O5‐03‐01: CONCURRENT DELIRIUM AND MILD COGNITIVE IMPAIRMENT IN OLDER SURGICAL PATIENTS ARE ASSOCIATED WITH GREATER POSTOPERATIVE COGNITIVE DECLINE
Annie M. RacineTamara G. FongEdward R. MarcantonioRichard N. JonesEva M. SchmittThomas G. TravisonBrad C. DickersonSharon K. Inouye
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Surgery is increasingly common in older adults. Mild cognitive impairment (MCI) and delirium, the most common surgical complication in older adults, are both associated with post-operative cognitive decline. Our study objective was to determine if patients with both delirium and MCI have the greatest post-operative cognitive decline compared to patients with only MCI, only delirium, or neither condition. The Successful Aging after Elective Surgery (SAGES) cohort (N=560) includes older adults (≥70 years) without dementia who underwent scheduled elective surgery. MCI was defined (as previously) by a pre-operative Modified Mini-Mental State Examination score ≤80 if education ≤8 years and ≤88 if education ≥9 years. Delirium was evaluated each postoperative day using the Confusion Assessment Method supplemented by medical chart review. Cognitive data was collected by a detailed neuropsychological battery administered at baseline; months 1, 2, and 6; and every 6 months thereafter. Cognitive outcomes included a General Cognitive Performance (GCP) measure and three z-score composites for executive function, language/semantic memory, and episodic memory. We used linear mixed effects models to examine cognitive decline from months 2-36, controlling for age, sex, and education. We compared cognitive slopes between patients with both MCI and delirium (MCI+/delirium+), MCI only (MCI+/delirium), or delirium only (MCI-/delirium+) to patients with neither MCI nor delirium (MCI-/delirium-). 366 (65%) were MCI-/Delirium-, 60 (11%) were MCI+/Delirium-, 95 (17%) were MCI-/Delirium+, and 39 (7%) were MCI+/Delirium+. The MCI+/Delirium+ group had the greatest difference in cognitive slopes (b) compared to the MCI-/Delirium- group (p<.001, Figures 1-3 for GCP (b = -1.06), executive function (b = -0.11), and language/semantic memory (b = -0.09). In contrast, only MCI-/Del+ showed significantly greater decline in episodic memory compared to MCI-/Delirium- (b = -0.07, p=.005; Figure 4). Additional slopes and group comparisons are provided in Table 1. General Cognitive Performance (GCP): Patients with MCI only (MCI+/Delirium-, green), Delirium only (MCI-/Delirium+, red), or both (MCI+/Delirium+, orange) exhibited greater decline in GCP than patients with neither MCI nor Delirium (MCI-/Delirium, blue). Patients with both MCI and Delirium declined the most. Note: Although patients were also evaluated preoperatively and at 1 month post-surgery, these time points were not analyzed in order to account for the strongest practice/retest effects commonly observed between the first 2-3 administrations. Executive Function Z-Score Cognitive Composite: Patients with MCI only (MCI+/Delirium-, green), Delirium only (MCI-/Delirium+, red), or both (MCI+/Delirium+, orange) exhibited greater decline in Executive Function than patients with neither MCI nor Delirium (MCI /Delirium, blue). Patients with both MCI and Delirium declined the most. Cognitive tests included in the composite: Trail Making Test Part B, Digit Symbol, Visual Search and Attention Task, Digit Span. Language/Semantic Memory Z-Score Cognitive Composite: Only patients with both MCI and delirium (MCI+/Delirium+, orange) exhibited greater decline in Episodic Memory than patients with neither MCI nor Delirium (MCI-/Delirium, blue). Patients with Delirium only (MCI- /Delirium+, red) or MCI only (MCI+/Delirium-, green) were not statistically different from patients with neither MCI nor Delirium. Cognitive tests included in the composite: Category Fluency, Boston Naming Test, F-A-S Fluency. Episodic Memory Z-Score Cognitive Composite: Only patients Delirium only (MCI- /Delirium+, red) exhibited greater decline in Episodic Memory than patients with neither MCI nor Delirium (MCI-/Delirium, blue). Patients with MCI only (MCI+/Delirium-, green) or both (MCI+/Delirium+, orange) were not statistically different from patients with neither MCI nor Delirium. Cognitive tests included in the composite: Hopkins Verbal Learning Test delayed and total. The greatest post-operative cognitive decline was observed in MCI patients who also developed post-operative delirium, suggesting that surgical patients with MCI may benefit most from known delirium prevention strategies. Greater recognition of both conditions, targeted delirium prevention, and development of interventions targeting the specific cognitive domains most affected could lessen the degree of post-operative cognitive decline in older surgical patients.Keywords:
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Main Outcome Measures: The cognitive test battery was composed of tests of memory, vocabulary, executive function (composed of 1 reasoning and 2 fluency tests), and a global cognitive score summarizing performance across all 5 tests. Smoking status was assessed over the entire study period. Linear mixed models were used to assess the association between smoking history and 10-year cognitive decline, expressed as z scores. Results: In men, 10-year cognitive decline in all tests except vocabulary among never smokers ranged from a quarter to a third of the baseline standard deviation. Faster cognitive decline was observed among current smokers compared with never smokers in men (mean difference in 10-year decline in global cognition=−0.09 [95% CI, −0.15 to −0.03] and executive function=−0.11 [95% CI, −0.17 to −0.05]). Recent ex-smokers had greater decline in executive function (−0.08 [95% CI, −0.14 to −0.02]), while the decline in long-term ex-smokers was similar to that among never smokers. In analyses that additionally took dropout and death into account, these differences were 1.2 to 1.5 times larger. In women, cognitive decline did not vary as a function of smoking status.
