Jakub Kazmierski

Clinical utility and use of DSM-IV and ICD-10 Criteria and The Memorial Delirium Assessment Scale in establishing a diagnosis of delirium after cardiac surgery.

Authors evaluated the sensitivity and specificity of DSM-IV and ICD-10 criteria and the cutoff value of the Memorial Delirium Assessment Scale (MDAS) in diagnosing postoperative delirium in 260 cardiac surgery patients. Incidence of delirium diagnosed on the basis of DSM-IV and ICD-10 criteria, and with the use of the MDAS was 11.5%, 9.2%, and 6.5%, respectively. The DSM-IV criteria for delirium were found to be more inclusive than those of ICD-10. The cutoff point of 10 of the MDAS was optimal in relation to the presence or absence of delirium after cardiac surgery.

Cortisol levels and neuropsychiatric diagnosis as markers of postoperative delirium:a prospective cohort study

IntroductionThe pathophysiology of delirium after cardiac surgery is largely unknown. Thepurpose of this study was to investigate whether increased concentration ofpreoperative and postoperative plasma cortisol predicts the development ofdelirium after coronary artery bypass graft surgery. A second aim was to assesswhether the association between cortisol and delirium is stress related ormediated by other pathologies, such as major depressive disorder (MDD) orcognitive impairment.MethodsThe patients were examined 1 day preoperatively with the Mini InternationalNeuropsychiatric Interview and the Montreal Cognitive Assessment and the TrailMaking Test to screen for depression and for cognitive impairment, respectively.Blood samples for cortisol levels were collected both preoperatively andpostoperatively. The Confusion Assessment Method for the Intensive Care Unit wasused within the first 5 days postoperatively to screen for a diagnosis ofdelirium.ResultsPostoperative delirium developed in 36% (41 of 113) of participants. Multivariatelogistic regression analysis revealed two groups independently associated with anincreased risk of developing delirium: those with preoperatively raised cortisollevels; and those with a preoperative diagnosis of MDD associated with raisedlevels of cortisol postoperatively. According to receiver operating characteristicanalysis, the most optimal cutoff values of the preoperative and postoperativecortisol concentration that predict the development of delirium were 353.55 nmol/land 994.10 nmol/l, respectively.ConclusionRaised perioperative plasma cortisol concentrations are associated with deliriumafter coronary artery bypass graft surgery. This may be an importantpathophysiological consideration in the increased risk of postoperative deliriumseen in patients with a preoperative diagnosis of MDD.

Raised IL-2 and TNF-α concentrations are associated with postoperative delirium in patients undergoing coronary-artery bypass graft surgery

BACKGROUND The knowledge base regarding the pathogenesis of postoperative delirium is limited. The primary aim of this study is to investigate whether increased levels of IL-2 and TNF-α are associated with delirium in patients who underwent coronary-artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). The secondary aim is to establish whether any association between raised cytokine levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing conditions associated with raised cytokine levels, such as major depressive disorder (MDD), cognitive impairment, or aging. METHODS Patients were examined and screened for MDD and cognitive impairment one day preoperatively, using the Mini International Neuropsychiatric Interview and The Montreal Cognitive Assessment and Trail Making Test Part B. Blood samples were collected postoperatively for cytokine levels. RESULTS Postoperative delirium screening was found positive in 36% (41 of 113) of patients. A multivariate logistic regression revealed that an increased concentration of pro-inflammatory cytokines is associated with delirium, and related to advancing age, preoperative cognitive decline of participants, and duration of CPB. According to receiver operating characteristic analysis, the most optimal cut-off for IL-2 and TNF-α concentrations in predicting the development of delirium were 907.5 U/ml and 10.95 pg/ml, respectively. CONCLUSIONS The present study suggests that raised postoperative cytokine concentrations are associated with delirium after CABG surgery. Postoperative monitoring of pro-inflammatory markers combined with regular surveillance may be helpful in the early detection of postoperative delirium in this patient group.

