,4 Department of Computer Science, State University of New York at Binghamton, Binghamton, NY, USA
| | - Michele Cavallari
- 5 Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charles Rg Guttmann
- 5 Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dominik S Meier
- 5 Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eva M Schmitt
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Bradford C Dickerson
- 6 Martinos Center for Biomedical Imaging, Psychiatric Neuroimaging Division, Department of Psychiatry, and Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Daniel Z Press
- 7 Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Edward R Marcantonio
- 8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard N Jones
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,9 Departments of Psychiatry and Human Behavior and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Yun Ray Gou
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Thomas G Travison
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tamara G Fong
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,7 Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Long Ngo
- 8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sharon K Inouye
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David C Alsop
- 3 Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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31
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Sun V, Burhenn PS, Lai L, Hurria A. The Impact of Comorbidity on Surgical Outcomes in Older Adults with Cancer. Semin Oncol Nurs 2017; 33:80-86. [PMID: 28062326 DOI: 10.1016/j.soncn.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To provide an overview of the impact of comorbidity on surgical outcomes and postoperative geriatric events in older adults with cancer, and review key components of quality perioperative nursing care of older adults with cancer. DATA SOURCES Journal articles, research reports, state of the science papers, position papers, and clinical guidelines from professional organizations. CONCLUSION The high prevalence of multiple comorbidities and the associated burden of geriatric events in older adults after cancer surgery have a substantial impact on surgical outcomes, quality of life, and health care costs. Practical and efficient models of comprehensive assessment, prevention, and management of postoperative geriatric events and comorbid conditions are needed to improve surgical outcomes for this vulnerable cancer population. IMPLICATIONS FOR NURSING PRACTICE Oncology nurses practicing in clinical and research settings have a responsibility to arm themselves with evidence-based knowledge and resources to improve the perioperative care of older adults with cancer.
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32
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Asken BM, Sullan MJ, Snyder AR, Houck ZM, Bryant VE, Hizel LP, McLaren ME, Dede DE, Jaffee MS, DeKosky ST, Bauer RM. Factors Influencing Clinical Correlates of Chronic Traumatic Encephalopathy (CTE): a Review. Neuropsychol Rev 2016; 26:340-363. [PMID: 27561662 PMCID: PMC5507554 DOI: 10.1007/s11065-016-9327-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 08/08/2016] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neuropathologically defined disease reportedly linked to a history of repetitive brain trauma. As such, retired collision sport athletes are likely at heightened risk for developing CTE. Researchers have described distinct pathological features of CTE as well a wide range of clinical symptom presentations, recently termed traumatic encephalopathy syndrome (TES). These clinical symptoms are highly variable, non-specific to individuals described as having CTE pathology in case reports, and are often associated with many other factors. This review describes the cognitive, emotional, and behavioral changes associated with 1) developmental and demographic factors, 2) neurodevelopmental disorders, 3) normal aging, 4) adjusting to retirement, 5) drug and alcohol abuse, 6) surgeries and anesthesia, and 7) sleep difficulties, as well as the relationship between these factors and risk for developing dementia-related neurodegenerative disease. We discuss why some professional athletes may be particularly susceptible to many of these effects and the importance of choosing appropriate controls groups when designing research protocols. We conclude that these factors should be considered as modifiers predominantly of the clinical outcomes associated with repetitive brain trauma within a broader biopsychosocial framework when interpreting and attributing symptom development, though also note potential effects on neuropathological outcomes. Importantly, this could have significant treatment implications for improving quality of life.
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Affiliation(s)
- Breton M Asken
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA.
