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Marquetand J, Bode L, Fuchs S, Ernst J, von Känel R, Boettger S. Delirium: Prevalence and outcome in the very old in 27 medical departments during a one-year prospective study. Palliat Support Care 2022; 20:779-784. [PMID: 36942581 DOI: 10.1017/s1478951521001814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The prevalence and effects of delirium in very old individuals aged ≥80 years have not yet been systematically evaluated. Therefore, this large single-center study of the one-year prevalence of delirium in 3,076 patients in 27 medical departments of the University Hospital of Zurich was conducted. METHODS Patient scores on the Delirium Observation Screening scale, Intensive Care Delirium Screening Checklist, Diagnostic and Statistical Manual, 5th edition, and electronic Patient Assessment-Acute Care (nursing tool) resulted in the inclusion of 3,076 individuals in 27 departments. The prevalence rates were determined by simple logistic regressions, odds ratios (ORs), and confidence intervals. RESULTS Of the 3,076 patients, 1,285 (41.8%) developed delirium. The prevalence rates in the 27 departments ranged from 15% in rheumatology (OR = 0.30) to 73% in intensive care (OR = 5.25). Delirious patients were more likely to have been admitted from long-term care facilities (OR = 2.26) or because of emergencies (OR = 2.24). The length of their hospital stay was twice as long as that for other patients. Some died before discharge (OR = 24.88), and others were discharged to nursing homes (OR = 2.96) or assisted living facilities (OR = 2.2). CONCLUSION This is the largest study to date regarding the prevalence of delirium in patients aged ≥80 years and the medical characteristics of these patients. Almost two out of five patients developed delirium, with a high risk of loss of independence and mortality.
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Affiliation(s)
- Justus Marquetand
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Epileptology, Hertie-Institute for Clinical Brain Research, University of Tubingen, Tubingen, Germany
- Department of Neural Dynamics and Magnetoencephalography, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- MEG-Center, University of Tübingen, Tübingen, Germany
| | - Leonie Bode
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon Fuchs
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Institute of Nursing Science, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Soenke Boettger
- University Hospital Zurich, University Zurich, Zurich, Switzerland
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Bansal A, Saad A, Jain V, Gad MM, Unai S, Yun JJ, Krishnaswamy A, Kapadia SR. Delirium Predicts Worse Outcomes in Both Transcatheter and Surgical Aortic Valve Replacement. JACC Cardiovasc Interv 2021; 14:1738-1740. [PMID: 34353606 DOI: 10.1016/j.jcin.2021.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/27/2021] [Accepted: 05/18/2021] [Indexed: 12/20/2022]
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Zhao Y, Yue J, Lei P, Lin T, Peng X, Xie D, Gao L, Shu X, Wu C. Neutrophil-lymphocyte ratio as a predictor of delirium in older internal medicine patients: a prospective cohort study. BMC Geriatr 2021; 21:334. [PMID: 34034650 PMCID: PMC8147036 DOI: 10.1186/s12877-021-02284-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 05/11/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUNDS Delirium is a common neuropsychiatric syndrome in older hospitalized patients. Previous studies have suggested that inflammation and oxidative stress contribute to the pathophysiology of delirium. However, it remains unclear whether neutrophil-lymphocyte ratio (NLR), an indicator of systematic inflammation, is associated with delirium. This study aimed to investigate the value of NLR as an independent risk factor for delirium among older hospitalized patients. METHODS We conducted a prospective study of 740 hospitalized patients aged ≥ 70 years in the geriatric ward of West China Hospital of Sichuan University. Neutrophil and lymphocyte counts were collected within 24 h after hospital admission. Delirium was assessed on admission and every 48 h thereafter. We used the receiver operating characteristic analysis to assess the ability of the NLR for predicting delirium. The optimal cut-point value of the NLR was determined based on the highest Youden index (sensitivity + specificity - 1). Patients were categorized according to the cut-point value and quartiles of NLR, respectively. We then used logistic regression to identify the unadjusted and adjusted associations between NLR as a categorical variable and delirium. RESULTS The optimal cut-point value of NLR for predicting delirium was 3.626 (sensitivity: 75.2 %; specificity: 63.4 %; Youden index: 0.386). The incidence of delirium was significantly higher in patients with NLR > 3.626 than NLR ≤ 3.626 (24.5 % vs. 5.8 %; P < 0.001). Significantly fewer patients in the first quartile of NLR experienced delirium than in the third (4.3 % vs. 20.0 %; P < 0.001) and fourth quartiles of NLR (4.3 % vs. 24.9 %; P < 0.001). Results from the multivariable logistic regression models showed that NLR was independently associated with delirium. CONCLUSIONS NLR is a simple and practical marker that can predict the development of delirium in older internal medicine patients.
