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Neuropsychologia Aug 2023Disorientation is a frequent consequence of acute brain injury or diffuse disorders, such as confusional states or dementia. Its anatomical correlates are debated.... (Observational Study)
Observational Study
BACKGROUND AND OBJECTIVES
Disorientation is a frequent consequence of acute brain injury or diffuse disorders, such as confusional states or dementia. Its anatomical correlates are debated. Impaired memory as its commonly assumed mechanism predicts that disorientation is associated with medial temporal damage. The alternative is that disorientation reflects defective orbitofrontal reality filtering (ORFi) - a specific failure to identify whether thoughts or memories refer to present reality or not. The latter is a function of the posterior orbitofrontal cortex and connected structures. This study examined the mechanisms and anatomical basis of disorientation in an unselected group of patients with first-ever subacute brain injury.
METHODS
Participants hospitalized for neurorehabilitation were asked to participate in this observational cohort study if they had first-ever organic hemispheric brain dysfunction as evident in a localizable brain lesion or verbal amnesia (often without localizable brain damage). Orientation to time, place, situation and person was tested with a 20-items questionnaire. To identify the mechanisms of disorientation, we determined its correlations with executive tasks, verbal episodic memory, and ORFi in all patients. ORFi was examined with a continuous recognition task, which measures learning and item recognition in the first run, and ORFi as reflected in the increase of false positive responses in the second run (temporal context confusion). Lesions of patients having localizable brain damage were manually delineated and normalized before entering multivariate lesion-symptom-mapping (LSM) to determine anatomical predictors of orientation.
RESULTS
Eighty-four patients (61.1 ± 14.4 years, 29 women) were included. Among measures of memory and executive functioning, a step-wise regression retained temporal context confusion (R = -0.71, p < 0.0001), item recognition (R = 0.67, p < 0.0001) and delayed free recall (R = 0.63, p < 0.0001) as significant predictors of orientation. LSM was possible in 67 participants; it revealed an association of disorientation with damage of the right OFC and the bilateral head of the caudate nucleus.
CONCLUSION
Disorientation in non-confused, non-demented patients with first-ever brain damage is associated with impaired orbitofrontal reality filtering and memory dysfunction, but not with executive dysfunction. Its main anatomical determinant is damage to the orbitofrontal cortex and its subcortical relay, the head of the caudate.
Topics: Humans; Female; Confusion; Recognition, Psychology; Brain Injuries; Prefrontal Cortex; Memory, Episodic
PubMed: 37263576
DOI: 10.1016/j.neuropsychologia.2023.108601 -
Anesthesia and Analgesia Jan 2023Delirium is an acute syndrome characterized by inattention, disorganized thinking, and an altered level of consciousness. A reliable biomarker for tracking delirium does...
BACKGROUND
Delirium is an acute syndrome characterized by inattention, disorganized thinking, and an altered level of consciousness. A reliable biomarker for tracking delirium does not exist, but oscillations in the electroencephalogram (EEG) could address this need. We evaluated whether the frequencies of EEG oscillations are associated with delirium onset, severity, and recovery in the postoperative period.
METHODS
Twenty-six adults enrolled in the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES; ClinicalTrials.gov NCT02241655) study underwent major surgery requiring general anesthesia, and provided longitudinal postoperative EEG recordings for this prespecified substudy. The presence and severity of delirium were evaluated with the confusion assessment method (CAM) or the CAM-intensive care unit. EEG data obtained during awake eyes-open and eyes-closed states yielded relative power in the delta (1-4 Hz), theta (4-8 Hz), and alpha (8-13 Hz) bands. Discriminability for delirium presence was evaluated with c-statistics. To account for correlation among repeated measures within patients, mixed-effects models were generated to assess relationships between: (1) delirium severity and EEG relative power (ordinal), and (2) EEG relative power and time (linear). Slopes of ordinal and linear mixed-effects models are reported as the change in delirium severity score/change in EEG relative power, and the change in EEG relative power/time (days), respectively. Bonferroni correction was applied to confidence intervals (CIs) to account for multiple comparisons.