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The aim of this article is to review the association between diabetes mellitus, cognitive decline and dementia, including the effects of cognitive decline and dementia on self management of diabetes. This is a literature review of primary research articles. A number of contemporary research articles that met the inclusion criteria were selected for this review paper. These articles were selected using a number of search strategies and electronic databases, such as EBSCOhost Research and SwetsWise databases. The duration of diabetes, glycated haemoglobin levels and glycaemic fluctuations were associated with cognitive decline and dementia. Similarly, hypoglycaemia was significantly related to increased risk of developing cognitive decline and dementia. Furthermore, cognitive decline and dementia were associated with poorer diabetes management. There is evidence of the association between diabetes, cognitive decline and dementia including the shared pathogenesis between diabetes and Alzheimer’s disease. In addition, the self management of diabetes is affected by dementia and cognitive decline. It could be suggested that the association between diabetes and dementia is bidirectional with the potential to proceed to a vicious cycle. Further studies are needed in order to fully establish the relationship between diabetes, cognitive decline and dementia. Patients who have diabetes and dementia could benefit from structured education strategies, which should involve empowerment programmes and lifestyle changes. The detection of cognitive decline should highlight the need for education strategies.
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Abstract Background Early detection of dementia is critical for intervention and care planning but remains difficult. Computerized cognitive testing provides an accessible and promising solution to address these current challenges. This study evaluated a computerized cognitive testing battery (BrainCheck) for its diagnostic accuracy and ability to distinguish the severity of cognitive impairment. Methods 99 participants diagnosed with Dementia, Mild Cognitive Impairment (MCI), or Normal Cognition (NC) completed the BrainCheck battery. Statistical analyses compared participant performances on BrainCheck based on their diagnostic group. Results BrainCheck battery performance showed significant differences between the NC, MCI, and Dementia groups, achieving ≥88% sensitivity/specificity for separating NC from Dementia, and ≥77% sensitivity/specificity in separating the MCI group from NC/Dementia groups. Three-group classification found true positive rates ≥80% for the NC and Dementia groups and ≥64% for the MCI group. Conclusions BrainCheck was able to distinguish between diagnoses of Dementia, MCI, and NC, providing a potentially reliable tool for early detection of cognitive impairment.
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In Brief Delirium is common in older adults who have dementia, but too often nurses confuse the symptoms of delirium with those of dementia and it goes unrecognized and untreated. Delirium can signal a serious underlying condition such as infection or dehydration and can increase the risk of falling and the length of hospitalization. This article presents an algorithm meant to guide nurses in the assessment and treatment of delirium superimposed on dementia. For a free online video demonstrating the use of this algorithm, go to https://links.lww.com/A209. Too often nurses confuse the symptoms of delirium with those of dementia and it goes unrecognized and untreated. This article presents an algorithm to guide nurses in the assessment and treatment of delirium superimposed on dementia.
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Delirium or acute confusional state is an acute neuropsychiatric syndrome, with varied cognitive dysfunctions. However, no comprehensive studies about this common condition have been carried out in India.To assess cognitive dysfunctions in hypoactive and hyperactive delirium.Forty cases of delirium including hypoactive and hyperactive delirium and 40 other patients (neuropsychiatric patients) were studied as controls. Cognitive status estimation test, mini mental state examination and memorial delirium assessment scale were administered to each patient. All assessments were carried out three times in 24 hour cycle of day and night. The data was analysed using two sample independent t-test.The mean age (standard deviation) of study and control group was 27.85 (13.73) and 33.10 (11.26) years respectively. 70% patients had hyperactive delirium while 30% were having hypoactive delirium. Hypoactive delirium had more cognitive impairment compared to hyperactive delirium (p=0.001). The difference between highest and lowest score of MMSE in both types of delirium (day to night) was found to be statically significant (p=0.001).The fluctuation in intensity of cognitive symptoms varies from day to night in both types of delirium, but more in hypoactive delirium and wider fluctuation in cognitive dysfunctions was noted in delirium cases with psychosis.
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Delirium and dementia are common causes of cognitive impairment in older adults. They are distinct but interrelated. Delirium, an acute confusional state, has been linked to the chronic and progressive loss of cognitive ability seen in dementia. Individuals with dementia are at higher risk for delirium, and delirium itself is a risk factor for incident dementia. Additionally, delirium in individuals with dementia can hasten underlying cognitive decline. In this review, we summarize recent literature linking these conditions, including epidemiological, clinicopathological, neuroimaging, biomarker, and experimental evidence supporting the intersection between these conditions. Strategies for evaluation and diagnosis that focus on distinguishing delirium from dementia in clinical settings and recommendations for delirium prevention interventions for patients with dementia are presented. We also discuss studies that provide evidence that delirium may be a modifiable risk factor for dementia and consider the impact of delirium prevention interventions on long-term outcomes.
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