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Affiliation(s)
- Yanli Zhao
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China.
| | - Peng Lei
- Department of Neurology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Taiping Lin
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Xuchao Peng
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Dongmei Xie
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Langli Gao
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Xiaoyu Shu
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Chenkai Wu
- Global Health Research Center, Duke Kunshan University, 215300, Kunshan, Jiangsu Province, China
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4
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Functional Status and Instrumental Activities of Daily Living After Transcatheter Aortic Valve Replacement. TOPICS IN GERIATRIC REHABILITATION 2021. [DOI: 10.1097/tgr.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Humbert M, Büla CJ, Muller O, Krief H, Monney P. Delirium in older patients undergoing aortic valve replacement: incidence, predictors, and cognitive prognosis. BMC Geriatr 2021; 21:153. [PMID: 33653285 PMCID: PMC7927377 DOI: 10.1186/s12877-021-02100-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/22/2021] [Indexed: 12/14/2022] Open
Abstract
Background Transcatheter aortic valve replacement is increasingly performed in frail older patients who were previously ineligible for a standard surgical procedure. The objectives of this study are to determine delirium incidence, predictors, and relationship with cognitive performance at 3-month follow-up in older patients undergoing aortic valve replacement (AVR). Methods Patients (N = 93) aged 70 years and older, undergoing transcatheter (TAVR, N = 66) or surgical (SAVR, N = 27) aortic valve replacement in an academic medical center were enrolled in this prospective cohort study. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days 1, 2, 3, and 7. Data on patients’ socio-demographics, functional status (including instrumental activities of daily living (IADL), and surgical risk scores (including Society of Thoracic Surgeons (STS) risk score), were collected at baseline. Cognitive status was assessed with the Mini-Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) at baseline and 3 months after AVR. Results Delirium occurred in 21 (23%) patients, within the first three postoperative days in 95% (20/21) of the cases. Delirium incidence was lower in TAVR (13/66 = 20%) than SAVR (8/27 = 30%) patients, but this difference was not statistically significant (p = .298). Patients with delirium had lower baseline cognitive performance (median MMSE score 27.0 ± 3.0 vs 28.0 ± 3.0, p = .029), lower performance in IADL (7.0 vs 8.0, p = .038), and higher STS risk scores (4.7 ± 2.7 vs 2.9 ± 2.3, p = .020). In multivariate analyses, patients with intermediate (score > 3 to ≤8) and high (score > 8) STS risk scores had 4.3 (95%CI 1.2–15.1, p = .025) and 16.5 (95%CI 2.0–138.2, p = .010), respectively, higher odds of incident delirium compared to patients with low (score ≤ 3) STS risk scores. At 3-month follow-up (N = 77), patients with delirium still had lower MMSE score (27.0 ± 8.0 vs 28.0 ± 2.0, p = .007) but this difference did not remain significant once adjusting for baseline MMSE (β-coefficient 1.11, 95%CI [− 3.03–0.80], p = .248). Conclusions Delirium occurred in about one in five older patients undergoing AVR, almost essentially within the first three postoperative days. Beside cognitive performance, STS risk score could enhance the identification of high-risk older patients to better target preventative interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02100-5.
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Affiliation(s)
- Marc Humbert
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland.
| | - Christophe J Büla
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| | - Olivier Muller
- Service of Cardiology, Department of Cardio-Vascular Medicine and Surgery, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| | - Hélène Krief
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| | - Pierre Monney
- Service of Cardiology, Department of Cardio-Vascular Medicine and Surgery, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
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Skaar E, Øksnes A, Eide LSP, Norekvål TM, Ranhoff AH, Nordrehaug JE, Forman DE, Schoenenberger AW, Hufthammer KO, Kuiper KKJ, Bleie Ø, Packer EJS, Langørgen J, Haaverstad R, Schaufel MA. Baseline frailty status and outcomes important for shared decision-making in older adults receiving transcatheter aortic valve implantation, a prospective observational study. Aging Clin Exp Res 2021; 33:345-352. [PMID: 32193850 PMCID: PMC7914240 DOI: 10.1007/s40520-020-01525-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/26/2020] [Indexed: 02/07/2023]
Abstract
AIMS The objective of this study was to examine baseline frailty status (including cognitive deficits) and important clinical outcomes, to inform shared decision-making in older adults receiving transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS We conducted a prospective, observational study of 82 TAVI patients, recruited 2013 to 2015, with 2-year follow-up. Mean age was 83 years (standard deviation (SD) 4.7). Eighteen percent of the patients were frail, as assessed with an 8-item frailty scale. Fifteen patients (18%) had a Mini-Mental Status Examination (MMSE) score below 24 points at baseline, indicating cognitive impairment or dementia and five patients had an MMSE below 20 points. Mean New York Heart Association (NYHA) class at baseline and 6 months was 2.5 (SD 0.6) and 1.4 (SD 0.6), (p < 0.001). There was no change in mean Nottingham Extended Activities of Daily Living (NEADL) scale between baseline and 6 months, 54.2 (SD 11.5) and 54.5 (SD 10.3) points, respectively, mean difference 0.3 (p = 0.7). At 2 years, six patients (7%) had died, four (5%, n = 79) lived in a nursing home, four (5%) suffered from disabling stroke, and six (7%) contracted infective endocarditis. CONCLUSIONS TAVI patients had improvement in symptoms and maintenance of activity of daily living at 6 months. They had low mortality and most patients lived in their own home 2 years after TAVI. Complications like death, stroke, and endocarditis occurred. Some patients had cognitive impairment before the procedure which might influence decision-making. Our findings may be used to develop pre-TAVI decision aids.
