The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients.
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ABSTRACT: Introduction
As the relationship between delirium and long-term cognitive decline has not been well-explored, we evaluated this association in a prospective study.Methods
SAGES is an ongoing study involving 560 adults age 70 years or more without dementia scheduled for major surgery. Delirium was assessed daily in the postoperative period using the Confusion Assessment Method. General Cognitive Performance (GCP) and the Informant Questionnaire for Cognitive Decline in the Elderly were assessed preoperatively then repeatedly out to 36 months.Results
On average, patients with postoperative delirium had significantly lower preoperative cognitive performance, greater immediate (1 month) impairment, equivalent recovery at 2 months, and significantly greater long-term cognitive decline relative to the nondelirium group. Proxy reports corroborated the clinical significance of the long-term cognitive decline in delirious patients.Discussion
Cognitive decline after surgery is biphasic and accelerated among persons with delirium. The pace of long-term decline is similar to that seen with mild cognitive impairment.
SUBMITTER: Inouye SK
PROVIDER: S-EPMC4947419 | biostudies-literature | 2016 Jul
REPOSITORIES: biostudies-literature
Publications
The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients.
Inouye Sharon K SK Marcantonio Edward R ER Kosar Cyrus M CM Tommet Douglas D Schmitt Eva M EM Travison Thomas G TG Saczynski Jane S JS Ngo Long H LH Alsop David C DC Jones Richard N RN
Alzheimer's & dementia : the journal of the Alzheimer's Association 20160418 7
<h4>Introduction</h4>As the relationship between delirium and long-term cognitive decline has not been well-explored, we evaluated this association in a prospective study.<h4>Methods</h4>SAGES is an ongoing study involving 560 adults age 70 years or more without dementia scheduled for major surgery. Delirium was assessed daily in the postoperative period using the Confusion Assessment Method. General Cognitive Performance (GCP) and the Informant Questionnaire for Cognitive Decline in the Elderly ...[more]
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Project description:Background :Increasing evidence suggests that postoperative delirium may result in long-term cognitive decline among older adults. Risk factors for such cognitive decline are unknown. Methods :We studied 126 older participants without delirium or dementia upon entering the Successful AGing After Elective Surgery (SAGES) study, who developed postoperative delirium and completed repeated cognitive assessments (up to 36 months of follow-up). Pre-surgical factors were assessed preoperatively and divided into nine groupings of related factors ("domains"). Delirium was evaluated at baseline and daily during hospitalization using the Confusion Assessment Method diagnostic algorithm, and cognitive function was assessed using a neuropsychological battery and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) at baseline and 6-month intervals over 3 years. Linear regression was used to examine associations between potential risk factors and rate of long-term cognitive decline over time. A domain-specific and then overall selection method based on adjusted R2 values was used to identify explanatory factors for the outcome. Results :The General Cognitive Performance (GCP) score (combining all neuropsychological test scores), IQCODE score, and living alone were significantly associated with long-term cognitive decline. GCP score explained the most variation in rate of cognitive decline (13%), and six additional factors-IQCODE score, cognitive independent activities of daily living impairment, living alone, cerebrovascular disease, Charlson comorbidity index score, and exhaustion level-in combination explained 32% of variation in this outcome. Conclusions :Global cognitive performance was most strongly associated with long-term cognitive decline following delirium. Pre-surgical factors may substantially predict this outcome.
