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Wang XJ. Research progress of postoperative delirium in neurosurgery. World J Psychiatry 2025; 15:104708. [DOI: 10.5498/wjp.v15.i4.104708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2024] [Revised: 01/25/2025] [Accepted: 03/07/2025] [Indexed: 03/25/2025] Open
Abstract
Delirium is a transient and acute syndrome of encephalopathy, characterized by disturbances in consciousness, orientation, cognition, perception, and emotional regulation, often accompanied by hallucinations, illusions, psychomotor agitation, and restlessness. Postoperative delirium (POD), a common complication particularly in elderly patients, significantly impacts recovery by prolonging mechanical ventilation, neurosurgical intensive care unit stays, and overall hospitalization durations, while severely diminishing patients’ quality of life after discharge. Despite its prevalence, POD remains underrecognized in clinical practice, with significant gaps in its diagnosis and management. This review explores the definition, diagnostic criteria, underlying pathogenesis, and associated risk factors of POD in neurosurgical patients, aiming to offer valuable insights for improving clinical diagnosis and therapeutic strategies.
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Affiliation(s)
- Xue-Jian Wang
- Department of Neurosurgery, Affiliated Hospital 2 of Nantong University, Nantong 226000, Jiangsu Province, China
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Fallon JM, Hashemaghaie M, Peterson CE, Tran D, Wu SR, Valdes JM, Pedicini NM, Adams ME, Soltis M, Mansour W, Wright MC, Raghunathan K, Treggiari MM, Sasannejad C, Devinney MJ. Protocol and design of the REPOSE study: a double-blinded, randomised, placebo-controlled trial to evaluate the efficacy of suvorexant to improve postoperative sleep and reduce delirium severity in older patients undergoing non-cardiac surgery. BMJ Open 2025; 15:e091099. [PMID: 40081971 PMCID: PMC11907038 DOI: 10.1136/bmjopen-2024-091099] [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] [Indexed: 03/16/2025] Open
Abstract
INTRODUCTION Postoperative delirium occurs in up to 40% of older surgical patients and has been associated with prolonged hospital stays, long-term cognitive impairment and increased 1-year postoperative mortality. Postoperative sleep disturbances may increase the risk of delirium, but studies investigating pharmacotherapies to improve postoperative sleep to prevent delirium remain limited. Suvorexant is a selective antagonist of orexin 1 and 2 receptors and is approved for insomnia pharmacotherapy by the Food and Drug Administration. It has the potential to improve postoperative sleep and reduce postoperative delirium rates, but randomised controlled trials (RCTs) are needed to determine the efficacy of postoperative suvorexant administration. The REPOSE study (reducing delirium by enhancing postoperative sleep with suvorexant) is a single-centre, randomised, double-blinded RCT that aims to evaluate the efficacy of suvorexant in increasing total sleep time (TST) and decreasing delirium severity in older patients undergoing non-cardiac surgery. METHODS AND ANALYSIS REPOSE will enroll 130 patients (aged ≥65 years) undergoing non-cardiac surgery with a planned postoperative inpatient stay. Participants will be randomised to receive 20 mg oral suvorexant or placebo nightly on postoperative nights 0, 1 and 2. The primary endpoint is TST on the first postoperative night, as measured using an electroencephalography headband. The secondary endpoint is peak postoperative delirium severity as measured by the 3-minute diagnostic interview for the confusion assessment method severity scores. Primary endpoint data will be analysed with a two-sample t-test using an intent-to-treat approach to compare TST on the first night that a patient received a study drug dose. Secondary and exploratory endpoint data will be analysed using two-sample t-tests between groups. ETHICS AND DISSEMINATION Ethical approval was obtained from the Duke Institutional Review Board (protocol #00111869). Results of the REPOSE study will be published in a peer-reviewed journal and presented at academic conferences. Trial data will be deposited in ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT05733286.
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Affiliation(s)
- John Michael Fallon
- Duke University, Trinity College of Arts and Sciences, Durham, North Carolina, USA
| | - Mona Hashemaghaie
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christy E Peterson
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dieplinh Tran
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | - Sophie R Wu
- Duke University Pratt School of Engineering, Durham, North Carolina, USA
| | - Jonathan M Valdes
- Duke University, Trinity College of Arts and Sciences, Durham, North Carolina, USA
| | - Nicole M Pedicini
- Duke University, Trinity College of Arts and Sciences, Durham, North Carolina, USA
| | - Melissa E Adams
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Marjorie Soltis
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wissam Mansour
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mary Cooter Wright
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cina Sasannejad
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael J Devinney
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
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Cai X, Yu X, Qin J, Zhou K, Li Z, Zhang J, Zheng D, Wang P, Yan F. Development and validation of a nomogram for delirium in the old ischaemic stroke patients. Psychogeriatrics 2025; 25:e13247. [PMID: 39865775 DOI: 10.1111/psyg.13247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Revised: 12/17/2024] [Accepted: 01/04/2025] [Indexed: 01/28/2025]
Abstract
AIM To investigate the predictors of post-stroke delirium (PSD) in the old ischaemic stroke patients, and develop a nomogram to predict the risk of PSD. METHODS A cross-observational study was conducted. The old ischaemic stroke patients in a tertiary hospital in South China were recruited and randomly divided into the train group and test group. Multivariate logistic regression analysis was performed in the train group to screen out predictors of PSD, and develop a nomogram. The receiver operating characteristic (ROC) curve, calibration curve, Hosmer-Lemeshow goodness-of-fit test (H-L test) and decision curve analysis (DCA) were used to evaluate the nomogram. The internal validation was performed in test group. RESULTS The incidence of PSD was 21.1% (105/497). Coronary heart disease (CHD), indwelling catheter, physical restraint, and neutrophil-to-lymphocyte ratio (NLR) were significantly associated with PSD. The area under the ROC curve of the nomogram was 0.885 in the train group, and 0.865 in the test group. The calibration curves of the two groups were close to the standardised line. The P-values of H-L test were over 0.05. The DCA presented some net benefits in the two groups. CONCLUSION CHD, indwelling catheter, restraint, and NLR were strongly associated with PSD in the old. A nomogram with good prediction effect and advisable clinical applicability was developed.
