Cognitive Trajectories after Postoperative Delirium

Division of Geriatric Medicine and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA 01605, USA.
New England Journal of Medicine (Impact Factor: 55.87). 07/2012; 367(1):30-9. DOI: 10.1056/NEJMoa1112923
Source: PubMed


BACKGROUND: Delirium is common after cardiac surgery and may be associated with long-term changes in cognitive function. We examined postoperative delirium and the cognitive trajectory during the first year after cardiac surgery.
METHODS: We enrolled 225 patients 60 years of age or older who were planning to undergo coronary-artery bypass grafting or valve replacement. Patients were assessed preoperatively, daily during hospitalization beginning on postoperative day 2, and at 1, 6, and 12 months after surgery. Cognitive function was assessed with the use of the Mini-Mental State Examination (MMSE; score range, 0 to 30, with lower scores indicating poorer performance). Delirium was diagnosed with the use of the Confusion Assessment Method. We examined performance on the MMSE in the first year after surgery, controlling for demographic characteristics, coexisting conditions, hospital, and surgery type.
RESULTS: The 103 participants (46%) in whom delirium developed postoperatively had lower preoperative mean MMSE scores than those in whom delirium did not develop (25.8 vs. 26.9, P
CONCLUSIONS: Delirium is associated with a significant decline in cognitive ability during the first year after cardiac surgery, with a trajectory characterized by an initial decline and prolonged impairment. (Funded by the Harvard Older Americans Independence Center and others.).

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    • "Global and regional perfusion abnormalities have been also observed on brain imaging of delirious patients (Fong et al., 2006;Siepe et al., 2011). As neuroimaging advanced, technology has become available to characterize the chronology of structural and functional brain abnormalities related to delirium and provided clues to the pathogenesis of delirium and associated cognitive decline (Hughes et al., 2012;Saczynski et al., 2012). MRI-derived measures of global and regional brain atrophy and cerebral white-matter damage have been associated with the occurrence of delirium (for a systematic review, seeAlsop et al., 2006). "
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    ABSTRACT: Postoperative delirium is a common complication in older people and is associated with increased mortality, morbidity, institutionalization, and caregiver burden. Although delirium is an acute confusional state characterized by global impairments in attention and cognition, it has been implicated in permanent cognitive impairment and dementia. The pathogenesis of delirium and the mechanisms leading to these disabling consequences remain unclear. The present study is the first to address the potential predisposing role of brain morphologic changes toward postoperative delirium in a large prospective cohort of patients undergoing elective surgery using state-of-the-art magnetic resonance imaging (MRI) techniques conducted before admission. We investigated the association of MRI-derived quantitative measures of white-matter damage, global brain, and hippocampal volume with the incidence and severity of delirium. Presurgical white-matter hyperintensities (WMHs), whole brain, and hippocampal volume were measured in 146 consecutively enrolled subjects, ≥70 years old, without dementia who were undergoing elective surgery. These 3 presurgical MRI indices were tested as predictors of incidence and severity of subsequent delirium. Out of 146 subjects, 32 (22%) developed delirium. We found no statistically significant differences in WMH, whole brain, or hippocampal volume between subjects with and without delirium. Both unadjusted and adjusted (age, gender, vascular comorbidity, and general cognitive performance) regression analyses demonstrated no statistically significant association between any of the MRI measures with respect to delirium incidence or severity. In persons without dementia, preexisting cerebral WMHs, general and hippocampal atrophy may not predispose to postoperative delirium or worsen its severity. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Feb 2015 · Neurobiology of aging
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    • "Furthermore, to the best of the authors' knowledge, no previous study has explored short-term cognitive outcomes. Delirium experienced in hospital can and does clear (see, e.g., Saczynski et al., 2012). The mean duration of episodes has been quoted as being between 1 and 8 days in acute care settings (see, e.g., Inouye et al., 2007) although episodes may last a little longer, with a mean of 11.5 days in older long-term care residents (see, e.g., Cole et al., 2012). "
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    ABSTRACT: The aim of this study was to examine early cognitive performance after a delirium in elderly general hospital patients. Patients were divided into a delirium (n = 47) and a control (n = 25) group. One week before discharge and after delirium had cleared in the first group, all patients completed a neuropsychological test battery (The Cambridge Cognitive Examination-Revised [CAMCOG-R]). Group differences in cognitive performance were analyzed adjusting for differences in baseline sociodemographic and clinical variables. Adjusting for group differences in baseline variables, the delirium group performed significantly worse than the control group on CAMCOG-R; its subdomains language, praxis, and executive functioning; and on Mini Mental State Examination derived from CAMCOG-R. The occurrence of delirium in hospital thus detrimentally affects early cognitive performance.
    Full-text · Article · Sep 2014 · The Journal of nervous and mental disease
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    • "Delirium is a serious neuropsychiatric syndrome, characterized by disturbances in attention and other cognitive functions (Bisschop, de Rooij, Zwinderman, van Oosten, & van Munster, 2011). The prevalence of delirium is observed in 10–62% of all hospitalizations and is more prevalent in the elderly (van Munster et al., 2008), which is associated with a prolonged length of stay, high rate of institutionalization, and increased morbidity and mortality (Saczynski et al., 2012). "
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    ABSTRACT: Few studies have examined the association between perioperative blood transfusion and postoperative delirium (POD) in aged patients undergoing total hip replacement surgery. In this prospective study, 186 patients older than 65 yr undergoing elective unilateral total hip replacement surgery were enrolled. Of those, 94 patients were randomly assigned to the restrictive strategy transfusion strategy group, in which red blood cells were transfused in order to maintain 10.0 g/dL > hemoglobin ≧ 8.0 g/dL. Ninety-two patients were randomly assigned to the liberal transfusion strategy group, in which red blood cells were transfused in order to maintain hemoglobin ≧ 10.0 g/dL. POD was diagnosed by confusion assessment method. The baseline characteristics of patients, the length of hospital stay, the incidence of POD, myocardial infarction, stroke, wound infection, pulmonary embolism, and the transfusion volume were recorded. No difference was observed in the baseline characteristics, the length of hospital stay, and the incidence of POD, myocardial infarction, stroke, wound infection, and pulmonary embolism between the two groups (P > 0.05). The proportion of patients transfused with red blood cell and frozen plasma was decreased in the restrictive transfusion group compared with the liberal transfusion group (P < 0.05). In conclusion, restrictive transfusion does not influence the incidence of POD but reduces blood transfusion. Thus, restrictive transfusion may serve as an effective and safe strategy for aged patients following total hip replacement.
    Full-text · Article · Jul 2014 · Archives of gerontology and geriatrics
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