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Delirium After TAVR. JACC Cardiovasc Interv 2020; 13:2453-2466. [DOI: 10.1016/j.jcin.2020.07.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/02/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
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Beishuizen SJ, Festen S, Loonstra YE, van der Werf HW, de Rooij SE, van Munster BC. Delirium, functional decline and quality of life after transcatheter aortic valve implantation: An explorative study. Geriatr Gerontol Int 2020; 20:1202-1207. [PMID: 33098368 PMCID: PMC7756254 DOI: 10.1111/ggi.14064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 09/08/2020] [Accepted: 10/01/2020] [Indexed: 12/17/2022]
Abstract
AIM Transcatheter aortic valve implantation (TAVI) has become an important treatment option for older patients with severe aortic stenosis. However, not all patients benefit from this procedure in terms of functional outcome and quality of life. This complicates patient selection and shared decision-making. Postoperative delirium might negatively affect patient outcomes after TAVI. We therefore studied the potential relationship between postoperative delirium and functional outcome, and how this impacts quality of life after TAVI. METHODS This was a prospective cohort study of 91 consecutive patients undergoing TAVI between 2015 and 2017 at an academic medical center. All patients underwent a Comprehensive Geriatric Assessment before TAVI. Delirium symptoms were assessed daily during hospitalization. Follow up was carried out between 6 and 12 months postprocedure. The primary outcome was functional decline or death at follow up. Secondarily, we measured quality of life at follow up. RESULTS The incidence of postoperative delirium was 15.4%. In total, 38.5% of patients experienced functional decline, and 11.0% died during a median follow-up period of 7 months. Delirium resulted in a fourfold increased odds of the combined outcome of functional decline or death. Quality of life was lower in patients that experienced this outcome. CONCLUSION In a cohort of TAVI patients, functional decline or death was a frequent outcome in the first year postprocedure. Postoperative delirium increased the odds for this outcome substantially. This suggests that delirium risk should be an important factor to consider in shared decision-making for TAVI patients. Geriatr Gerontol Int 2020; 20: 1202-1207.
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Affiliation(s)
- Sara J Beishuizen
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Suzanne Festen
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Yvette E Loonstra
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Hindrik W van der Werf
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Sophia E de Rooij
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands.,Medical School Twente, Medical Spectrum Twente, Enschede, the Netherlands
| | - Barbara C van Munster
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
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Rao A, Shi SM, Afilalo J, Popma JJ, Khabbaz KR, Laham RJ, Guibone K, Marcantonio ER, Kim DH. Physical Performance and Risk of Postoperative Delirium in Older Adults Undergoing Aortic Valve Replacement. Clin Interv Aging 2020; 15:1471-1479. [PMID: 32921993 PMCID: PMC7455771 DOI: 10.2147/cia.s257079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022] Open
Abstract
Background Delirium is a major risk factor for poor recovery after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). It is unclear whether preoperative physical performance tests improve delirium prediction. Objective To examine whether physical performance tests can predict delirium after SAVR and TAVR, and adapt an existing delirium prediction rule for cardiac surgery, which includes Mini-Mental State Examination (MMSE), depression, prior stroke, and albumin level. Design Prospective cohort, 2014-2017. Setting Single academic center. Subjects A total of 187 patients undergoing SAVR (n=77) or TAVR (n=110). Methods The Short Physical Performance Battery (SPPB) score was calculated based on gait speed, balance, and chair stands (range: 0-12 points, lower scores indicate poor performance). Delirium was assessed using the Confusion Assessment Method. We fitted logistic regression to predict delirium using SPPB components and risk factors of delirium. Results Delirium occurred in 35.8% (50.7% in SAVR and 25.5% in TAVR). The risk of delirium increased for lower SPPB scores: 10-12 (28.2%), 7-9 (34.5%), 4-6 (37.5%) and 0-3 (44.1%) (p-for-trend=0.001). A model that included gait speed <0.46 meter/second (OR, 2.7; 95% CI, 1.2-6.4), chair stands time ≥11.2 seconds (OR, 3.5; 95% CI, 1.0-12.4), MMSE <24 points (OR, 2.9; 95% CI, 1.3-6.4), isolated SAVR (OR, 5.4; 95% CI, 2.1-13.8), and SAVR and coronary artery bypass grafting (OR, 15.8; 95% CI, 5.5-45.7) predicted delirium better than the existing prediction rule (C statistics: 0.71 vs 0.61; p=0.035). Conclusion Assessing physical performance, in addition to cognitive function, can help identify high-risk patients for delirium after SAVR and TAVR.