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Affiliation(s)
- Xiaoyan Cai
- Department of Nursing, Foshan Stomatology Hospital, the Affiliated Stomatology Hospital of Foshan University, Foshan, China
- School of Nursing, Jinan University, Guangzhou, China
| | - Xuefen Yu
- General Department, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jieying Qin
- School of Nursing, Jinan University, Guangzhou, China
| | - Kebing Zhou
- School of Nursing, Jinan University, Guangzhou, China
| | - Zhiying Li
- School of Nursing, Jinan University, Guangzhou, China
| | - Jiahui Zhang
- School of Nursing, Jinan University, Guangzhou, China
| | - Dongxiang Zheng
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Peng Wang
- Department of Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Fengxia Yan
- School of Nursing, Jinan University, Guangzhou, China
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Leroy S, Bublitz V, Grittner U, Fleischmann R, von Dincklage F, Antonenko D. Modulating delirium through stimulation (MoDeSt): study protocol for a randomized, double-blind, sham-controlled trial assessing the effect of postoperative transcranial electrical stimulation on delirium incidence. Trials 2025; 26:4. [PMID: 39754196 PMCID: PMC11697754 DOI: 10.1186/s13063-024-08699-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 12/13/2024] [Indexed: 01/07/2025] Open
Abstract
BACKGROUND Postoperative delirium (POD) is the most common neurological adverse event among elderly patients undergoing surgery. POD is associated with an increased risk for postoperative complications, long-term cognitive decline, an increase in morbidity and mortality as well as extended hospital stays. Delirium prevention and treatment options are currently limited. This study will evaluate the effect of transcranial electrical stimulation (tES) on the incidence of POD. METHODS We will perform a randomized, double-blind, sham-controlled trial using single-session postoperative application of tES in the recovery room in 225 patients (> 65 years) undergoing elective major surgery. Patients will be randomly allocated (ratio 1:1:1) to one of three study groups: (1) alpha-tACS over posterior parietal cortex [2 mA, 20 min], (2) anodal tDCS over left dorsolateral prefrontal cortex [2 mA, 20 min], (3) sham [2 mA, 30 s]. Delirium will be screened twice daily with the 3-min diagnostic interview Confusion Assessment Method (3D-CAM) in the 5 days following surgery. The primary outcome is the incidence of POD defined as at least one positive screening during the five first postoperative days compared between tACS and sham groups. Secondary outcomes include delirium severity, duration, phenotype, postoperative pain, postoperative nausea and vomiting, electroencephalographic (EEG) markers, and fluid biomarkers. DISCUSSION If effective, tES is a novel, easily applicable, non-invasive method to prevent the occurrence of POD. The comprehensive neurophysiological and biofluid assessments for markers of (neuro-)inflammation and neurodegeneration will shed light on the pathomechanisms behind POD and further elucidate the (after-)effects of tES. The potential implications for the postoperative recovery comprise enhanced patient safety, neurocognitive outcome, perioperative manageability but also reduced healthcare costs. TRIAL REGISTRATION German Clinical Trial Registry DRKS00033703. Registered on February 23, 2024.
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Affiliation(s)
- Sophie Leroy
- Delirium Prevention Unit, Universitätsmedizin Greifswald, Fleischmannstraße 6, Greifswald, 17489, Germany.
- Department of Neurology, Universitätsmedizin Greifswald, Fleischmannstraße 6, Greifswald, 17489, Germany.
| | - Viktor Bublitz
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Universitätsmedizin Greifswald, Fleischmannstraße 6, Greifswald, 17489, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, Berlin, 10117, Germany
| | - Robert Fleischmann
- Delirium Prevention Unit, Universitätsmedizin Greifswald, Fleischmannstraße 6, Greifswald, 17489, Germany
- Department of Neurology, Universitätsmedizin Greifswald, Fleischmannstraße 6, Greifswald, 17489, Germany
| | - Falk von Dincklage
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Universitätsmedizin Greifswald, Fleischmannstraße 6, Greifswald, 17489, Germany
| | - Daria Antonenko
- Department of Neurology, Universitätsmedizin Greifswald, Fleischmannstraße 6, Greifswald, 17489, Germany
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Devinney MJ, Wong MK, Wright MC, Marcantonio ER, Terrando N, Browndyke JN, Whitson HE, Cohen HJ, Nackley AG, Klein ME, Ely EW, Mathew JP, Berger M. Role of Blood-Brain Barrier Dysfunction in Delirium following Non-cardiac Surgery in Older Adults. Ann Neurol 2023; 94:1024-1035. [PMID: 37615660 PMCID: PMC10841407 DOI: 10.1002/ana.26771] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/21/2023] [Accepted: 08/12/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative recovery in humans is unclear. Thus, we evaluated the role of blood-brain barrier dysfunction in postoperative delirium and hospital length of stay among older surgery patients. METHODS Cognitive testing, delirium assessment, and cerebrospinal fluid and blood sampling were prospectively performed before and after non-cardiac, non-neurologic surgery. Blood-brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio (CPAR). RESULTS Of 207 patients (median age = 68 years, 45% female) with complete CPAR and delirium data, 26 (12.6%) developed postoperative delirium. Overall, CPAR increased from before to 24 hours after surgery (median change = 0.28, interquartile range [IQR] = -0.48 to 1.24, Wilcoxon p = 0.001). Preoperative to 24 hours postoperative change in CPAR was greater among patients who developed delirium versus those who did not (median [IQR] = 1.31 [0.004 to 2.34] vs 0.19 [-0.55 to 1.08], p = 0.003). In a multivariable model adjusting for age, baseline cognition, and surgery type, preoperative to 24 hours postoperative change in CPAR was independently associated with delirium occurrence (per CPAR increase of 1, odds ratio = 1.30, 95% confidence interval [CI] = 1.03-1.63, p = 0.026) and increased hospital length of stay (incidence rate ratio = 1.15, 95% CI = 1.09-1.22, p < 0.001). INTERPRETATION Postoperative increases in blood-brain barrier permeability are independently associated with increased delirium rates and postoperative hospital length of stay. Although these findings do not establish causality, studies are warranted to determine whether interventions to reduce postoperative blood-brain barrier dysfunction would reduce postoperative delirium rates and hospital length of stay. ANN NEUROL 2023;94:1024-1035.