RESULTS
Occipital alpha relative power during eyes-closed states offered moderate discriminability (c-statistic, 0.75; 98% CI, 0.58-0.87), varying inversely with delirium severity (slope, -0.67; 98% CI, -1.36 to -0.01; P = .01) and with severity of inattention (slope, -1.44; 98% CI, -2.30 to -0.58; P = .002). Occipital theta relative power during eyes-open states correlated directly with severity of delirium (slope, 1.28; 98% CI, 0.12-2.44; P = .007), inattention (slope, 2.00; 98% CI, 0.48-3.54; P = .01), and disorganized thinking (slope, 3.15; 98% CI, 0.66-5.65; P = .01). Corresponding frontal EEG measures recapitulated these relationships to varying degrees. Severity of altered level of consciousness correlated with frontal theta relative power during eyes-open states (slope, 11.52; 98% CI, 6.33-16.71; P < .001). Frontal theta relative power during eyes-open states correlated inversely with time (slope, -0.05; 98% CI, -0.12 to -0.04; P = .002).
CONCLUSIONS
Presence, severity, and core features of postoperative delirium covary with spectral features of the EEG. The cost and accessibility of EEG facilitate the translation of these findings to future mechanistic and interventional trials.
Topics: Adult; Humans; Aged; Emergence Delirium; Delirium; Consciousness Disorders; Electroencephalography; Cognition
PubMed: 36130079
DOI: 10.1213/ANE.0000000000006075 -
Journal of Clinical Anesthesia Sep 2023Postoperative delirium (POD) is a common surgical complication associated with increased morbidity and mortality in elderly. Although the underlying mechanisms remain...
BACKGROUND
Postoperative delirium (POD) is a common surgical complication associated with increased morbidity and mortality in elderly. Although the underlying mechanisms remain elusive, perioperative risk factors were reported to be closely related to its development. This study was designed to investigate the association between the duration of intraoperative hypotension and POD incidence following thoracic and orthopedic surgery in elderly.
METHOD
The perioperative data from 605 elderly undergoing thoracic and orthopedic surgery from January 2021 to July 2022 were analyzed. The primary exposure was a cumulative duration of mean arterial pressure (MAP) ≤ 65 mmHg. The primary end-point was the POD incidence assessed with confusion assessment method (CAM) or CAM-ICU for three days after surgery. Restricted cubic spline (RCS) was conducted to examine the continuous relationship between the duration of intraoperative hypotension and POD incidence adjusted with patients' demographics and surgery related factors. Then the duration of intraoperative hypotension was categorized into three groups: no hypotension, short (< 5 mins) or long duration (≥ 5 mins) of hypotension for further analysis.
RESULT
The incidence of POD was 14.7% (89 cases out of 605) within three days after surgery. The duration of hypotension presented a non-linear and "inverted L-shaped" effect on POD development. Compared to no hypotension, long duration (adjusted OR 3.93; 95% CI: 2.07-7.45; P < 0.001) rather than short duration of MAP ≤65 mmHg (adjusted OR 1.18; 95% CI: 0.56-2.50; P = 0.671) was closely related to the POD incidence.
CONCLUSION
Intraoperative hypotension (MAP ≤65 mmHg) for ≥5 mins was associated with an increased incidence of POD after thoracic and orthopedic surgery in elderly.
Topics: Humans; Aged; Emergence Delirium; Delirium; Postoperative Complications; Hypotension; Orthopedic Procedures; Risk Factors
PubMed: 37084642
DOI: 10.1016/j.jclinane.2023.111125 -
The Journal of Thoracic and... Mar 2018
Topics: Confusion; Delirium; Esophagectomy; Humans; Starch
PubMed: 29452477
DOI: 10.1016/j.jtcvs.2017.11.052 -
Intensive Care Medicine May 2022To compare the prevalence, characteristics, drug treatment for delirium, and outcomes of patients with Natural Language Processing (NLP) diagnosed behavioral disturbance...
