Pre-existing Cognitive Impairment Research Articles

Abstract P53: Long-Term Mortality Among Ischemic Stroke Patients With Pre-Existing Mild Cognitive Impairment or Dementia

Introduction: The contribution of preexisting mild cognitive impairment (MCI) or dementia (MCID) towards long term mortality in Ischemic Stroke (IS) patients is under studied. Methods: We conducted a propensity score (PS) matched analysis of pooled data from 39 healthcare organizations to evaluate the association between MCID and post stroke mortality (PSM) through a 5-year period. Using ICD-10 codes for MCI, Alzheimer disease, vascular/other dementias, and MCID specific medications; we flagged preexisting MCID diagnoses up till 1 month prior to the index IS event (MCID group). The non-MCID group had no documented MCID diagnoses till after 1 month of the index event. Groups were PS matched on demographic (age, sex, race, ethnicity) and comorbidity variables. Risk Ratios (RR) and 95% confidence intervals (CI) were calculated. Results: Among 544,700 IS patients, 124,892 (22.9%) had preexisting MCID. MCID patients (vs. non-MCID) were older (mean age: 67.8 vs. 64.8 years), had higher proportion (%) of females (52.8 vs. 49.4) and Blacks (21.1 vs. 17.1). A higher proportion (%) of MCID patients had hypertension (77.3 vs. 36.0), diabetes (36.9 vs. 17.4), ischemic heart disease (31.6 vs 13.5), chronic kidney disease (21.4 vs. 7.8) and liver disease (9.5 vs. 3.1). Optimal co-variate balance was achieved post PS match (figure). In the unmatched sample, 8.6% of MCID and 6.0% of non-MCID patients experienced PSM by the 1-year time point; representing 56.2% and 64.2% of the total 5-year PSM, respectively. Matched and unmatched RR (CI) for PSM at 3 month and 1,3,5-year are reported (figure). An increasing risk of PSM was observed across the four time-points which was significantly higher for years 1,3, and 5 in the matched sample. Conclusion: A 24% long term increased risk of PSM was observed in a large national sample of IS patients with preexisting MCID. Majority of PSM burden is experienced by 1 year. MCID screening and exploring mechanisms of MCID-linked PSM is critical among IS patients.

External carotid artery stenting in patients with ipsilateral internal carotid artery occlusion: Peri-operative and 12-month follow-up.

This study aimed to evaluate the safety and clinical efficacy of external carotid artery (ECA) stenting in patients with ipsilateral internal carotid artery (ICA) occlusion. In patients with ICA occlusion, severe ipsilateral ECA stenosis may exacerbate pre-existing cerebral ischemia and cognitive impairment. It remains unclear whether ECA stenting to normalize ECA collaterals to the cerebralis alleviates cerebral ischemia and improves cognitive function. From January 2008 to June 2019, we retrospectively collected clinical data of 36 consecutive patients with ipsilateral ICA occlusion who had undergone ECA stenting (mean age, 66.7 ± 8.3 years; males, n = 26 [72.2%]). Neurocognitive test results, including Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA) tests, symptom assessment, and adverse events were recorded. ECA stenting was successful in all 36 patients. Intra-operatively, six (16.7%) patients experienced hemodynamic depression during balloon dilation and recovered completely within 2 days. Within a 12-month follow-up period, two patients experienced a transient ischemic attack, one patient had a contralateral minor stroke, and 33 patients remained asymptomatic. No other adverse events occurred in the peri-operative or follow-up periods. Compared with baseline, significant MMSE (25.3 ± 1.3 vs. 23.6 ± 1.7; p < .05) and MOCA (24.1 ± 1.3 vs. 22.8 ± 1.7; p < .05) test score improvements were observed 3 months post-operatively and were maintained throughout follow-up. ECA stenting may improve cerebral ischemia and cognitive function in patients with severe ECA stenosis and ipsilateral ICA occlusion; however, further research is required to support our findings.

Interleukin-1β Modulates Synaptic Transmission and Synaptic Plasticity During the Acute Phase of Sepsis in the Senescence-Accelerated Mouse Hippocampus.

BackgroundAging and pre-existing cognitive impairment are considered to be independent risk factors for sepsis-associated encephalopathy. This study aimed to investigate the manner in which aging and pre-existing cognitive dysfunction modified neuroinflammation, synaptic plasticity, and basal synaptic transmission during the acute phase of sepsis using Senescence-Accelerated Mice Prone 8 (SAMP8) and Senescence-Accelerated Resistant Mice 1 (SAMR1).MethodsWe used 6-month-old SAMP8 and SAMR1. Sepsis was induced using cecal ligation and puncture (CLP). The animal’s hippocampi and blood were collected for subsequent investigations 24 h after surgery.ResultsLong-term potentiation (LTP) was impaired in the Shaffer-collateral (SC)-CA1 pathway of the hippocampus in SAMP8 without surgery compared to the age-matched SAMR1, which was reflective of cognitive dysfunction in SAMP8. CLP impaired the SC-CA1 LTP in SAMR1 compared to the sham-operated controls, but not in SAMP8. Moreover, CLP decreased the input-output curve and increased the paired-pulse ratio in SAMP8, suggesting the reduced probability of basal synaptic transmission due to sepsis. Immunohistochemical analysis revealed that CLP elevated IL-1β levels, especially in the hippocampi of SAMP8 with microglial activation. In vivo peripheral IL-1 receptor antagonist (IL-1ra) administration in the septic SAMP8 revealed that the neuroinflammation was not correlated with the peripheral elevation of IL-1β. Ex vivo IL-1ra administration to the hippocampus ameliorated LTP impairment in SAMR1 and the reduction in basal transmission in SAMP8 after sepsis.ConclusionsThe mechanism of the modulation of synaptic transmission and synaptic plasticity by the acute stage of sepsis differed between SAMR1 and SAMP8. These changes were related to centrally derived IL-1 receptor-mediated signaling and were accompanied by microglial activation, especially in SAMP8.