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Affiliation(s)
- Michael J. Devinney
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
| | | | - Mary Cooter Wright
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | - Edward R. Marcantonio
- Division of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Department of Cell Biology, Duke University School of Medicine, Durham NC
- Department of Immunology, Duke University School of Medicine, Durham NC
| | - Jeffrey N. Browndyke
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham NC
| | - Heather E. Whitson
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham NC
| | - Harvey J. Cohen
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham NC
| | - Andrea G. Nackley
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | | | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN
| | - Joseph P. Mathew
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | - Miles Berger
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
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Devinney MJ, Wong MK, Wright MC, Marcantonio ER, Terrando N, Browndyke JN, Whitson HE, Cohen HJ, Nackley AG, Klein ME, Ely EW, Mathew JP, Berger M. A Role for Blood-brain Barrier Dysfunction in Delirium following Non-Cardiac Surgery in Older adults. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.07.23288303. [PMID: 37214925 PMCID: PMC10197714 DOI: 10.1101/2023.04.07.23288303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Objective Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative recovery in humans is unclear. Thus, we evaluated the role of blood-brain barrier dysfunction in postoperative delirium and hospital length of stay among older surgery patients. Methods Cognitive testing, delirium assessment, and cerebrospinal fluid and blood sampling were prospectively performed before and after non-cardiac, non-neurologic surgery. Blood-brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio (CPAR). Results Of 207 patients (median age 68, 45% female) with complete CPAR and delirium data, 26 (12.6%) developed postoperative delirium. Overall, CPAR increased from before to 24-hours after surgery (median postoperative change 0.28, [IQR] [-0.48-1.24]; Wilcoxon p=0.001). Preoperative to 24-hour postoperative change in CPAR was greater among patients who developed delirium vs those who did not (median [IQR] 1.31 [0.004, 2.34] vs 0.19 [-0.55, 1.08]; p=0.003). In a multivariable model adjusting for age, baseline cognition, and surgery type, preoperative to 24-hour postoperative change in CPAR was independently associated with delirium incidence (per CPAR increase of 1, OR = 1.30, [95% CI 1.03-1.63]; p=0.026) and increased hospital length of stay (IRR = 1.15 [95% CI 1.09-1.22]; p<0.001). Interpretation Postoperative increases in blood-brain barrier permeability are independently associated with increased delirium rates and postoperative hospital length of stay. Although these findings do not establish causality, studies are warranted to determine whether interventions to reduce postoperative blood-brain barrier dysfunction would reduce postoperative delirium rates and hospital length of stay.
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Affiliation(s)
- Michael J. Devinney
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
| | | | - Mary Cooter Wright
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | - Edward R. Marcantonio
- Division of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Department of Cell Biology, Duke University School of Medicine, Durham NC
- Department of Immunology, Duke University School of Medicine, Durham NC
| | - Jeffrey N. Browndyke
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham NC
| | - Heather E. Whitson
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham NC
| | - Harvey J. Cohen
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham NC
| | - Andrea G. Nackley
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | | | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN
| | - Joseph P. Mathew
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | - Miles Berger
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
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Oldham MA, Slooter AJC, Ely EW, Crone C, Maldonado JR, Rosenthal LJ. An Interdisciplinary Reappraisal of Delirium and Proposed Subtypes. J Acad Consult Liaison Psychiatry 2023; 64:248-261. [PMID: 35840003 PMCID: PMC9839895 DOI: 10.1016/j.jaclp.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/10/2022] [Accepted: 07/04/2022] [Indexed: 01/17/2023]
Abstract
An interdisciplinary plenary session entitled "Rethinking and Rehashing Delirium" was held during the 2021 Annual Meeting of the Academy of Consultation-Liaison Psychiatry to facilitate dialog on the prevalent approach to delirium. Panel members included a psychiatrist, neurointensivist, and critical care specialist, and attendee comments were solicited with the goal of developing a statement. Discussion was focused on a reappraisal of delirium and, in particular, its disparate terminology and history in relation to acute encephalopathy. The authors endorse a recent joint position statement that describes acute encephalopathy as a rapidly evolving (<4 weeks) pathobiological brain process that presents as subsyndromal delirium, delirium, or coma and suggest the following points of refinement: (1) to suggest that "delirium disorder" describe the diagnostic construct including its syndrome, precipitant(s), and unique pathophysiology; (2) to restrict the term "delirium" to describing the clinical syndrome encountered at the bedside; (3) to clarify that the disfavored term "altered mental status" may occasionally be an appropriate preliminary designation where the diagnosis cannot yet be specified further; and (4) to provide rationale for rejecting the terms acute brain injury, failure, or dysfunction. The final common pathway of delirium appears to involve higher-level brain network dysfunction, but there are many insults that can disrupt functional connectivity. We propose that future delirium classification systems should seek to characterize the unique pathophysiological disturbances ("endotypes") that underlie delirium and delirium's individual neuropsychiatric symptoms. We provide provisional means of classification in hopes that novel subtypes might lead to specific intervention to improve patient experience and outcomes. This paper concludes by considering future directions for the field. Key areas of opportunity include interdisciplinary initiatives to harmonize efforts across specialties and settings, enhance underrepresented groups in research, integration of delirium and encephalopathy in coding, development of relevant quality and safety measures, and exploration of opportunities for translational science.
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Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, Department of Psychiatry, Rochester, NY.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research Education Clinical Center (GRECC), TN Valley Veterans Affairs Medical Center, Nashville, TN
| | - Cathy Crone
- Inova Health System, Behavioral Health, Falls Church, VA; George Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Washington, DC
| | - José R Maldonado
- Stanford University School of Medicine, Department of Psychiatry & Behavioral Sciences, Stanford, CA
| | - Lisa J Rosenthal
- Northwestern University Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, Chicago, IL
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Hshieh TT, Gou RY, Jones RN, Leslie DL, Marcantonio ER, Xu G, Travison TG, Fong TG, Schmitt EM, Inouye SK. One-year Medicare costs associated with delirium in older hospitalized patients with and without Alzheimer's disease dementia and related disorders. Alzheimers Dement 2023; 19:1901-1912. [PMID: 36354163 PMCID: PMC10169545 DOI: 10.1002/alz.12826] [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: 02/05/2022] [Revised: 09/02/2022] [Accepted: 09/19/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION One-year health-care costs associated with delirium in older hospitalized patients with and without Alzheimer's disease and related dementias (ADRD) have not been examined previously. METHODS Medicare costs were determined prospectively at discharge, and at 30, 90, and 365 days in a cohort (n = 311) of older adults after hospital admission. RESULTS Seventy-six (24%) patients had ADRD and were more likely to develop delirium (51% vs. 24%, P < 0.001) and die within 1 year (38% vs. 21%, P = 0.002). In ADRD patients with versus without delirium, adjusted mean difference in costs associated with delirium were $34,828; most of the excess costs were incurred between 90 and 365 days (P = 0.03). In non-ADRD patients, delirium was associated with increased costs at all timepoints. Excess costs associated with delirium in ADRD patients increased progressively over 1 year, whereas in non-ADRD patients the increase was consistent across time periods. DISCUSSION Our findings highlight the complexity of health-care costs for ADRD patients who develop delirium, a potentially preventable source of expenditures. HIGHLIGHTS Novel examination of health-care costs of delirium in persons with and without Alzheimer's disease and related dementias (ADRD). Increased 1-year costs of $34,828 in ADRD patients with delirium (vs. without). Increased costs for delirium in ADRD occur later during the 365-day study period. For ADRD patients, cost differences between those with and without delirium increased over 1 year. For non-ADRD patients, the parallel cost differences were consistent over time.