Natural language processing diagnosed behavioral disturbance vs confusion assessment method for the intensive care unit: prevalence, patient characteristics, overlap, and association with treatment and outcome.
PURPOSE
To compare the prevalence, characteristics, drug treatment for delirium, and outcomes of patients with Natural Language Processing (NLP) diagnosed behavioral disturbance (NLP-Dx-BD) vs Confusion Assessment Method for intensive care unit (CAM-ICU) positivity.
METHODS
In three combined medical-surgical ICUs, we obtained data on demographics, treatment with antipsychotic medications, and outcomes. We applied NLP to caregiver progress notes to diagnose behavioral disturbance and analyzed simultaneous CAM-ICU.
RESULTS
We assessed 2313 patients with a median lowest Richmond Agitation-Sedation Scale (RASS) score of - 2 (- 4.0 to - 1.0) and median highest RASS score of 1 (0 to 1). Overall, 1246 (53.9%) patients were NLP-Dx-BD positive (NLP-Dx-BD) and 578 (25%) were CAM-ICU positive (CAM-ICU). Among NLP-Dx-BD patients, 539 (43.3%) were also CAM-ICU. In contrast, among CAM-ICU patients, 539 (93.3%) were also NLP-Dx-BD. The use of antipsychotic medications was highest in patients in the CAM-ICU and NLP-Dx-BD group (24.3%) followed by the CAM-ICU and NLP-Dx-BD group (10.5%). In NLP-Dx-BD patients, antipsychotic medication use was lower at 5.1% for CAM-ICU and NLP-Dx-BD patients and 2.3% for CAM-ICU and NLP-Dx-BD patients (overall P < 0.001). Regardless of CAM-ICU status, after adjustment and on time-dependent Cox modelling, NLP-Dx-BD was associated with greater antipsychotic medication use. Finally, regardless of CAM-ICU status, NLP-Dx-BD patients had longer duration of ICU and hospital stay and greater hospital mortality (all P < 0.001).
CONCLUSION
More patients were NLP-Dx-BD positive than CAM-ICU positive. NLP-Dx-BD and CAM-ICU assessment describe partly overlapping populations. However, NLP-Dx-BD identifies more patients likely to receive antipsychotic medications. In the absence of NLP-Dx-BD, treatment with antipsychotic medications is rare.
Topics: Antipsychotic Agents; Delirium; Humans; Intensive Care Units; Natural Language Processing; Prevalence; Treatment Outcome
PubMed: 35322288
DOI: 10.1007/s00134-022-06650-z -
Cellular and Molecular Gastroenterology... 2021
Topics: Cell Communication; Cell Fusion; Confusion; Humans
PubMed: 33068772
DOI: 10.1016/j.jcmgh.2020.09.018 -
The Western Journal of Medicine Jul 1989
Topics: Brain Edema; Child; Cognition Disorders; Confusion; Headache; Humans; Renal Dialysis; Syndrome
PubMed: 2763543
DOI: No ID Found -
Canadian Family Physician Medecin de... Jan 2001To outline current approaches to diagnosing and managing delirium in the elderly. (Review)
Review
OBJECTIVE
To outline current approaches to diagnosing and managing delirium in the elderly.
QUALITY OF EVIDENCE
A literature review was based on a MEDLINE search (1966 to 1998). Selected articles were reviewed and used as the basis for discussion of diagnosis and etiology. We planned to include all published randomized controlled trials regarding management but found only two. Consequently, we also used review articles and recent practice guidelines for delirium published by the American Psychiatric Association.
MAIN FINDINGS
Clinical diagnosis of delirium can be aided by using DSM-IV criteria, the Delirium Symptom Interview, or the confusion assessment method. Management must include investigation and treatment of underlying causes and general supportive measures. Providing optimal levels of stimulation, reorienting patients, education, and supporting families are important. Pharmacologic management of delirium should be considered only for specific symptoms or behaviours, e.g., aggression, severe agitation, or psychosis. Only one randomized controlled trial of tranquilizer use for delirium in medically ill people has been published. Findings support the current belief that neuroleptics are superior to benzodiazepines in most cases of delirium. Most authorities still consider haloperidol the neuroleptic of choice. Controlled trials of the new atypical neuroleptics for treating delirium are not yet available. Benzodiazepines with relatively short half-lives, such as lorazepam, are the drugs of choice for withdrawal symptoms.
