Rose C. van der Mast

Incidence of and preoperative predictors for delirium after cardiac surgery

Incidence of and preoperative predictors for postoperative delirium were studied in 296 patients (age 26-83 years, mean age 63 years) undergoing elective cardiac surgery. Delirium occurred in 40 (13.5%) patients. Predictors included old age, low level of albumin, poor physical condition, use of nifedipine, and a high ratio of the amino acids phenylalanine to the sum of isoleucine, leucine, valine, tyrosine, and tryptophan. These findings suggest that preoperative physical condition and amino acid disturbances may be related to delirium after cardiac surgery in the elderly.

Behavioural problems in Huntington's disease using the Problem Behaviours Assessment

OBJECTIVE To investigate behavioural problems in Huntingtons disease (HD). METHOD In 152 HD mutation carriers and a control group of 56 noncarriers at initial 50% risk, the Dutch version of the Problem Behaviours Assessment (PBA) was administered. Mutation carriers were divided into three groups according to the motor section of the Unified Huntingtons Disease Rating Scale (UHDRS): pre-(motor) symptomatic, early and advanced symptomatic subjects. The factor structure and interrater reliability of the PBA were investigated. RESULTS The clinically relevant interrater reliability of the PBA was 0.82 for severity scores and 0.73 for frequency scores. The PBA showed a three-factor solution: apathy, depression and irritability. Mutation carriers, including presymptomatic subjects, portrayed more apathy, depression and irritability than noncarriers. Early symptomatic subjects had more apathy, but not more depression or irritability, compared to presymptomatic subjects. Advanced symptomatic subjects had more apathy than early symptomatic subjects. CONCLUSIONS The PBA is a reliable and sensitive instrument. Behavioural problems occur in all stages of HD and arise before the onset of motor symptoms. Apathy is related to disease severity, whereas depression and irritability are not. The broad clinical phenotype of HD therefore requires adequate service delivery with integrated and multidisciplinary patient care.

Neuropsychiatric symptoms in a European Huntington's disease cohort (REGISTRY)

Background The majority of Huntingtons disease (HD) mutation carriers experience some psychopathology during their lifetime, varying from irritability to psychosis, but prevalences of particular symptoms vary widely due to diverse study populations in different stages of HD and the use of different assessment methods. Methods The study population consisted of 1993 HD mutation carriers from 15 European countries, all participating in the observational REGISTRY study. The behavioural section of the Unified HD Rating Scale was used to examine the prevalence and correlates of five neuropsychiatric features: depression, irritability/aggression, obsessive/compulsive behaviours, apathy and psychosis. Results Twenty-seven per cent of the participants did not have any neuropsychiatric symptom in the last month. Moderate to severe apathy occurred in 28.1% of the participants, whereas moderate to severe depression was found in 12.7%. Irritable/aggressive symptoms were present in 13.9% of the participants, and 13.2% showed obsessive/compulsive behaviours. Moderate to severe psychotic symptoms were found in only 1.2%. Only 54.9% of all participants with moderate to severe depression used antidepressants, suggesting undertreatment of depression. Obsessive/compulsive behaviours and irritability/aggression were inversely correlated with the Total Functional Capacity score, but with apathy showing the strongest inverse association. Conclusions A variety of neuropsychiatric symptoms are highly prevalent in different stages of HD in this European HD population, with apathy as the most frequent symptom. Depression, irritability/aggression and OCBs are prevalent in all stages of HD. Apathy was the key neuropsychiatric symptom occurring most often in advanced HD stages. Due to possible selection of relatively healthy participants, prevalences reported in this study might be an underestimation of prevalence in the entire HD population.

Delirium after cardiac surgery: A critical review

Numerous articles have been published investigating the incidence of and risk factors for delirium after cardiac surgery. Smith and Dimsdale reviewed the literature on postcardiotomy delirium in 1987 using a meta-analysis of 44 research studies. However, doubts about their methods and results caused the authors to re-examine the literature using these 44 references as well as computerized literature searches to gather research and review papers from medical journals. Delirium after cardiac surgery appeared to be ill-defined in most of these studies. The methods and instruments used to assess delirium proved to be very different, and the patient samples were rather heterogeneous. Therefore, in most cases, the results are not comparable. Only a small number of the studies that were examined fit the criteria for statistical meta-analysis. On the basis of our analysis, a tentative conclusion may be drawn that the incidence of postcardiotomy delirium has declined slightly and that no strong risk factors have yet been identified.

Excess mortality in general hospital patients with delirium : a 5-year follow-up of 519 patients seen in psychiatric consultation

Mortality was determined in 519 patients with delirium who were seen in psychiatric consultation in two general hospitals. Among 419 patients with simple delirium (DSM-III: 293.00) in-hospital mortality was 26%. As compared to average hospital patients the age adjusted in-hospital excess mortality ratio varied from 6.2 for patients with malignancies to 2.1 for patients with motor system disease. After hospital discharge the 5-yr cumulative mortality was 51%. As compared to the general population excess mortality was noted in most, but not in all diagnostic subgroups. The age and sex adjusted excess mortality ratio varied from 14.1 for malignancies to 1.3 for motor system disease. The figures underline a general notion that delirium may be an indicator of disorders of grave prognosis, but mortality appears to depend more on the medical condition than on the presence of delirium.