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Affiliation(s)
- Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ray Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Douglas L Leslie
- Center for Applied Studies in Health Economics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Edward R Marcantonio
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Guoquan Xu
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Thomas G Travison
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 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
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Banerji A, Sleigh JW, Voss LJ, Garcia PS, Gaskell AL. Deconstructing delirium in the post anaesthesia care unit. Front Aging Neurosci 2022; 14:930434. [PMID: 36268194 PMCID: PMC9577324 DOI: 10.3389/fnagi.2022.930434] [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: 04/27/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
The course of neuro-cognitive recovery following anaesthesia and surgery is distinctive and poorly understood. Our objective was to identify patterns of neuro-cognitive recovery of the domains routinely assessed for delirium diagnosis in the post anaesthesia care unit (PACU) and to compare them to the cognitive recovery patterns observed in other studies; thereby aiding in the identification of pathological (high risk) patterns of recovery in the PACU. We also compared which of the currently available tests (3D-CAM, CAM-ICU, and NuDESC) is the best to use in PACU. This was a post hoc secondary analysis of data from the Alpha Max study which involved 200 patients aged over 60 years, scheduled for elective surgery under general anaesthesia lasting more than 2 h. These patients were assessed for delirium at 30 min following arrival in the PACU, if they were adequately arousable (Richmond Agitation Sedation Score ≥ −2). All tests for delirium diagnosis (3D-CAM, CAM-ICU, and NuDESC) and the sub-domains assessed were compared to understand temporal recovery of neurocognitive domains. These data were also analysed to determine the best predictor of PACU delirium. We found the incidence of PACU delirium was 35% (3D-CAM). Individual cognitive domains were affected differently. Few individuals had vigilance deficits (6.5%, n = 10 CAM-ICU) or disorganized thinking (19% CAM-ICU, 27.5% 3D-CAM), in contrast attention deficits were common (72%, n = 144) and most of these patients (89.5%, n = 129) were not sedated (RASS ≥ −2). CAM-ICU (27%) and NuDESC (52.8%) detected fewer cases of PACU delirium compared to 3D-CAM. In conclusion, return of neurocognitive function is a stepwise process; Vigilance and Disorganized Thinking are the earliest cognitive functions to return to baseline and lingering deficits in these domains could indicate an abnormal cognitive recovery. Attention deficits are relatively common at 30 min in the PACU even in individuals who appear to be awake. The 3D CAM is a robust test to check for delirium in the PACU.
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Affiliation(s)
- Antara Banerji
- Department of Anaesthesia, Waikato Clinical Campus, University of Auckland, Auckland, New Zealand
- *Correspondence: Antara Banerji,
| | - Jamie W. Sleigh
- Department of Anaesthesia, Waikato Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Logan J. Voss
- Department of Anaesthesia, Waikato Clinical Campus, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
| | - Paul S. Garcia
- Department of Anesthesiology, Chief Neuroanesthesia Division, Columbia University Medical Center New York Presbyterian Hospital – Irving, Columbia University, New York, NY, United States
| | - Amy L. Gaskell
- Department of Anaesthesia, Waikato Clinical Campus, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia and Pain Medicine, Waikato District Health Board, Hamilton, New Zealand
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10
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Tabloski PA, Arias F, Flanagan N, Webb M, Gregas M, Schmitt EM, Travison TG, Jones RN, Inouye SK, Fong TG. Predictors of Caregiver Burden in Delirium: Patient and Caregiver Factors. J Gerontol Nurs 2021; 47:32-38. [PMID: 34432572 DOI: 10.3928/00989134-20210803-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The current study examined the association of patient factors, patient/caregiver relationships, and living arrangements with caregiver burden due to delirium. The sample included a subset (N = 207) of hospitalized medical and surgical patients (aged >70 years) enrolled in the Better Assessment of Illness Study and their care-givers. The majority of caregivers were female (57%) and married (43%), and 47% reported living with the patient. Delirium occurred in 22% of the sample, and delirium severity, pre-existing cognitive impairment, and impairment of any activities of daily living (ADL) were associated with higher caregiver burden. However, only the ADL impairment of needing assistance with transfers was independently significantly associated with higher burden (p < 0.01). Child, child-in-law, and other relatives living with or apart from the patient reported significantly higher caregiver burden compared to spouse/partners (p < 0.01), indicating caregiver relationship and living arrangement are associated with burden. Future studies should examine additional factors contributing to delirium burden. [Journal of Gerontological Nursing, 47(9), 32-39.].
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11
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Delirium in Geriatric Trauma Patients. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00204-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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12
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A nurse-administered 3-Minute diagnostic interview for CAM-defined Delirium (3D-CAM Chinese version) in hospitalized elderly patients: A validation study. Int J Nurs Stud 2020; 110:103701. [PMID: 32736252 DOI: 10.1016/j.ijnurstu.2020.103701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 06/22/2020] [Accepted: 06/22/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Delirium is a common complication in hospitalized elderly patients, yet often remains unrecognized in the clinical care unit. The newly developed 3-Minute Diagnostic Interview for CAM-Defined Delirium (3D-CAM) has high sensitivity and specificity when administered by trained researchers. However, diagnostic characteristics of the 3D-CAM as performed in routine practice are unclear. OBJECTIVE To determine the diagnostic characteristics of a Chinese version of the 3D-CAM administered to hospitalized elderly patients by bedside nurses. DESIGN A prospective cohort study. SETTING A tertiary geriatric hospital in China. PARTICIPANTS 323 patients and 49 bedside nurses. METHODS This prospective cohort study was conducted at a tertiary geriatric hospital in China. A Chinese version of 3D-CAM was administered by trained bedside nurses and compared against the reference standard performed by experienced neurologists using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. All assessors were blinded to each other's assessment results. Sensitivity and specificity of the 3D-CAM among bedside nurses were analysed by comparing with the reference standard to test the ability of 3D-CAM in detecting delirium. RESULTS A total of 323 patients were included in the study, of whom 64 were classified as delirium positive by the neurologists. The 3D-CAM had a sensitivity of 92% (95% confidence interval, 82-97%), specificity of 89% (95% confidence interval, 84-92%), respectively. CONCLUSION The Chinese version of 3D-CAM demonstrated good performance as a bedside nurse-administered screening tool for delirium detection among hospitalized Chinese geriatric patients. Registration number: ChiCTR-IOR-17,010,368.