| S-EPMC5861861 | biostudies-other
Project description:ImportanceThe study results suggest that delirium is the most common postoperative complication in older adults and is associated with poor outcomes, including long-term cognitive decline and incident dementia.ObjectiveTo examine the patterns and pace of cognitive decline up to 72 months (6 years) in a cohort of older adults following delirium.Design, setting, and participantsThis was a prospective, observational cohort study with long-term follow-up including 560 community-dwelling older adults (older than 70 years) in the ongoing Successful Aging after Elective Surgery study that began in 2010. The data were analyzed from 2021 to 2022.ExposureDevelopment of incident delirium following major elective surgery.Main outcomes and measuresDelirium was assessed daily during hospitalization using the Confusion Assessment Method, which was supplemented with medical record review. Cognitive performance using a comprehensive battery of neuropsychological tests was assessed preoperatively and across multiple points postoperatively to 72 months of follow-up. We evaluated longitudinal cognitive change using a composite measure of neuropsychological performance called the general cognitive performance (GCP), which is scaled so that 10 points on the GCP is equivalent to 1 population SD. Retest effects were adjusted using cognitive test results in a nonsurgical comparison group.ResultsThe 560 participants (326 women [58%]; mean [SD] age, 76.7 [5.2] years) provided a total of 2637 person-years of follow-up. One hundred thirty-four participants (24%) developed postoperative delirium. Cognitive change following surgery was complex: we found evidence for differences in acute, post-short-term, intermediate, and longer-term change from the time of surgery that were associated with the development of postoperative delirium. Long-term cognitive change, which was adjusted for practice and recovery effects, occurred at a pace of about -1.0 GCP units (95% CI, -1.1 to -0.9) per year (about 0.10 population SD units per year). Participants with delirium showed significantly faster long-term cognitive change with an additional -0.4 GCP units (95% CI, -0.1 to -0.7) or -1.4 units per year (about 0.14 population SD units per year).Conclusions and relevanceThis cohort study found that delirium was associated with a 40% acceleration in the slope of cognitive decline out to 72 months following elective surgery. Because this is an observational study, we cannot be sure whether delirium directly causes subsequent cognitive decline, or whether patients with preclinical brain disease are more likely to develop delirium. Future research is needed to understand the causal pathway between delirium and cognitive decline.
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Project description:ImportanceIndividuals with total joint arthroplasty (TJA) have long-term exposure to metal-containing implants; however, whether long-term exposure to artificial implants is associated with cognitive function is unknown.ObjectiveTo compare long-term cognitive trajectories in individuals with and without TJA.Design, setting, and participantsThis population-based cohort study assessed serial cognitive evaluations of 5550 participants (≥50 years of age) from the Mayo Clinic Study of Aging between November 1, 2004, and December 31, 2020.ExposuresTotal joint arthroplasty of the hip or the knee.Main outcomes and measuresLinear mixed-effects models were used to compare the annualized rate of change in global and domain-specific cognitive scores in participants with and without TJA, adjusting for age, sex, educational level, apolipoprotein E ε4 carrier status, and cognitive test practice effects.ResultsA total of 5550 participants (mean [SD] age at baseline, 73.04 [10.02] years; 2830 [51.0%] male) were evaluated. A total of 952 participants had undergone at least 1 TJA of the hip (THA, n = 430) or the knee (TKA, n = 626) before or after entry into the cohort. Participants with TJA were older, more likely to be female, and had a higher body mass index than participants without TJA. No difference was observed in the rate of cognitive decline in participants with and without TJA until 80 years of age. A slightly faster cognitive decline at 80 years or older and more than 8 years from surgery was observed (b = -0.03; 95% CI, -0.04 to -0.02). In stratified analyses by surgery type, the faster decline was observed primarily among older participants with TKA (b = -0.04; 95% CI, -0.06 to -0.02).Conclusions and relevanceIn this cohort study, long-term cognitive trajectories in individuals with and without TJA were largely similar except for a slightly faster decline among the oldest patients with TKA; however, the magnitude of difference was small and of unknown clinical significance.
| S-EPMC9664257 | biostudies-literature
Project description:Skill acquisition requires practice to stimulate neuroplasticity. Changes in inhibitory and excitatory neurotransmitters, such as gamma-aminobutyric acid (GABA) and glutamate, are believed to play a crucial role in promoting neuroplasticity. Magnetic resonance spectroscopy (MRS) at 3 T, using the MEGA-PRESS sequence, and behavioral data were collected from 62 volunteers. Participants completed a 4-week protocol, practicing either complex (n = 32) or simple (n = 30) bimanual tracking tasks (BTT). Neurotransmitter levels and skill levels at baseline, after 2 and 4 weeks of motor training were compared for the left and right primary sensorimotor cortex (SM1) and the left dorsal premotor cortex (PMd). Furthermore, task-related modulations of neurotransmitter levels in the left PMd were assessed. The study yielded that baseline neurotransmitter levels in motor-related brain regions predicted training success. Furthermore, lower GABA+ (p = 0.0347) and higher Glx (glutamate + glutamine compound) levels (p = 0.0234) in left PMd correlated with better long-term learning of simple and complex tasks, respectively, whereas higher GABA+ in right SM1 correlated with complex task learning (p = 0.0064). Resting neurometabolite levels changed during the intervention: Left SM1 Glx decreased with complex training toward Week 4 (p = 0.0135), whereas right SM1 Glx was increased at Week 2 (p = 0.0043), regardless of training type. Group-level analysis showed no task-related neurometabolite modulation in the left PMd. However, individual baseline GABA+ and Glx modulation influenced short-term motor learning (interaction: p = 0.0213). These findings underscore the importance of an interplay between inhibitory and excitatory neurotransmitters during motor learning and suggest potential for future personalized approaches to optimize motor learning.