| | - Molly J Sullan
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Aliyah R Snyder
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Zachary M Houck
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Vaughn E Bryant
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Loren P Hizel
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Molly E McLaren
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Duane E Dede
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Michael S Jaffee
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Steven T DeKosky
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Russell M Bauer
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
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Kolanowski A, Fick D, Litaker M, Mulhall P, Clare L, Hill N, Mogle J, Boustani M, Gill D, Yevchak-Sillner A. Effect of Cognitively Stimulating Activities on Symptom Management of Delirium Superimposed on Dementia: A Randomized Controlled Trial. J Am Geriatr Soc 2016; 64:2424-2432. [PMID: 27861718 DOI: 10.1111/jgs.14511] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether cognitively stimulating activities would reduce duration and severity of delirium and improve cognitive and physical function to a greater extent than usual care. DESIGN Single-blind randomized clinical trial. SETTING Eight post-acute care (PAC) facilities. PARTICIPANTS Community-dwelling older adults with dementia and delirium (N = 283). INTERVENTION Research staff provided cognitively stimulating activities daily for up to 30 days. MEASUREMENTS Primary outcomes were delirium duration (Confusion Assessment Method) and delirium severity (Delirium Rating Scale). Secondary outcomes were cognitive function (Digits Forward, Montreal Cognitive Assessment, CLOX) and physical function (Barthel Index). RESULTS Mean percentage of delirium-free days (intervention: 64.8%, 95% confidence interval (CI) = 59.6-70.1; control: 68.7%, 95% CI = 63.9-73.6; P = .37, Wilcoxon rank sum test) and delirium severity (range 0-39: intervention: 10.77, 95% CI = 10.10-11.45; control: 11.15, 95% CI = 10.50-11.80; difference 0.37, 95% CI = 0.56-1.31, P = .43) were similar in both groups. Significant differences for secondary outcomes favoring intervention were found (executive function (range 0-15): intervention: 6.58, 95% CI = 6.12-7.04; control: 5.89, 95% CI = 5.45-6.33; difference -0.69, 95% CI = 1.33 to -0.06, P = .03; constructional praxis (range 0-15): intervention: 8.84, 95% CI = 8.83-9.34; control: 7.53, 95% CI = 7.04-8.01; difference -1.31, 95% CI = 2.01 to -0.61, P < .001). After adjusting for baseline constructional praxis, the group comparison was no longer significant. Average length of stay was shorter in the intervention (36.09 days) than the control (53.13 days) group (standard error = 0.15, P = .01, negative binomial regression). CONCLUSION Cognitively stimulating activities did not improve delirium but improved executive function and reduced length of stay. Resolution of delirium may require more-intense nonpharmacological management when the individual has dementia.
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Affiliation(s)
- Ann Kolanowski
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Donna Fick
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Mark Litaker
- School of Dentistry, University of Alabama, Birmingham, Alabama
| | - Paula Mulhall
- Prevention Research Center, College of Health and Human Development, Pennsylvania State University, University Park, Pennsylvania
| | - Linda Clare
- Centre for Research in Ageing and Cognitive Health, Washington Singer Laboratories, Exeter, United Kingdom
| | - Nikki Hill
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Jacqueline Mogle
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Malaz Boustani
- School of Medicine and Aging Brain Center, Indiana University, Indianapolis, Indiana
| | - David Gill
- Rochester Regional Health, University of Rochester, Rochester, New York.,Department of Neurology, University of Rochester, Rochester, New York
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Jones RN, Marcantonio ER, Saczynski JS, Tommet D, Gross AL, Travison TG, Alsop DC, Schmitt EM, Fong TG, Cizginer S, Shafi MM, Pascual-Leone A, Inouye SK. Preoperative Cognitive Performance Dominates Risk for Delirium Among Older Adults. J Geriatr Psychiatry Neurol 2016; 29:320-327. [PMID: 27647793 PMCID: PMC5357583 DOI: 10.1177/0891988716666380] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cognitive impairment is a well-recognized risk factor for delirium. Our goal was to determine whether the level of cognitive performance across the nondemented cognitive ability spectrum is correlated with delirium risk and to gauge the importance of cognition relative to other known risk factors for delirium. METHODS The Successful Aging after Elective Surgery study enrolled 566 adults aged ≥70 years scheduled for major surgery. Patients were assessed preoperatively and daily during hospitalization for the occurrence of delirium using the Confusion Assessment Method. Cognitive function was assessed preoperatively with an 11-test neuropsychological battery combined into a composite score for general cognitive performance (GCP). We examined the risk for delirium attributable to GCP, as well as demographic factors, vocabulary ability, and informant-rated cognitive decline, and compared the strength of association with risk factors identified in a previously published delirium prediction rule for delirium. RESULTS Delirium occurred in 135 (24%) patients. Lower GCP score was strongly and linearly predictive of delirium risk (relative risk = 2.0 per each half standard deviation difference in GCP score, 95% confidence interval, 1.5-2.5). This effect was not attenuated by statistical adjustment for demographics, vocabulary ability, and informant-rated cognitive decline. The effect was stronger than, and largely independent from, both standard delirium risk factors and comorbidity. CONCLUSION Risk of delirium is linearly and strongly related to presurgical cognitive performance level even at levels above the population median, which would be considered unimpaired.