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13
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Vasunilashorn SM, Devinney MJ, Acker L, Jung Y, Ngo L, Cooter M, Huang R, Marcantonio ER, Berger M. A New Severity Scoring Scale for the 3-Minute Confusion Assessment Method (3D-CAM). J Am Geriatr Soc 2020; 68:1874-1876. [PMID: 32479640 DOI: 10.1111/jgs.16538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Sarinnapha M Vasunilashorn
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Leah Acker
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Yoojin Jung
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Long Ngo
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Richard Huang
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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14
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Wang W, Lin N, Oberhaus JD, Avidan MS. Assessing method agreement for paired repeated binary measurements administered by multiple raters. Stat Med 2020; 39:279-293. [PMID: 31788847 DOI: 10.1002/sim.8398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 06/07/2019] [Accepted: 07/03/2019] [Indexed: 11/08/2022]
Abstract
Method comparison studies are essential for development in medical and clinical fields. These studies often compare a cheaper, faster, or less invasive measuring method with a widely used one to see if they have sufficient agreement for interchangeable use. Moreover, unlike simply reading measurements from devices, eg, reading body temperature from a thermometer, the response measurement in many clinical and medical assessments is impacted not only by the measuring device but also by the rater. For example, widespread inconsistencies are commonly observed among raters in psychological or cognitive assessment studies due to different characteristics such as rater training and experience, especially in large-scale assessment studies when many raters are employed. This paper proposes a model-based approach to assess agreement of two measuring methods for paired repeated binary measurements under the scenario where the agreement between two measuring methods and the agreement among raters are required to be studied simultaneously. Based upon the generalized linear mixed models (GLMMs), the decision on the adequacy of interchangeable use is made by testing the equality of fixed effects of methods. Approaches for assessing method agreement, such as the Bland-Altman diagram and Cohen's kappa, are also developed for repeated binary measurements based upon the latent variables in GLMMs. We assess our novel model-based approach by simulation studies and a real clinical application, in which patients are evaluated repeatedly for delirium with two validated screening methods. Both the simulation studies and the real data analyses demonstrate that our proposed approach can effectively assess method agreement.
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Affiliation(s)
- Wei Wang
- Department of Mathematics and Statistics, Washington University in St. Louis, St. Louis, Missouri
| | - Nan Lin
- Department of Mathematics and Statistics, Washington University in St. Louis, St. Louis, Missouri.,Division of Biostatistics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jordan D Oberhaus
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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15
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VanDusen KW, Eleswarpu S, Moretti EW, Devinney MJ, Crabtree DM, Laskowitz DT, Woldorff MG, Roberts KC, Whittle J, Browndyke JN, Cooter M, Rockhold FW, Anakwenze O, Bolognesi MP, Easley ME, Ferrandino MN, Jiranek WA, Berger M, Adams SB, Amundsen CL, Avasarala P, Barber MD, Berchuck A, Blazer DG, Brassard R, Brigman BE, Christensen SK, Cox MW, Davidson BA, DeOrio JK, Erdmann D, Erickson MM, Funk BL, Gadsden J, Gage MJ, Gingrich JR, Greenup RA, Ha C, Habib A, Hachem RA, Hall AE, Hartwig MG, Havrilesky LJ, Heflin MT, Holland C, Hollenbeck ST, Hopkins TJ, Inman BA, Jang DW, Kahmke RR, Karikari I, Kawasaki A, Klapper JA, Klifto CS, Klinger R, Knechtle SJ, Lagoo-Deenadayalan SA, Lee WT, Levinson H, Lewis BD, Lidsky ME, Lipkin ME, Mantyh CR, McDonald SR, Migaly J, Miller TE, Mithani SK, Mosca PJ, Moul JW, Novick TL, Olson SA, Pappas TN, Park JJ, Peterson AC, Phillips BT, Polascik TJ, Potash P, Preminger GM, Previs RA, Robertson CN, Scales CD, Shah KN, Scheri RP, Siddiqui NY, Smani S, Southerland KW, Stang MT, Syed A, Szydlowska A, Thacker JK, Terrando N, Toulgoat-DuBois Y, Visco AG, Weidner AC, Yanamadala M, Zani S. The MARBLE Study Protocol: Modulating ApoE Signaling to Reduce Brain Inflammation, DeLirium, and PostopErative Cognitive Dysfunction. J Alzheimers Dis 2020; 75:1319-1328. [PMID: 32417770 PMCID: PMC7923142 DOI: 10.3233/jad-191185] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative neurocognitive disorders (PND) are common complications in older adults associated with increased 1-year mortality and long-term cognitive decline. One risk factor for worsened long-term postoperative cognitive trajectory is the Alzheimer's disease (AD) genetic risk factor APOE4. APOE4 is thought to elevate AD risk partly by increasing neuroinflammation, which is also a theorized mechanism for PND. Yet, it is unclear whether modulating apoE4 protein signaling in older surgical patients would reduce PND risk or severity. OBJECTIVE MARBLE is a randomized, blinded, placebo-controlled phase II sequential dose escalation trial designed to evaluate perioperative administration of an apoE mimetic peptide drug, CN-105, in older adults (age≥60 years). The primary aim is evaluating the safety of CN-105 administration, as measured by adverse event rates in CN-105 versus placebo-treated patients. Secondary aims include assessing perioperative CN-105 administration feasibility and its efficacy for reducing postoperative neuroinflammation and PND severity. METHODS 201 patients undergoing non-cardiac, non-neurological surgery will be randomized to control or CN-105 treatment groups and receive placebo or drug before and every six hours after surgery, for up to three days after surgery. Chart reviews, pre- and postoperative cognitive testing, delirium screening, and blood and CSF analyses will be performed to examine effects of CN-105 on perioperative adverse event rates, cognition, and neuroinflammation. Trial results will be disseminated by presentations at conferences and peer-reviewed publications. CONCLUSION MARBLE is a transdisciplinary study designed to measure CN-105 safety and efficacy for preventing PND in older adults and to provide insight into the pathogenesis of these geriatric syndromes.