| S-EPMC11877351 | biostudies-literature
Project description:AIM:The determinants of cognitive impairment and delirium during acute illness are poorly understood, despite being common among older people. Anemia is common in older people, and there is ongoing debate regarding the association between anemia, cognitive impairment and delirium, primarily in non-surgical patients. METHODS:Using data from the Older Persons Surgical Outcomes Collaboration 2013 and 2014 audit cycles, we examined the association between anemia and cognitive outcomes in patients aged ≥65 years admitted to five UK acute surgical units. On admission, the Confusion Assessment Method was carried out to detect delirium. Cognition was assessed using the Montreal Cognitive Assessment, and two levels of impairment were defined as Montreal Cognitive Assessment <26 and <20. Logistic regression models were constructed to examine these associations in all participants, and individuals aged ≥75 years only. RESULTS:A total of 653 patients, with a median age of 76.5 years (interquartile range 73.0-80.0 years) and 53% women, were included. Statistically significant associations were found between anemia and age; polypharmacy; hyperglycemia; and hypoalbuminemia. There was no association between anemia and cognitive impairment or delirium. The adjusted odds ratios of cognitive impairment were 0.95 (95% CI 0.56-1.61) and 1.00 (95% CI 0.61-1.64) for the Montreal Cognitive Assessment <26 and <20, respectively. The adjusted odds ratio of delirium was 1.00 (95% CI 0.48-2.10) in patients with anemia compared with those without. Similar results were observed for the ≥75 years age group. CONCLUSIONS:There was no association between anemia and cognitive outcomes among older people in this acute surgical setting. Considering the retrospective nature of the study and possible lack of power, findings should be taken with caution. Geriatr Gerontol Int 2018; 18: 1025-1030.
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Project description:BackgroundDelirium has been associated with more rapid cognitive decline. However, it is unknown whether increased delirium severity is associated with a higher rate of long-term cognitive decline.ObjectiveTo evaluate delirium severity and the presence and rate of cognitive decline over 36 months following surgery.MethodsWe examined patients from the Successful Aging after Elective Surgery Study, who were age ≥70 years undergoing major elective surgery (N = 560). Delirium severity was determined by the peak Confusion Assessment Method-Severity (CAM-S) score for each patient's hospitalization and grouped based on the sample distribution: scores of 0-2, 3-7, and 8-19. A neuropsychological composite, General Cognitive Performance (GCP), and proxy-reported Informant Questionnaire for Cognitive Decline (IQCODE) were used to examine cognitive outcomes following surgery at 0, 1, and 2 months, and then every 6 months for up to 3 years.ResultsNo significant cognitive decline was observed for patients with peak CAM-S scores 0-2 (-0.17 GCP units/year, 95% confidence interval [CI] -0.35, 0.01). GCP scores decreased significantly in the group with peak CAM-S scores 3-7 (-0.30 GCP units/year, 95% CI -0.51, -0.09), and decreased almost three times faster in the highest delirium severity group (peak CAM-S scores 8-19; -0.82 GCP units/year, 95% CI -1.28, -0.37). A similar association was found for delirium severity and the proportion of patients who developed IQCODE impairment over time.ConclusionPatients with the highest delirium severity experienced the greatest rate of cognitive decline, which exceeds the rate previously observed for patients with dementia, on serial neuropsychological testing administered over 3 years, with a dose-response relationship between delirium severity and long-term cognitive decline.