Suicidal ideation in a European Huntington's disease population.

BACKGROUND Previous studies indicate increased prevalences of suicidal ideation, suicide attempts, and completed suicide in Huntingtons disease (HD) compared with the general population. This study investigates correlates and predictors of suicidal ideation in HD. METHODS The study cohort consisted of 2106 HD mutation carriers, all participating in the REGISTRY study of the European Huntingtons Disease Network. Of the 1937 participants without suicidal ideation at baseline, 945 had one or more follow-up measurements. Participants were assessed for suicidal ideation by the behavioural subscale of the Unified Huntingtons Disease Rating Scale (UHDRS). Correlates of suicidal ideation were analyzed using logistic regression analysis and predictors were analyzed using Cox regression analysis. RESULTS At baseline, 169 (8.0%) mutation carriers endorsed suicidal ideation. Disease duration (odds ratio [OR]=0.96; 95% confidence interval [CI]: 0.9-1.0), anxiety (OR=2.14; 95%CI: 1.4-3.3), aggression (OR=2.41; 95%CI: 1.5-3.8), a previous suicide attempt (OR=3.95; 95%CI: 2.4-6.6), and a depressed mood (OR=13.71; 95%CI: 6.7-28.0) were independently correlated to suicidal ideation at baseline. The 4-year cumulative incidence of suicidal ideation was 9.9%. Longitudinally, the presence of a depressed mood (hazard ratio [HR]=2.05; 95%CI: 1.1-4.0) and use of benzodiazepines (HR=2.44; 95%CI: 1.2-5.0) at baseline were independent predictors of incident suicidal ideation, whereas a previous suicide attempt was not predictive. LIMITATIONS As suicidal ideation was assessed by only one item, and participants were a selection of all HD mutation carriers, the prevalence of suicidal ideation was likely underestimated. CONCLUSIONS Suicidal ideation in HD frequently occurs. Assessment of suicidal ideation is a priority in mutation carriers with a depressed mood and in those using benzodiazepines.

Hypothalamic-pituitary-adrenal axis functioning in Huntington's disease mutation carriers compared with mutation-negative first-degree controls.

Neurodegeneration in Huntingtons disease (HD) occurs in various brain regions including the hypothalamus. In this cross-sectional study, hypothalamic-pituitary-adrenal (HPA) axis functioning was studied in 26 presymptomatic and 58 symptomatic HD mutation carriers, and 28 controls. HPA axis functioning was measured through salivary cortisol in the day curve, the cortisol awakening response (CAR), the area under the curve (AUC), the morning rise, and the dexamethasone suppression test (DST). Only the CAR was statistically different between the three groups, being explained by higher cortisol concentrations at 45 and 60 min post-awakening for presymptomatic mutation carriers compared to both symptomatic mutation carriers and controls. No differences were found for the AUC, evening and post-DST cortisol concentrations. Our study indicates a mild disturbance in morning cortisol secretion in HD mutation carriers that precedes the onset of motor symptoms.

Platelet serotonin and [3H]paroxetine binding correlate with recurrence of suicidal behavior.

Abstract To distinguish state-from trait-dependent associations between serotonergic function and suicidal behavior, platelet serotonergic measures were repeatedly measured, during a 1-year follow-up, in 106 patients who had recently attempted suicide for at least a second time. A major DSM-III-R axis I diagnosis or use of antidepressants were reasons for exclusion. A higher affinity constant (KD) of platelet [3H]paroxetine binding was related to a higher risk of short-term recurrence of a suicide attempt, suggesting a state relationship. Higher levels of platelet serotonin at baseline were a significant predictor of a recurrent suicide attempt within the year of follow-up, suggesting a trait relationship. These associations held equally within the subgroup of 73 patients with a borderline personality disorder. Neither the maximum number of binding sites (Bmax) of [3H]paroxetine nor platelet monoamine oxidase activity correlated with suicidality. The observed association between indicators of platelet serotonin uptake and suicidal behavior suggests a state-and trait-dependency between suicidality and central serotonergic dysfunction.

Early diagnosis of delirium after cardiac surgery

In order to detect patients who become delirious after cardiac surgery in an early postoperative stage, an observational checklist was used. Fifteen patients were constantly observed during their 48-hour stay at the intensive care unit for postoperative care. Two (13%) male patients developed postoperative delirium according to DSM-III-R criteria. It was possible to detect these patients in an early postoperative stage (within 48 hours) by means of systematic observations of their behavior.

High preoperative plasma neopterin predicts delirium after cardiac surgery in older adults

To examine the association between plasma levels of pterins and amino acids and postoperative delirium.