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Affiliation(s)
- Keith W. VanDusen
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Sarada Eleswarpu
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Eugene W. Moretti
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Donna M. Crabtree
- Duke Office of Clinical Research, Duke University, Durham, North Carolina
| | | | - Marty G. Woldorff
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
- Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
| | - Kenneth C. Roberts
- Center for Cognitive Neuroscience, Duke University Medical Center, Durham, North Carolina
| | - John Whittle
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jeffrey N. Browndyke
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Oke Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - Mark E. Easley
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - William A. Jiranek
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Miles Berger
- Department of Anesthesiology, Duke University, Durham, North Carolina
- Center for Cognitive Neuroscience, Duke University Medical Center, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
| | | | - Samuel B. Adams
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Cindy L. Amundsen
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Pallavi Avasarala
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Matthew D. Barber
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Andrew Berchuck
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | | | - Rachele Brassard
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Brian E. Brigman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - Mitchel W. Cox
- Department of Surgery, Duke University, Durham, North Carolina
| | - Brittany A. Davidson
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - James K. DeOrio
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Detlev Erdmann
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Bonita L. Funk
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jeffrey Gadsden
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Mark J. Gage
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | | | - Christine Ha
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Ashraf Habib
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Ralph Abi Hachem
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Ashley E. Hall
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Mitchell T. Heflin
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Courtney Holland
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Thomas J. Hopkins
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Brant A. Inman
- Department of Surgery, Duke University, Durham, North Carolina
| | - David W. Jang
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Isaac Karikari
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Amie Kawasaki
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | | | | | - Rebecca Klinger
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | - Walter T. Lee
- Department of Surgery, Duke University, Durham, North Carolina
| | - Howard Levinson
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Dermatology, Duke University, Durham, North Carolina
- Department of Pathology, Duke University, Durham, North Carolina
| | - Brian D. Lewis
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | | | - Shelley R. McDonald
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - John Migaly
- Department of Surgery, Duke University, Durham, North Carolina
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Paul J. Mosca
- Department of Surgery, Duke University, Durham, North Carolina
| | - Judd W. Moul
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Steven A. Olson
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - John J. Park
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | | | - Peter Potash
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Rebecca A. Previs
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | | | - Charles D. Scales
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Kevin N. Shah
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Nazema Y. Siddiqui
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Shayan Smani
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | - Ayesha Syed
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Alicja Szydlowska
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Niccolò Terrando
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Anthony G. Visco
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Alison C. Weidner
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Mamata Yanamadala
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Sabino Zani
- Department of Surgery, Duke University, Durham, North Carolina
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina
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Kimchi EY, Neelagiri A, Whitt W, Sagi AR, Ryan SL, Gadbois G, Groothuysen D, Westover MB. Clinical EEG slowing correlates with delirium severity and predicts poor clinical outcomes. Neurology 2019; 93:e1260-e1271. [PMID: 31467255 PMCID: PMC7011865 DOI: 10.1212/wnl.0000000000008164] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/30/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To determine which findings on routine clinical EEGs correlate with delirium severity across various presentations and to determine whether EEG findings independently predict important clinical outcomes. METHODS We prospectively studied a cohort of nonintubated inpatients undergoing EEG for evaluation of altered mental status. Patients were assessed for delirium within 1 hour of EEG with the 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and 3D-CAM severity score. EEGs were interpreted clinically by neurophysiologists, and reports were reviewed to identify features such as theta or delta slowing and triphasic waves. Generalized linear models were used to quantify associations among EEG findings, delirium, and clinical outcomes, including length of stay, Glasgow Outcome Scale scores, and mortality. RESULTS We evaluated 200 patients (median age 60 years, IQR 48.5-72 years); 121 (60.5%) met delirium criteria. The EEG finding most strongly associated with delirium presence was a composite of generalized theta or delta slowing (odds ratio 10.3, 95% confidence interval 5.3-20.1). The prevalence of slowing correlated not only with overall delirium severity (R 2 = 0.907) but also with the severity of each feature assessed by CAM-based delirium algorithms. Slowing was common in delirium even with normal arousal. EEG slowing was associated with longer hospitalizations, worse functional outcomes, and increased mortality, even after adjustment for delirium presence or severity. CONCLUSIONS Generalized slowing on routine clinical EEG strongly correlates with delirium and may be a valuable biomarker for delirium severity. In addition, generalized EEG slowing should trigger elevated concern for the prognosis of patients with altered mental status.
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Affiliation(s)
- Eyal Y Kimchi
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston.
| | - Anudeepthi Neelagiri
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Wade Whitt
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Avinash Rao Sagi
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Sophia L Ryan
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Greta Gadbois
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - Daniël Groothuysen
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
| | - M Brandon Westover
- From the Department of Neurology (E.Y.K., A.N., W.W., A.R.S., S.L.R., G.G., D.G., M.B.W.) and Clinical Data Animation Center (M.B.W.), Massachusetts General Hospital, Boston
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17
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Home-based Cognitive Prehabilitation in Older Surgical Patients: A Feasibility Study. J Neurosurg Anesthesiol 2019; 31:212-217. [PMID: 30557230 DOI: 10.1097/ana.0000000000000569] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cognitive training is beneficial in various clinical settings, although its perioperative feasibility and impact remain unknown. The objective of this pilot study was to determine the feasibility of home-based cognitive prehabilitation before major surgery in older adults. MATERIALS AND METHODS Sixty-one patients were enrolled, randomized, and allocated to either a home-based preoperative cognitive training regimen or no training before surgery. Outcomes included postoperative delirium incidence (primary outcome; assessed with the 3D-Confusion Assessment Method), perioperative cognitive function based on NIH Toolbox measures, hospital length of stay, and physical therapy session participation. Reasons for declining enrollment were reported, as were reasons for opting out of the training program. RESULTS Postoperative delirium incidence was 6 of 23 (26%) in the prehabilitation group compared with 5 of 29 (17%) in the control group (P=0.507). There were no significant differences between groups in NIH Toolbox cognitive function scoring, hospital length of stay, or physical therapy participation rates. Study feasibility data were also collected and reported. The most common reasons for declining enrollment were lack of computer access (n=19), time commitment (n=9), and feeling overwhelmed (n=9). In the training group, only 5 of 29 (17%) included patients were able to complete the prescribed 7 days of training, and 14 of 29 (48%) opted out of training once home. Most common reasons were feeling overwhelmed (n=4) and computer difficulties (n=3). CONCLUSIONS Short-term, home-based cognitive training before surgery is unlikely to be feasible for many older patients. Barriers to training include feeling overwhelmed, technical issues with training, and preoperative time commitment.