CONCLUSION
Delirium is frequently underdiagnosed in clinical practice. It should be suspected with acute changes in behaviour. Careful investigation of the underlying cause permits appropriate management.
Topics: Aged; Antipsychotic Agents; Delirium; Diagnosis, Differential; Female; Geriatrics; Haloperidol; Humans; Male; Practice Guidelines as Topic
PubMed: 11212421
DOI: No ID Found -
Journal of Neurovirology Feb 2021With the growing number of COVID-19 cases in recent times. significant set of patients with extra pulmonary symptoms has been reported worldwide. Here we venture out to...
With the growing number of COVID-19 cases in recent times. significant set of patients with extra pulmonary symptoms has been reported worldwide. Here we venture out to summarize the clinical profile, investigations, and radiological findings among patients with SARS-CoV-2-associated meningoencephalitis in the form of a systemic review. This review was carried out based on the existing PRISMA (Preferred Report for Systematic Review and Meta analyses) consensus statement. The data for this review was collected from four databases: Pubmed/Medline, NIH Litcovid, Embase, and Cochrane library and Preprint servers up till 30 June 2020. Search strategy comprised of a range of keywords from relevant medical subject headings which includes "SARS-COV-2," "COVID-19," and "meningoencephalitis." All peer reviewed, case-control, case report, pre print articles satisfying our inclusion criteria were involved in the study. Quantitative data was expressed in mean ± SD, while the qualitative date in percentages. Paired t test was used for analysing the data based on differences between mean and respective values with a p < 0.05 considered to be statistically significant. A total of 61 cases were included from 25 studies after screening from databases and preprint servers, out of which 54 of them had completed investigation profile and were included in the final analysis. Clinical, laboratory findings, neuroimaging abnormalities, and EEG findings were analyzed in detail. This present review summarizes the available evidences related to the occurrence of meningoencephalitis in COVID-19.
Topics: Adult; Aged; Antiviral Agents; Azithromycin; COVID-19; Confusion; Cough; Dyspnea; Electroencephalography; Fatigue; Female; Fever; Humans; Hydroxychloroquine; Male; Meningoencephalitis; Middle Aged; Neuroimaging; SARS-CoV-2; COVID-19 Drug Treatment
PubMed: 33367960
DOI: 10.1007/s13365-020-00923-3 -
Medicina Intensiva Oct 2013Patients with acute lung injury or acute respiratory distress syndrome (ARDS) admitted to the ICU present neuropsychological alterations, which in most cases extend... (Review)
Review
Patients with acute lung injury or acute respiratory distress syndrome (ARDS) admitted to the ICU present neuropsychological alterations, which in most cases extend beyond the acute phase and have an important adverse effect upon quality of life. The aim of this review is to deepen in the analysis of the complex interaction between lung and brain in critically ill patients subjected to mechanical ventilation. This update first describes the neuropsychological alterations occurring both during the acute phase of ICU stay and at discharge, followed by an analysis of lung-brain interactions during mechanical ventilation, and finally explores the etiology and mechanisms leading to the neurological disorders observed in these patients. The management of critical patients requires an integral approach focused on minimizing the deleterious effects over the short, middle or long term.
Topics: Acute Disease; Acute Lung Injury; Attention; Blood-Brain Barrier; Brain; Brain Damage, Chronic; Catecholamines; Cognition Disorders; Confusion; Critical Illness; Cytokines; Delirium; Executive Function; Humans; Hypoxia, Brain; Intensive Care Units; Lung; Neuropeptides; Neuropsychological Tests; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 23260265
DOI: 10.1016/j.medin.2012.10.005