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Project description:ObjectivesTo characterize the risk of long-term cognitive impairment associated with delirium in acute neurologic injury patients.DesignWe analyzed a 10-year cohort of adult acute neurologic injury patients (stroke and traumatic brain injury) without preexisting mild cognitive impairment or dementia, utilizing administrative databases. Patients were followed for in-hospital delirium and mild cognitive impairment or dementia. We report incidence and adjusted hazard ratios for mild cognitive impairment or dementia associated with delirium. Subgroups analyzed include acute neurologic injury categories, dementia subtypes, repeated delirium exposure, and age strata.SettingWe used state emergency department and state inpatient databases for New York, Florida, and California. All visits are included in the databases regardless of payer status.PatientsWe included adult patients with diagnosis of stroke and traumatic brain injury as acute neurologic injury. Patients with preexisting mild cognitive impairment or dementia were excluded.InterventionsNone.Measurements and main resultsAmong 911,380 acute neurologic injury patients, 5.2% were diagnosed with delirium. Mild cognitive impairment or dementia incidence among delirium patients was approximately twice that of nondelirium patients. In adjusted models, risk of mild cognitive impairment or dementia was higher among patients with delirium (adjusted hazard ratio, 1.58). Increased risk was observed across all subgroups including patients less than or equal to 55 years old.ConclusionsIdentification, management, and prevention of in-hospital delirium could potentially improve long-term cognitive outcomes in acute neurologic injury patients.
| S-EPMC7314325 | biostudies-literature
Project description:ImportanceDelirium is associated with increased hospital costs, health care complications, and increased mortality. Long-term consequences of delirium on cognition have not been synthesized and quantified via meta-analysis.ObjectiveTo determine if an episode of delirium was an independent risk factor for long-term cognitive decline, and if it was, whether it was causative or an epiphenomenon in already compromised individuals.Data sourcesA systematic search in PubMed, Cochrane, and Embase was conducted from January 1, 1965, to December 31, 2018. A systematic review guided by Preferred Reporting Items for Systematic Reviews and Meta-analyses was conducted. Search terms included delirium AND postoperative cognitive dysfunction; delirium and cognitive decline; delirium AND dementia; and delirium AND memory.Study selectionInclusion criteria for studies included contrast between groups with delirium and without delirium; an objective continuous or binary measure of cognitive outcome; a final time point of 3 or more months after the delirium episode. The electronic search was conducted according to established methodologies and was executed on October 17, 2018.Data extraction and synthesisThree authors extracted data on individual characteristics, study design, and outcome, followed by a second independent check on outcome measures. Effect sizes were calculated as Hedges g. If necessary, binary outcomes were also converted to g. Only a single effect size was calculated for each study.Main outcomes and measuresThe planned main outcome was magnitude of cognitive decline in Hedges g effect size in delirium groups when contrasted with groups that did not experience delirium.ResultsOf 1583 articles, data subjected from the 24 studies (including 3562 patients who experienced delirium and 6987 controls who did not) were included in a random-effects meta-analysis for pooled effect estimates and random-effects meta-regressions to identify sources of study variance. One study was excluded as an outlier. There was a significant association between delirium and long-term cognitive decline, as the estimated effect size (Hedges g) for 23 studies was 0.45 (95% CI, 0.34-0.57; P < .001). In all studies, the group that experienced delirium had worse cognition at the final time point. The I2 measure of between-study variability in g was 0.81. A multivariable meta-regression suggested that duration of follow-up (longer with larger gs), number of covariates controlled (greater numbers were associated with smaller gs), and baseline cognitive matching (matching was associated with larger gs) were significant sources of variance. More specialized subgroup and meta-regressions were consistent with predictions that suggested that delirium may be a causative factor in cognitive decline.Conclusions and relevanceIn this meta-analysis, delirium was significantly associated with long-term cognitive decline in both surgical and nonsurgical patients.
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Project description:Both short- and long-term memories decline with healthy ageing. The aims of the current study were twofold: firstly, to build on previous studies and investigate the presence of a relationship between short- and long-term memories and, secondly, to examine cross-sectionally whether there are changes in this relationship with age. In two experiments, participants across the age range were tested on contextual-spatial memories after short and long memory durations. Experimental control in stimulus materials and task demands enabled the analogous encoding and probing for both memory durations, allowing us to examine the relationship between the two memory systems. Across two experiments, in line with previous studies, we found both short-term memory and long-term memory declined from early to late adulthood. Additionally, there was a significant relationship between short- and long-term memory performance, which, interestingly, persisted throughout the age range. Our findings suggest a significant degree of common vulnerability to healthy ageing for short- and long-term memories sharing the same spatial-contextual associations. Furthermore, our tasks provide a sensitive and promising framework for assessing and comparing memory function at different timescales in disorders with memory deficits at their core.
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