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Affiliation(s)
- Aarti Rao
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sandra M Shi
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Jonathan Afilalo
- Division of Cardiology and Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeffrey J Popma
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kamal R Khabbaz
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Roger J Laham
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kimberly Guibone
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Edward R Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dae Hyun Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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Khan SH, Xu C, Wang S, Gao S, Lasiter S, Kesler K, Khan BA. Effect of Delirium on Physical Function in Noncardiac Thoracic Surgery Patients. Am J Crit Care 2020; 29:e39-e43. [PMID: 32114617 DOI: 10.4037/ajcc2020579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The effect of delirium on physical function in patients undergoing noncardiac thoracic surgery has not been well described and may differ from that in other surgical populations. OBJECTIVE To determine the effects of delirium on muscle strength and functional independence. The primary end point was change in Medical Research Council sum score (MRC-SS) by delirium status. METHODS A secondary analysis of data from a clinical trial involving English-speaking adults aged 18 years or older who were undergoing major noncardiac thoracic surgery. Exclusion criteria were history of schizophrenia, Parkinson disease, dementia, alcohol abuse, or neuroleptic malignant syndrome; haloperidol allergy; being pregnant or nursing; QT prolongation; and taking levodopa or cholinesterase inhibitors. Delirium was assessed twice daily using the Confusion Assessment Method for the Intensive Care Unit. Preoperatively and postoperatively, muscle strength was assessed using the modified MRC-SS and functional independence was assessed using the Katz scale of activities of daily living. Changes in MRC-SS and Katz score by delirium status were analyzed using the Fisher exact test. RESULTS Seventy-three patients were included in the analysis. Median (interquartile range) MRC-SS and Katz score before surgery did not differ significantly between patients without and with delirium (MRC-SS: 30 [30-30] vs 30 [30-30], P > .99; Katz score: 6 [6-6] vs 6 [6-6], P = .63). The percentage of patients with a change in MRC-SS was similar in patients without and with delirium (17% vs 13%, respectively; P > .99). More patients in the delirium group had a change in Katz score (13% vs 0%, P = .04). CONCLUSIONS Postoperative delirium was not associated with change in muscle strength. Follow-up studies using other muscle measures may be needed.
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Affiliation(s)
| | | | - Sophia Wang
- Sophia Wang is an assistant clinical professor, Department of Psychiatry, Indiana University School of Medicine
| | - Sujuan Gao
- Sujuan Gao is a professor, Department of Biostatistics, Indiana University School of Medicine
| | - Sue Lasiter
- Sue Lasiter is an associate professor, University of Missouri–Kansas City School of Nursing and Health Studies, Kansas City, Missouri
| | - Kenneth Kesler
- Kenneth Kesler is a professor, Department of Cardiothoracic Surgery, Indiana University School of Medicine
| | - Babar A. Khan
- Babar A. Khan is an associate professor, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, and IU Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana
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Strike E, Arklina B, Stradins P, Cusimano RJ, Osten M, Horlick E, Styra R, Poonawala H, Carroll J, Djaiani G. Postoperative Pain Management Strategies and Delirium After Transapical Aortic Valve Replacement: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2019; 33:1668-1672. [DOI: 10.1053/j.jvca.2018.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Indexed: 11/11/2022]
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12
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Shi SM, Sung M, Afilalo J, Lipsitz LA, Kim CA, Popma JJ, Khabbaz KR, Laham RJ, Guibone K, Lee J, Marcantonio ER, Kim DH. Delirium Incidence and Functional Outcomes After Transcatheter and Surgical Aortic Valve Replacement. J Am Geriatr Soc 2019; 67:1393-1401. [PMID: 30882905 DOI: 10.1111/jgs.15867] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/13/2019] [Accepted: 02/13/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) may be associated with less delirium and allow faster recovery than surgical aortic valve replacement (SAVR). OBJECTIVE To examine the association of delirium and its severity with clinical and functional outcomes after SAVR and TAVR. DESIGN Prospective cohort study. SETTING An academic medical center. PARTICIPANTS A total of 187 patients, aged 70 years and older, undergoing SAVR (N = 77) and TAVR (N = 110) in 2014 to 2016. MEASUREMENTS Delirium was assessed daily using the Confusion Assessment Method (CAM), with severity measured by the CAM-Severity (CAM-S) score (range = 0-19). Outcomes were prolonged hospitalization (9 days or more); institutional discharge; and functional status, measured by ability to perform 22 daily activities and physical tasks over 12 months. RESULTS SAVR patients had a higher incidence of delirium than TAVR patients (50.7% vs 25.5%; P < .001), despite younger mean age (77.9 vs 83.7 years) and higher baseline Mini-Mental State Examination score (26.9 vs 24.7). SAVR patients with delirium had a shorter duration (2.2 vs 3.4 days; P = .04) with a lower mean CAM-S score (4.5 vs 5.7; P = .01) than TAVR patients with delirium. The risk of prolonged hospitalization in no, mild, and severe delirium was 18.4%, 30.8%, and 61.5% after SAVR (P for trend = .009) and 26.8%, 38.5%, and 73.3% after TAVR (P for trend = .001), respectively. The risk of institutional discharge was 42.1%, 58.3%, and 84.6% after SAVR (P for trend = .01) and 32.5%, 69.2%, and 80.0% after TAVR (P for trend <.001), respectively. Severe delirium was associated with delayed functional recovery after SAVR and persistent functional impairment after TAVR at 12 months. CONCLUSION Less invasive TAVR was associated with lower incidence of delirium than SAVR. Once delirium developed, TAVR patients had more severe delirium and worse functional status trajectory than SAVR patients did. REGISTRATION NCT01845207.