Delirium in Older Patients With COVID-19: Prevalence, Risk Factors, and Clinical Relevance.

BackgroundDelirium prevalence increases with age and is associated with poor outcomes. We aimed to investigate the prevalence and risk factors for delirium in older patients hospitalized with COVID-19, as well as its association with length of stay and mortality.MethodThis was a retrospective study of patients aged 65 years and older hospitalized with COVID-19. Data were collected from computerized medical records and all patients had delirium assessment at admission. Risk factors for delirium as well as the outcomes mentioned above were studied by 2-group comparison, logistic regression, and Cox proportional hazard models.ResultsOf a total of 235 Caucasian patients, 48 (20.4%) presented with delirium, which was hypoactive in 41.6% of cases, and hyperactive and mixed in 35.4% and 23.0%, respectively. Patients with cognitive impairment had a nearly 4 times higher risk of developing delirium compared to patients who were cognitively normal before SARS-CoV-2 infection (odds ratio 3.7; 95% CI: 1.7–7.9, p = .001). The presence of delirium did not modify the time from symptoms’ onset to hospitalization or the length of stay in acute care, but it was associated with an increased risk of dying (hazard ratio 2.1; 95% CI: 1.2–3.7, p = .0113).ConclusionDelirium was a prevalent condition in older people admitted with COVID-19 and preexisting cognitive impairment was its main risk factor. Delirium was associated with higher in-hospital mortality. These results highlight the importance of early recognition of delirium especially when premorbid cognitive comorbidities are present.

Impact of Preexisting Cognitive Impairment and Race/Ethnicity on Functional Outcomes Following Intracerebral Hemorrhage.

In intracerebral hemorrhage (ICH), preexisting cognitive impairment has been identified as a risk factor for increased mortality and morbidity. However, previous studies examined predominantly White populations; therefore, the prevalence and effect of preICH cognitive impairment has not been studied in a multiethnic cohort. This limits the generalizability of previous findings. We sought to investigate the role of preexisting cognitive impairment in a multiethnic population on short-term mortality and functional outcomes after ICH. Patients with ICH were prospectively enrolled as cases for the GERFHS III (Genetic and Environmental Risk Factors for Hemorrhagic Stroke) Study and the Ethnic/Racial Variations of ICH (ERICH) Study. Cognitive impairment before ICH was defined as positive history of dementia or treatment with donepezil, galantamine, memantine, or rivastigmine on chart abstraction or baseline interview. Specific outcomes-modified Rankin Scale score at 3 months (0-2 versus ≥3), Barthel Index score (<100 versus 100) at 3 months, and withdrawal of care-were analyzed using multivariable logistic regression. Propensity score matching and analysis was done because of imbalances between cognitively impaired and cognitively intact groups. Of the 3537 cases of ICH, 304 patients had cognitive impairment predating ICH. Cognitively impaired subjects were more likely to experience withdrawal of care during hospitalization, and for survivors, greater disability (modified Rankin Scale score of ≥3) and lower Barthel scores after ICH. After propensity score matching, preexisting cognitive impairment was associated with a lower modified Rankin Scale at 3 months in the White, Black, and Hispanic subgroups. Preexisting cognitive impairment was associated with loss of independence 3-month post-ICH, when matching for risk factors of cognitive impairment, in the White, Black, and Hispanic subgroups. This suggests that preexisting cognitive impairment has a negative effect in obtaining functional independence following ICH, irrespective of race/ethnicity.

Delirium occurrence in older Irish adults admitted to an acute medical hospital: a prospective cohort study.

Delirium, which is associated with adverse health outcomes, is poorly detected in hospital settings. This study aimed to determine delirium occurrence among older medical inpatients and to capture associated risk factors. This prospective cohort study was performed at an Irish University Hospital. Medical inpatients 70 years and over were included. Baseline assessments within 72 hours of admission included delirium status and severity as determined by the Revised Delirium Rating Scale (DRS-R-98), cognition, physical illness severity and physical functioning. Pre-existing cognitive impairment was determined with Short Informant Questionnaire on Cognitive Decline (IQCODE). Serial assessment of delirium status, cognition and the physical illness severity were undertaken every 3 (±1) days during participants' hospital admission. Of 198 study participants, 92 (46.5%) were women and mean age was 80.6 years (s.d. 6.81; range 70-97). Using DRS-R-98, 17.7% (n = 35) had delirium on admission and 11.6% (n = 23) had new-onset delirium during admission. In regression analysis, older age, impaired cognition and lower functional ability at admission were associated with a significant likelihood of delirium. In this study, almost one-third of older medical inpatients in an acute hospital had delirium during admission. Findings that increasing age, impaired cognition and lower functional ability at admission were associated with increased delirium risk suggest target groups for enhanced delirium detection and prevention strategies. This may improve clinical outcomes.