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18
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Hongyu X, Qingting W, Xiaoling S, Liwu Z, Ailing Y, Xin L. Penehyclidine hydrochloride on postoperatively cognitive function. Med Hypotheses 2019; 129:109246. [PMID: 31371081 DOI: 10.1016/j.mehy.2019.109246] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/21/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022]
Abstract
There are many drugs that affect postoperative cognitive function in patients under general anesthesia. Pentanethaquine hydrochloride (PHC), as a new type of anti-cholinergic drug, has been widely used. In clinical practice, many patients, especially elderly patients, have suffered from obvious postoperative cognitive dysfunction, but the incidence of pulmonary infection, reduced probably due to the decease of secretion production. Therefore, the effect of PHC on postoperative cognitive functions and inflammatory factors in elderly lung cancer patients under general anesthesia were mainly discussed to determine the clinical advantages and disadvantages. Ninety elderly patients undergoing thoracoscopic surgery for lung cancer under general anesthesia were selected and divided into PHC group (group A, n = 30), atropine group (group B, n = 30) and normal saline control group (group C, n = 30). The incidence of postoperative blurred vision was higher in group A compared to group B and C (both p < 0.05). The incidence of other adverse reactions was higher in group A compared to group C (all p < 0.05), but there was no difference between group A and group B (all p > 0.05). There was no significant difference in preoperative and day 1 post-surgery mini-mental state examination (MMSE) scores among the three groups (both p > 0.05), but the day 1 post-surgery MMSE scores of three groups were lower (all p < 0.05). PHC increased the incidence of postoperative cognitive impairment and postoperative delirium in elderly lung cancer patients undergoing thoracoscopic surgery under general anesthesia, but reduced the incidence of postoperative pulmonary complications possibly by reducing the expression of pro-inflammatory cytokines.
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Affiliation(s)
- X Hongyu
- Department of Anesthesiology, Central Hospital of Zibo City, Zibo 255036, Shandong Province, China
| | - W Qingting
- Department of Anesthesiology, Central Hospital of Zibo City, Zibo 255036, Shandong Province, China
| | - S Xiaoling
- Department of Anesthesiology, Central Hospital of Zibo City, Zibo 255036, Shandong Province, China
| | - Z Liwu
- Department of Anesthesiology, Central Hospital of Zibo City, Zibo 255036, Shandong Province, China
| | - Y Ailing
- Department of Anesthesiology, Central Hospital of Zibo City, Zibo 255036, Shandong Province, China
| | - L Xin
- Department of Anesthesiology, Maternal and Child Health Hospital of Zibo City, Zibo 255029, Shandong Province, China.
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19
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Abstract
Approximately 35% to 37% of older emergency department (ED) patients will have delirium or dementia, which can negatively affect safe and appropriate clinical care. This article describes the epidemiology of delirium and dementia in the ED and how it affects clinical care and patient outcomes. Screening for delirium and dementia in the context of the busy ED environment, as well as their diagnostic evaluation and management, is discussed.
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Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Center for Quality Aging, Vanderbilt University Medical Center, 311 Oxford House, Nashville, TN 37232, USA.
| | - Joe Suyama
- Department of Emergency Medicine, Magee-Womens Hospital of UPMC, University of Pittsburgh School of Medicine, 3600 Forbes Tower, Pittsburgh, PA 15213, USA
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20
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Smulter N, Claesson Lingehall H, Gustafson Y, Olofsson B, Engström KG. The use of a screening scale improves the recognition of delirium in older patients after cardiac surgery-A retrospective observational study. J Clin Nurs 2019; 28:2309-2318. [PMID: 30791158 DOI: 10.1111/jocn.14838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 12/16/2018] [Accepted: 02/09/2019] [Indexed: 12/29/2022]
Abstract
AIMS AND OBJECTIVES To analyse postoperative delirium (POD) in clinical practice after cardiac surgery, how it is detected and documented and if the use of a screening scale improves the detection rate. BACKGROUND Cardiac surgery is considered a routine procedure with few complications. However, POD remains a concern, although often being overlooked in clinical practice. DESIGN Retrospective observational analysis. METHODS Patients 70 years and older with POD (n = 78) undergoing cardiac surgery were included in the study. Discharge summaries of both nurses and physicians were reviewed together with the clinical database for information about POD, to be compared with symptom screening using the Nursing Delirium Screening Scale (Nu-DESC). A quantitative content analysis was used for the review of discharge summaries, with a coding scheme adopted from the Nu-DESC method. The STROBE checklist was followed. RESULTS In discharge summaries, 41 of the 78 POD patients were correctly recognised, and 22 of these were identified in the clinical database. Screening by the Nu-DESC identified delirium at a measurably higher rate, 56/78 patients. The review of discharge summaries showed that patients expressing "inappropriate behaviour" was the most easily identified sign for POD for both nurses and physicians. CONCLUSIONS Healthcare professionals underdiagnose delirium after cardiac surgery, with a low detection rate described in both discharge summaries and in the clinical database. Recognition of delirium improved when Nu-DESC was used for systematic screening. RELEVANCE TO CLINICAL PRACTICE This study emphasises the need for better screening for the detection of delirium in daily clinical practice.
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Affiliation(s)
- Nina Smulter
- Department of Surgery and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Department of Nursing, Umeå University, Umeå, Sweden
| | - Helena Claesson Lingehall
- Department of Nursing, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Heart Centre, Umeå University, Umeå, Sweden
| | - Yngve Gustafson
- Geriatric Medicine Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | | | - Karl Gunnar Engström
- Department of Surgery and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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21
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Jones RN, Cizginer S, Pavlech L, Albuquerque A, Daiello LA, Dharmarajan K, Gleason LJ, Helfand B, Massimo L, Oh E, Okereke OI, Tabloski P, Rabin LA, Yue J, Marcantonio ER, Fong TG, Hshieh TT, Metzger ED, Erickson K, Schmitt EM, Inouye SK. Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review. JAMA Intern Med 2019; 179:231-239. [PMID: 30556827 PMCID: PMC6382582 DOI: 10.1001/jamainternmed.2018.6975] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition. Objectives To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments. Evidence Review This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key words delirium, severity, tests, measures, and intensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus. Findings Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method-Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale. Conclusions and Relevance The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.