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Affiliation(s)
- Sandra M Shi
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Minhee Sung
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Jonathan Afilalo
- Division of Cardiology and Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Lewis A Lipsitz
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Caroline A Kim
- Division of Hospital Medicine, South Shore Hospital, Weymouth, Massachusetts
| | - Jeffrey J Popma
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kamal R Khabbaz
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Roger J Laham
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kimberly Guibone
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jung Lee
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Edward R Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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13
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Potter BJ, Thompson C, Green P, Clancy S. Incremental cost and length of stay associated with postprocedure delirium in transcatheter and surgical aortic valve replacement patients in the United States. Catheter Cardiovasc Interv 2018; 93:1132-1136. [PMID: 30549428 DOI: 10.1002/ccd.28014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 11/07/2018] [Accepted: 11/14/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To explore the impact of post-procedure delirium on resource utilization following transcatheter and surgical aortic valve replacement (TAVR and SAVR, respectively). BACKGROUND Postprocedure delirium is associated with worse long-term survival after TAVR and SAVR. However, its effect on resource utilization has been understudied. METHODS Using the 2015 Medicare Provider Analysis and Review File (MedPAR), we retrospectively analyzed elderly (≥80 years) Medicare beneficiaries receiving either SAVR or endovascular TAVR in the United States. Multivariate regression models estimating hospitalization cost and length of stay (LoS) were adjusted for patient demographics, comorbidities, and nondelirium complications. RESULTS A total of 21,088 discharges were available for analysis (12,114 TAVR and 8,974 SAVR). TAVR patients were older (87 ± 3.8 vs. 84 ± 2.7 years; P < 0.001) with a higher comorbidity burden (Charlson index 3.0 ± 1.8 vs. 2.1 ± 1.7; P < 0.0001). Despite this, fewer TAVR patients (1.6%) experienced postoperative delirium during the index hospitalization compared to surgical patients (3.6%; P < 0.0001). Delirium was associated with a 4.16 [3.51-4.81] day longer hospital LoS and $15,592 ($12,849-$18,334) higher incremental hospitalization cost. When stratified by treatment approach, the adjusted incremental cost of delirium was +$13,862 ($9,431-$18,292) with TAVR and +$16,656 ($13,177-$20,136) with SAVR with an additional hospital LoS of +3.39 (2.34-4.43) days and +4.63 (3.81-5.45) days for TAVR and SAVR, respectively. CONCLUSIONS Postprocedure delirium is associated with significantly increased hospitalization costs and LoS following AVR. TAVR was associated with a lower postoperative delirium rate compared to SAVR. Post-TAVR delirium may be associated with less resource consumption than post-SAVR delirium.
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Affiliation(s)
- Brian J Potter
- Interventional Cardiology Service, Cardiovascular Center, University of Montreal Hospital Center (CHUM), Montreal, Quebec, Canada.,Carrefour d'innovation et d'évaluation en santé (CIÉS), Research Center of the University of Montreal Hospital Center (CRCHUM), Montreal, Quebec, Canada
| | | | - Philip Green
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
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14
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Tilley E, Psaltis PJ, Loetscher T, Davis DH, Harrison SL, Kim S, Keage HA. Meta-analysis of Prevalence and Risk Factors for Delirium After Transcatheter Aortic Valve Implantation. Am J Cardiol 2018; 122:1917-1923. [PMID: 30293651 PMCID: PMC6269593 DOI: 10.1016/j.amjcard.2018.08.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/10/2018] [Accepted: 08/16/2018] [Indexed: 12/21/2022]
Abstract
Delirium is a severe and common complication following transcatheter aortic valve implantation (TAVI). We sought to identify the prevalence and risk factors associated with the development of postprocedural delirium in patients aged over 60 years who underwent elective TAVI for aortic stenosis. Overall, 1,051 articles were searched, from which 9 studies were included. The prevalence of delirium following TAVI was higher in studies that assessed delirium for a minimum of 3 consecutive days (24.9%) compared with the studies that did not (2%). There were large effect sizes (d > 0.8) for 3 risk factors: acute kidney injury (odds ratio [OR] 5, p < 0.001), transapical approach (OR 4, p < 0.001) and carotid artery disease (OR 4, p < 0.001), whilst small effect sizes were found for a history of atrial fibrillation, prior stroke/transient ischemic attack, peripheral artery disease, hypertension, and prior cognitive impairment. In conclusion, 23% of patients 60 years and over who underwent TAVI experience delirium, a preventative cause of cognitive impairment and dementia. Recognition of risk factors for delirium after TAVI, such as a history of carotid artery disease, development of acute kidney injury, or use of a transapical approach, provides an opportunity to implement proven delirium preventative measures.