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Affiliation(s)
| | | | | | | | | | | | - David C Alsop
- 2 Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Tamara G Fong
- 2 Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Mouhsin M Shafi
- 2 Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Sharon K Inouye
- 2 Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
- 5 Hebrew SeniorLife, Boston, MA, USA
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35
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Wildes TS, Winter AC, Maybrier HR, Mickle AM, Lenze EJ, Stark S, Lin N, Inouye SK, Schmitt EM, McKinnon SL, Muench MR, Murphy MR, Upadhyayula RT, Fritz BA, Escallier KE, Apakama GP, Emmert DA, Graetz TJ, Stevens TW, Palanca BJ, Hueneke RL, Melby S, Torres B, Leung J, Jacobsohn E, Avidan MS. Protocol for the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) study: a pragmatic, randomised clinical trial. BMJ Open 2016; 6:e011505. [PMID: 27311914 PMCID: PMC4916634 DOI: 10.1136/bmjopen-2016-011505] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Postoperative delirium, arbitrarily defined as occurring within 5 days of surgery, affects up to 50% of patients older than 60 after a major operation. This geriatric syndrome is associated with longer intensive care unit and hospital stay, readmission, persistent cognitive deterioration and mortality. No effective preventive methods have been identified, but preliminary evidence suggests that EEG monitoring during general anaesthesia, by facilitating reduced anaesthetic exposure and EEG suppression, might decrease incident postoperative delirium. This study hypothesises that EEG-guidance of anaesthetic administration prevents postoperative delirium and downstream sequelae, including falls and decreased quality of life. METHODS AND ANALYSIS This is a 1232 patient, block-randomised, double-blinded, comparative effectiveness trial. Patients older than 60, undergoing volatile agent-based general anaesthesia for major surgery, are eligible. Patients are randomised to 1 of 2 anaesthetic approaches. One group receives general anaesthesia with clinicians blinded to EEG monitoring. The other group receives EEG-guidance of anaesthetic agent administration. The outcomes of postoperative delirium (≤5 days), falls at 1 and 12 months and health-related quality of life at 1 and 12 months will be compared between groups. Postoperative delirium is assessed with the confusion assessment method, falls with ProFaNE consensus questions and quality of life with the Veteran's RAND 12-item Health Survey. The intention-to-treat principle will be followed for all analyses. Differences between groups will be presented with 95% CIs and will be considered statistically significant at a two-sided p<0.05. ETHICS AND DISSEMINATION Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) is approved by the ethics board at Washington University. Recruitment began in January 2015. Dissemination plans include presentations at scientific conferences, scientific publications, internet-based educational materials and mass media. TRIAL REGISTRATION NUMBER NCT02241655; Pre-results.
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Affiliation(s)
- T S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - A C Winter
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - H R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - A M Mickle
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - E J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - S Stark
- Department of Occupational Therapy, Washington University Institute for Public Health, School of Medicine, St. Louis, Missouri, USA
- Department of Neurology, Washington University Institute for Public Health, School of Medicine, St. Louis, Missouri, USA
| | - N Lin
- Department of Mathematics, Biostatistics Division, Washington University in St. Louis, St. Louis, Missouri, USA
| | - S K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - E M Schmitt
- Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - S L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M R Muench
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M R Murphy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - R T Upadhyayula
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - K E Escallier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - G P Apakama
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - D A Emmert
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - T J Graetz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - T W Stevens
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - R L Hueneke
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - S Melby
- Department of Surgery, Cardiothoracic Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - B Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - J Leung
- Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - E Jacobsohn
- Department of Anesthesia, University of Manitoba/Winnipeg Regional Health Authority Anesthesia Program, Winnipeg, Manitoba, Canada
| | - M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Grocott HP. Delirium after aortic replacement: A transvalvular approach is no panacea. J Thorac Cardiovasc Surg 2016; 151:823-824. [DOI: 10.1016/j.jtcvs.2015.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 11/30/2022]
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