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Affiliation(s)
- Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Sevdenur Cizginer
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Laura Pavlech
- Hirsh Health Sciences Library, Tufts University, Boston, Massachusetts
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Lori A Daiello
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Kumar Dharmarajan
- Center for Outcomes Research & Evaluation, Yale University School of Medicine, New Haven, Connecticut
| | - Lauren J Gleason
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Benjamin Helfand
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
- University of Massachusetts Medical School, Worcester
| | - Lauren Massimo
- Frontotemporal Degeneration Center, University of Pennsylvania School of Medicine, Philadelphia
| | - Esther Oh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olivia I Okereke
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Patricia Tabloski
- Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts
| | - Laura A Rabin
- Department of Psychology, Brooklyn College and the Graduate Center of City University of New York, Brooklyn, New York
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tammy T Hshieh
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eran D Metzger
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kristen Erickson
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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22
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Cirbus J, MacLullich AMJ, Noel C, Ely EW, Chandrasekhar R, Han JH. Delirium etiology subtypes and their effect on six-month function and cognition in older emergency department patients. Int Psychogeriatr 2019; 31:267-276. [PMID: 30021661 DOI: 10.1017/s1041610218000777] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTBackground:Delirium is heterogeneous and can vary by etiology. OBJECTIVES We sought to determine how delirium subtyped by etiology affected six-month function and cognition. DESIGN Prospective cohort study. SETTING Tertiary care, academic medical center. PARTICIPANTS A total of 228 hospitalized patients > 65 years old were admitted from the emergency department (ED). MEASUREMENTS The modified Brief Confusion Assessment Method was used to determine delirium in the ED. Delirium etiology was determined by three trained physician reviewers using a Delirium Etiology checklist. Pre-illness and six-month function and cognition were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire and the short-form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Multiple linear regression was performed to determine if delirium etiology subtypes were associated with six-month function and cognition adjusted for baseline OARS ADL and IQCODE. Two-factor interactions were incorporated to determine pre-illness function or cognition-modified relationships between delirium subtypes and six-month function and cognition. RESULTS In patients with poorer pre-illness function only, delirium secondary to metabolic disturbance (β coefficient = -2.9 points, 95%CI: -0.3 to -5.6) and organ dysfunction (β coefficient = -4.3 points, 95%CI: -7.2 to -1.4) was significantly associated with poorer six-month function. In patients with intact cognition only, delirium secondary to central nervous system insults was significantly associated with poorer cognition (β coefficient = 0.69, 95%CI: 0.19 to 1.20). CONCLUSIONS Delirium is heterogeneous and different etiologies may have different prognostic implications. Furthermore, the effect of these delirium etiologies on outcome may be dependent on the patient's pre-illness functional status and cognition.
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Affiliation(s)
- Jamie Cirbus
- Department of Emergency Medicine,Vanderbilt University Medical Center,Nashville,Tennessee,USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group,Geriatric Medicine Unit,University of Edinburgh,Edinburgh,UK
| | - Christopher Noel
- Department of Emergency Medicine,Vanderbilt University Medical Center,Nashville,Tennessee,USA
| | - E Wesley Ely
- Department of Medicine,Division of Allergy, Pulmonary, and Critical Care,Vanderbilt University Medical Center,Nashville,Tennessee,USA
| | - Rameela Chandrasekhar
- Department of Biostatistics,Vanderbilt University Medical Center,Nashville,Tennessee,USA
| | - Jin H Han
- Department of Emergency Medicine,Vanderbilt University Medical Center,Nashville,Tennessee,USA
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23
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El-Gabalawy R, Patel R, Kilborn K, Blaney C, Hoban C, Ryner L, Funk D, Legaspi R, Fisher JA, Duffin J, Mikulis DJ, Mutch WAC. A Novel Stress-Diathesis Model to Predict Risk of Post-operative Delirium: Implications for Intra-operative Management. Front Aging Neurosci 2017; 9:274. [PMID: 28868035 PMCID: PMC5563326 DOI: 10.3389/fnagi.2017.00274] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/28/2017] [Indexed: 12/24/2022] Open
Abstract
Introduction: Risk assessment for post-operative delirium (POD) is poorly developed. Improved metrics could greatly facilitate peri-operative care as costs associated with POD are staggering. In this preliminary study, we develop a novel stress-diathesis model based on comprehensive pre-operative psychiatric and neuropsychological testing, a blood oxygenation level-dependent (BOLD) magnetic resonance imaging (MRI) carbon dioxide (CO2) stress test, and high fidelity measures of intra-operative parameters that may interact facilitating POD. Methods: The study was approved by the ethics board at the University of Manitoba and registered at clinicaltrials.gov as NCT02126215. Twelve patients were studied. Pre-operative psychiatric symptom measures and neuropsychological testing preceded MRI featuring a BOLD MRI CO2 stress test whereby BOLD scans were conducted while exposing participants to a rigorously controlled CO2 stimulus. During surgery the patient had hemodynamics and end-tidal gases downloaded at 0.5 hz. Post-operatively, the presence of POD and POD severity was comprehensively assessed using the Confusion Assessment Measure -Severity (CAM-S) scoring instrument on days 0 (surgery) through post-operative day 5, and patients were followed up at least 1 month post-operatively. Results: Six of 12 patients had no evidence of POD (non-POD). Three patients had POD and 3 had clinically significant confusional states (referred as subthreshold POD; ST-POD) (score ≥ 5/19 on the CAM-S). Average severity for delirium was 1.3 in the non-POD group, 3.2 in ST-POD, and 6.1 in POD (F-statistic = 15.4, p < 0.001). Depressive symptoms, and cognitive measures of semantic fluency and executive functioning/processing speed were significantly associated with POD. Second level analysis revealed an increased inverse BOLD responsiveness to CO2 pre-operatively in ST-POD and marked increase in the POD groups when compared to the non-POD group. An association was also noted for the patient population to manifest leucoaraiosis as assessed with advanced neuroimaging techniques. Results provide preliminary support for the interacting of diatheses (vulnerabilities) and intra-operative stressors on the POD phenotype. Conclusions: The stress-diathesis model has the potential to aid in risk assessment for POD. Based on these initial findings, we make some recommendations for intra-operative management for patients at risk of POD.
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Affiliation(s)
- Renée El-Gabalawy
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada.,Department of Clinical Health Psychology, Rady Faculty of Health Sciences, University of ManitobaWinnipeg, MB, Canada
| | - Ronak Patel
- Department of Clinical Health Psychology, Rady Faculty of Health Sciences, University of ManitobaWinnipeg, MB, Canada
| | - Kayla Kilborn
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Caitlin Blaney
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Christopher Hoban
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Lawrence Ryner
- Department of Physics and Astronomy, Faculty of Science, University of ManitobaWinnipeg, MB, Canada
| | - Duane Funk
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Regina Legaspi
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Joseph A Fisher
- Department of Anesthesia, Faculty of Medicine, University of TorontoToronto, ON, Canada
| | - James Duffin
- Department of Physiology, Faculty of Medicine, University of TorontoToronto, ON, Canada
| | - David J Mikulis
- Department of Medical Imaging, Faculty of Medicine, University of TorontoToronto, ON, Canada
| | - W Alan C Mutch
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada.,Canada North Concussion NetworkWinnipeg, MB, Canada
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