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15
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Eide LS, Ranhoff AH, Lauck S, Fridlund B, Haaverstad R, Hufthammer KO, Kuiper KKJ, Nordrehaug JE, Norekvål TM. Indwelling urinary catheters, aortic valve treatment and delirium: a prospective cohort study. BMJ Open 2018; 8:e021708. [PMID: 30389757 PMCID: PMC6224736 DOI: 10.1136/bmjopen-2018-021708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/23/2018] [Accepted: 10/05/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES To determine whether an association exists between delirium and length of time indwelling urine catheters (IUC) are used in octogenarian patients treated with surgical aortic valve treatment (SAVR) or transcatheter aortic valve implantation (TAVI). DESIGN Prospective cohort study. SETTING Tertiary university hospital covering the western region of Norway. PARTICIPANTS Octogenarian patients undergoing elective SAVR or TAVI and willing to participate in the study were eligible. Patients unable to speak Norwegian were excluded. Between 2011 and 2013, 143 consecutive patients were included, and data from 136 of them are presented. PRIMARY OUTCOME Delirium. RESULTS Logistic regression analysis shows that lower cognitive function was positively associated with delirium (OR 0.86, CI 0.74 to 0.99, p=0.047). Besides, the interaction term in the model shows that IUC use and delirium differed between SAVR and TAVI patients (p=0.04). The difference corresponded to a weaker association between hours of IUC use and delirium for SAVR (OR 1.01, CI: 0.99 to 1.03, p=0.54) compared with that for TAVI (OR 1.04, CI: 1.01 to 1.08, p=0.004). CONCLUSIONS The association between IUC use and delirium is stronger for octogenarian patients treated with TAVI than for patients who received SAVR. Our results revealed a previously unknown association between the number of hours an IUC is used and postoperative delirium in octogenarian patients treated with TAVI.
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Affiliation(s)
- Leslie Sp Eide
- Department of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Anette H Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Kavli Research Center for Geriatrics and Dementia, Haraldsplass Hospital, Bergen, Norway
| | - Sandra Lauck
- Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, Canada
- University of British Columbia, Vancouver, Canada
| | - Bengt Fridlund
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune Haaverstad
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | | | - Karel K J Kuiper
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jan Erik Nordrehaug
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Tone Merete Norekvål
- Department of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
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16
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Abawi M, Pagnesi M, Agostoni P, Chiarito M, van Jaarsveld RC, van Dongen CS, Slooter AJC, Colombo A, Kooistra NHM, Doevendans PAFM, Latib A, Stella PR. Postoperative Delirium in Individuals Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2018; 66:2417-2424. [PMID: 30296342 DOI: 10.1111/jgs.15600] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/01/2018] [Accepted: 08/15/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate the incidence of in-hospital postoperative delirium (IHPOD) after transcatheter aortic valve replacement (TAVR). DESIGN Systematic review and meta-analysis. SETTING Elective procedures PARTICIPANTS: Individuals undergoing TAVR. MEASUREMENTS A literature search was conducted in PubMed, Embase, BioMedCentral, Google Scholar, and the Cochrane Central Register of Controlled Trials (up to December 2017). All observational studies reporting the incidence of IHPOD after TAVR (sample size > 25) were included in our meta-analysis. The reported incidence rates were weighted to obtain a pooled estimate rate with 95% confidence interval (CI). RESULTS Of 96 potentially relevant articles, 31 with a total of 32,389 individuals who underwent TAVR were included in the meta-analysis. The crude incidence of IHPOD after TAVR ranged from 0% to 44.6% in included studies, with a pooled estimate rate of 8.1% (95% CI=6.7-9.4%); heterogeneity was high (Q = 449; I = 93%; pheterogeneity < .001). The pooled estimate rate of IHPOD was 7.2% (95% CI=5.4-9.1%) after transfemoral (TF) TAVR and 21.4% (95% CI=10.3-32.5%) after non-TF TAVR. CONCLUSION Delirium occurs frequently after TAVR and is more common after non-TF than TF procedures. Recommendations are made with the aim of standardizing future research to reduce heterogeneity between studies on this important healthcare problem. J Am Geriatr Soc 66:2417-2424, 2018.
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Affiliation(s)
- Masieh Abawi
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Matteo Pagnesi
- Interventional Cardiology Unit San Raffaele Scientific Institute, Milan, Italy
| | - Pierfrancesco Agostoni
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Mauro Chiarito
- Cardio Center Humanitas Research Hospital, Rozzano Milan, Italy
| | - Romy C van Jaarsveld
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Charlotte S van Dongen
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Antonio Colombo
- Interventional Cardiology Unit San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Nynke H M Kooistra
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pieter A F M Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Azeem Latib
- Interventional Cardiology Unit San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Pieter R Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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17
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Tsui A, Kuh D, Richards M, Davis D. Delirium symptoms are associated with decline in cognitive function between ages 53 and 69 years: Findings from a British birth cohort study. Alzheimers Dement 2018; 14:617-622. [PMID: 29161540 PMCID: PMC5948100 DOI: 10.1016/j.jalz.2017.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/23/2017] [Accepted: 08/30/2017] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Few population studies have investigated whether longitudinal decline after delirium in mid-to-late life might affect specific cognitive domains. METHODS Participants from a birth cohort completing assessments of search speed, verbal memory, and the Addenbrooke's Cognitive Examination at age 69 were asked about delirium symptoms between ages 60 and 69 years. Linear regression models estimated associations between delirium symptoms and cognitive outcomes. RESULTS Period prevalence of delirium between 60 and 69 years was 4% (95% confidence interval 3.2%-4.9%). Self-reported symptoms of delirium over the seventh decade were associated with worse scores in the Addenbrooke's Cognitive Examination (-1.7 points; 95% confidence interval -3.2, -0.1; P = .04). In association with delirium symptoms, verbal memory scores were initially lower, with subsequent decline in search speed by the age of 69 years. These effects were independent of other Alzheimer's risk factors. DISCUSSION Delirium symptoms may be common even at relatively younger ages, and their presence may herald cognitive decline, particularly in search speed, over this time period.