Mild Cognitive Impairment with Associated Inflammatory and Cortisol Alterations as Independent Risk Factor for Postoperative Delirium

Aims: The present study aimed to determine the impact of mild cognitive impairment (MCI) on the development of postoperative delirium and, secondly, to assess the association between MCI and raised perioperative cortisol, cytokine, cobalamin and homocysteine levels. Methods: The study recruited 113 consecutive adult patients scheduled for cardiac surgery with cardiopulmonary bypass. The patients were examined preoperatively with the Montreal Cognitive Assessment and Trail Making Test. A diagnosis of MCI was established based upon the criteria of the National Institute on Aging and Alzheimers Association. Patients were screened for delirium within the first 5 days postoperatively. Results: MCI was diagnosed in 24.8% of the patients, whereas the frequency of delirium was 36%. A multivariate analysis demonstrated that individuals with MCI were at a significantly higher risk of postoperative delirium (OR = 6.33, p = 0.002). Preoperative cortisol, postoperative cortisol and IL-2 plasma levels were higher in the MCI group as compared to non-MCI subjects. Conclusion: MCI is associated with a higher risk of postoperative delirium. Perioperative cortisol and inflammatory alterations observed in MCI may provide a physiological explanation for this increased risk.

Is cortisol the key to the pathogenesis of delirium after coronary artery bypass graft surgery

Postoperative delirium is a serious complication of cardiac surgery. However, the pathophysiology of this mental syndrome is largely unknown. Recent findings suggest an association between elevated level of cortisol and postoperative delirium. Further studies should investigate the mechanisms responsible for excessive perioperative cortisol secretion.

The assessment of the T102C polymorphism of the 5HT2a receptor gene, 3723G/A polymorphism of the NMDA receptor 3A subunit gene (GRIN3A) and 421C/A polymorphism of the NMDA receptor 2B subunit gene (GRIN2B) among cardiac surgery patients with and without delirium

OBJECTIVE The studies regarding the role of genes polymorphism in development of postoperative delirium are extremely rare. Therefore, we investigated the potential association of polymorphism in 5HT2a receptor gene and N-methyl-d-aspartate (NMDA) receptor 3A and 2B subunits genes with postoperative delirium. METHOD We conducted a prospective, nested, case-control study. For analysis, 3723 G/A (rs3739722) polymorphism in the GRIN3A gene, 421 C/A (rs3764028) polymorphism in the GRIN2B gene and T102C (rs6313) polymorphism in the 5HT2A gene were selected. RESULTS Genetic analysis confirmed that there were significant differences in genotype frequencies for 3723 G/A between delirium patients and controls. No other significant associations were observed. Moreover, according to the multivariate conditional logistic regression analysis the presence of AG haplotype of GRIN3A gene was independently associated with postoperative delirium. CONCLUSIONS These findings suggest that the genetic variations of NR3A subunit of NMDA receptor may be a predisposing factor to delirium among the Polish population of cardiac surgery patients.

The Impact of a Long-Term Rivastigmine and Donepezil Treatment on All-Cause Mortality in Patients With Alzheimer’s Disease:

Cholinesterase inhibitors (ChEIs) are the mainstays of symptomatic treatment of Alzheimer’s disease (AD); however, their efficacy is limited, and their use was associated with deaths in some groups of patients. The aim of the current study was to assess the impact of the long-term use of ChEIs on mortality in patients with AD. This observational, longitudinal study included 1171 adult patients with a diagnosis of AD treated with donepezil or rivastigmine. Each patient was observed for 24 months or until death. The cognitive and functional assessments, the use of ChEIs, memantine, antipsychotics, antidepressants, and anxiolytics were recorded. The total number of deaths at the end of the observational period was 99 (8.45%). The patients who had received rivastigmine treatment were at an increased risk of death in the follow-up period. The higher risk of death in the rivastigmine group remained significant in multivariate Cox regression models.

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