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Affiliation(s)
- Alex Tsui
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK.
| | - Diana Kuh
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
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18
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Eggebrecht H, Bestehorn K, Rassaf T, Bestehorn M, Voigtländer T, Fleck E, Schächinger V, Schmermund A, Mehta RH. In-hospital outcomes after transcatheter or surgical aortic valve replacement in younger patients less than 75 years old: a propensity-matched comparison. EUROINTERVENTION 2018; 14:50-57. [DOI: 10.4244/eij-d-17-01051] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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19
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Khan MM, Herrmann N, Gallagher D, Gandell D, Fremes SE, Wijeysundera HC, Radhakrishnan S, Sun YR, Lanctôt KL. Cognitive Outcomes After Transcatheter Aortic Valve Implantation: A Metaanalysis. J Am Geriatr Soc 2017; 66:254-262. [PMID: 29159840 DOI: 10.1111/jgs.15123] [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] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To quantitatively summarize changes in cognitive performance in individuals with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). DESIGN Metaanalysis. PARTICIPANTS Individuals undergoing TAVI (N = 1,065 (48.5% male) from 18 studies, average age ≥80). MEASUREMENTS The MEDLINE, EMBASE, and Cochrane Central databases were searched for original peer-reviewed reports assessing cognitive performance using standardized cognitive tests before and after TAVI. Data were extracted for cognitive scores before TAVI; perioperatively (within 7 days after TAVI); 1, 3, and 6 months after TAVI, and 12 to 34 months after TAVI (over the long term). Standardized mean differences (SMDs) were generated using random-effects models for changes in cognition at each time point. Metaregression analyses were conducted to assess the association between population and procedural characteristics and cognitive outcomes. Risk of bias was assessed. RESULTS There were no significant changes from baseline in perioperative cognitive performance (SMD = 0.05, 95% confidence interval (CI) = -0.08-0.18; z = 0.75, P = .46), although overall cognitive performance had improved significantly 1 month after TAVI (SMD = -0.33, 95% CI = -0.50 to -0.16; z = 3.83, P < .001). There were no differences in cognitive performance 3 and 6 months after TAVI or over the long term. Cognitive outcomes were not associated with any covariates in regression analyses. CONCLUSION Cognitive performance is preserved after TAVI, suggesting TAVI is not detrimental to cognition.
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Affiliation(s)
- Maisha M Khan
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Nathan Herrmann
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Damien Gallagher
- Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Dov Gandell
- Department of Geriatric Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Sam Radhakrishnan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yue Ran Sun
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Krista L Lanctôt
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
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20
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Bagienski M, Kleczynski P, Dziewierz A, Rzeszutko L, Sorysz D, Trebacz J, Sobczynski R, Tomala M, Stapor M, Dudek D. Incidence of Postoperative Delirium and Its Impact on Outcomes After Transcatheter Aortic Valve Implantation. Am J Cardiol 2017; 120:1187-1192. [PMID: 28826892 DOI: 10.1016/j.amjcard.2017.06.068] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 05/30/2017] [Accepted: 06/15/2017] [Indexed: 01/05/2023]
Abstract
There are limited data on the occurrence of postoperative delirium after transcatheter aortic valve implantation (TAVI). We sought to investigate the incidence of delirium after TAVI and its impact on clinical outcomes. A total of 148 consecutive patients who underwent TAVI were enrolled. Of these patients, 141 patients survived hospital stay. The incidence of delirium was assessed in these patients for the first 4 days after the index procedure. The patients were divided into 2 groups based on the presence of delirium. Baseline characteristics, procedural and long-term outcomes, and frailty and quality-of-life indexes were compared among the groups. Of the 141 patients analyzed, 29 patients developed delirium. The transapical access was more common in patients with delirium (51.7% vs 8.9%, p <0.001). A greater median contrast volume load in the delirium group was noted (75 vs 100 ml, p = 0.001). Significantly more patients with delirium were considered as frail before TAVI. Thirty-day and 12-month all-cause mortality rates were higher in the delirium group (0.0% vs 17.2%, p <0.001; and 3.6% vs 37.9%, p <0.001, respectively). Differences in mortality were significant even after adjustment for baseline characteristics. The quality of life at 12 months, assessed by the 3-level version of the EuroQol 5-dimensional questionnaire, was similar in both groups. Despite a relatively minimally invasive character of TAVI as compared with surgery, some patients experience delirium after TAVI. Importantly, the occurrence of delirium after TAVI may help to identify patients with worse short- and long-term outcomes.
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Affiliation(s)
- Maciej Bagienski
- Institute of Cardiology, Jagiellonian University, Krakow, Poland
| | - Pawel Kleczynski
- Institute of Cardiology, Jagiellonian University, Krakow, Poland.
| | - Artur Dziewierz
- Institute of Cardiology, Jagiellonian University, Krakow, Poland
| | - Lukasz Rzeszutko
- Institute of Cardiology, Jagiellonian University, Krakow, Poland
| | - Danuta Sorysz
- Institute of Cardiology, Jagiellonian University, Krakow, Poland
| | - Jaroslaw Trebacz
- Institute of Cardiology, Jagiellonian University, Krakow, Poland
| | | | - Marek Tomala
- Institute of Cardiology, Jagiellonian University, Krakow, Poland
| | - Maciej Stapor
- Institute of Cardiology, Jagiellonian University, Krakow, Poland
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University, Krakow, Poland
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21
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"Eight Days of Nightmares … " - Octogenarian Patients' Experiences of Postoperative Delirium after Transcatheter or Surgical Aortic Valve Replacement. Heart Lung Circ 2017; 27:260-266. [PMID: 28396186 DOI: 10.1016/j.hlc.2017.02.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/05/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are increasingly performed in octogenarian patients with severe aortic stenosis (AS), including those with high surgical risk. Postoperative delirium (PD) is a common and serious complication in older patients, characterised by reduced awareness, change in consciousness, disturbance in logical thinking and hallucinations. METHODS To explore how octogenarian patients experienced PD, a qualitative study was conducted including five women and five men between 81 and 88 years. The incidence of PD was assessed for five days using the Confusion Assessment Method. Cognitive function was assessed preoperatively and at a 6-month follow-up using the Mini-Mental State Examination. In-depth interviews were conducted 6-12 months post-discharge, transcribed, and analysed using Giorgi's phenomenological method. RESULTS Postoperative delirium experiences were grouped into six themes: "Like dreaming while awake", "Disturbed experiences of time", "Existing in a twilight zone", "Trapped in medical tubes", "Moving between different surroundings" and "Meeting with death and the deceased". CONCLUSIONS For the first time, we show that octogenarian patients who undergo SAVR or TAVI have strong and distressing memories of their delirious state that can persist for up to 12 months later. These findings provide valuable new information that will likely improve delivery of health services and enhance professional and empathic care of octogenarians after SAVR and TAVI.
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22
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Eide LSP, Ranhoff AH, Fridlund B, Haaverstad R, Hufthammer KO, Kuiper KKJ, Nordrehaug JE, Norekvål TM. Readmissions and mortality in delirious versus non-delirious octogenarian patients after aortic valve therapy: a prospective cohort study. BMJ Open 2016; 6:e012683. [PMID: 27707832 PMCID: PMC5073576 DOI: 10.1136/bmjopen-2016-012683] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To determine whether postoperative delirium predicts first-time readmissions and mortality in octogenarian patients within 180 days after aortic valve therapy with surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI), and to determine the most common diagnoses at readmission. DESIGN Prospective cohort study of patients undergoing elective SAVR or TAVI. SETTING Tertiary university hospital that performs all SAVRs and TAVIs in Western Norway. PARTICIPANTS Patients 80+ years scheduled for SAVR or TAVI and willing to participate in the study were eligible. Those unable to speak Norwegian were excluded. Overall, 143 patients were included, and data from 136 are presented. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was a composite variable of time from discharge to first all-cause readmission or death. Secondary outcomes were all-cause first readmission alone and mortality within 180 days after discharge, and the primary diagnosis at discharge from first-time readmission. Delirium was assessed with the confusion assessment method. First-time readmissions, diagnoses and mortality were identified in hospital information registries. RESULTS Delirium was identified in 56% of patients. The effect of delirium on readmissions and mortality was greatest during the first 2 months after discharge (adjusted HR 2.9 (95% CI 1.5 to 5.7)). Of 30 first-time readmissions occurring within 30 days, 24 (80%) were patients who experienced delirium. 1 patient (non-delirium group) died within 30 days after therapy. Delirious patients comprised 35 (64%) of 55 first-time readmissions occurring within 180 days. Circulatory system diseases and injuries were common causes of first-time readmissions within 180 days in delirious patients. 8 patients died 180 days after the procedure; 6 (75%) of them experienced delirium. CONCLUSIONS Delirium in octogenarians after aortic valve therapy might be a serious risk factor for postoperative morbidity and mortality. Cardiovascular disorders and injuries were associated with first-time readmissions in these patients.
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Affiliation(s)
- Leslie S P Eide
- Faculty of Health and Social Sciences, Bergen University College, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anette H Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Bengt Fridlund
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Rune Haaverstad
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | | | - Karel K J Kuiper
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | | | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
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