Burst-suppression and Postoperative Delirium: Comment.

The recent report by Pedemonte et al.1 of their substudy of the Minimizing ICU Neurologic Dysfunction with Dexmedetomidine-induced Sleep (MINDDS) study2 emphasized the relationship between electroencephalogram (EEG) burst-suppression during cardiopulmonary bypass and delirium in elderly patients undergoing cardiac surgery. It raises several important points regarding the potential for cerebral monitoring to identify patients who may be at risk for significant postoperative neurologic complications, including delirium and postoperative cognitive dysfunction. However, interpreting these complex relationships requires certain safeguards to minimize the risk of potential false discovery, and thus maximize the confidence in a study’s conclusions. These safeguards include, but are not limited to, clear adherence to the prespecified substudy aims and a priori hypotheses, the development of a data statistical analytic plan before accessing the data, and consideration to the potential moderating effects in the substudy from the intervention of the parent trial. In this case, for example, the data from the substudy were derived from an ongoing randomized controlled trial investigating the potential effects of dexmedetomidine on postoperative delirium. It would seem reasonable then for any analysis in the substudy to be adjusted for the use of dexmedetomidine. Clarification as to whether and how this was done would be useful.Several other aspects of their study might also benefit from additional clarity. For example, adherence of reporting to the ordered prestated hypotheses seems to have been modified. For example, the primary hypothesis stated in their introduction was that “preexisting cognitive impairment accounts for electroencephalogram burst-suppression during CPB.”1 It is curious, then, that the article’s title, and the subsequent analysis and reporting of the study, principally focuses on postoperative delirium as opposed to preexisting cognitive impairment. This is particularly notable because their power analysis states that the “primary objective of the study was to detect the difference in mean preoperative cognitive scores between the burst-suppression and no burst-suppression groups.”1 The current delirium analysis, as they state, was likely underpowered.Although there is a potentially important relationship between preexisting cognitive impairment and delirium, and one that could be plausibly mediated via EEG burst-suppression, the primary analysis reported should have been the relationship between baseline cognition and EEG burst suppression, with the delirium-related analyses being secondary, and/or exploratory, and fully adjusted for multiple comparisons. Indeed, although some mention is made of adjustments to reduce false discovery, it is not clear where and how these were done. Furthermore, as the authors stated that the “data and statistical analyses plans were defined and written after the data were accessed,”1 it is not clear how much data and analyses mining might have been undertaken before these complex analyses were settled on and which results were chosen to be reported. The study’s actual primary objective found that the relationship between preexisting cognition (assessed using the abbreviated Montreal cognitive assessment) and EEG burst-suppression was not statistically significant (P = 0.965 in their table 1).These limitations should not dissuade the reader from considering the potentially important relationships that the authors have described, because they may in fact be quite meaningful. However, without adequate adjustment for the unit of randomization, consideration for the analytical plan being developed after the data was accessed, and the subsequent organization of the results around a hypothesis that was not the primary one, it does raise the question as to whether undue emphasis is being placed on the “positive” results surrounding delirium, as opposed to the “negative” results related to baseline cognition.The author declares no competing interests.

Preoperative Cognitive Impairment as a Perioperative Risk Factor in Patients Undergoing Total Knee Arthroplasty.

Background:The study assessed whether pre-existing cognitive impairment (CI) prior to elective total knee arthroplasty (TKA) is associated with worse postoperative outcomes such as delirium, in-hospital medical complications, 30-day mortality, hospital length of stay and non-home discharge.Methods:A retrospective database analysis from the NSQIP Geriatric Surgery Pilot Project was used. There was an initial cohort of 6350 patients undergoing elective TKA, 104 patients with CI were propensity score matched to 104 patients without CI.Results:Analysis demonstrated a significantly increased incidence of post-operative delirium (POD) in the cohort with pre-op CI (p = < .001), a worsened functional status (p = < .001) and increased nonhome discharge postoperatively compared to the group without CI (p = 0.029). Other post-operative outcomes included 30-day mortality of 0% in both groups, and low rate of complications such as infection (2.88% vs 0.96%), pneumonia (1.92% vs 0%), failure to wean (0.96% vs 0%), and reintubation (0.96% vs 0%). Some other differences between the CI group and non-CI group, although not statistically significant, included increased rate of transfusion (10.58% vs 6.73%), and sepsis (1.92% vs 0%). The length of stay was increased in the non-CI group (4.28% vs 2.32%, p = 0.122).Conclusion:CI in patients undergoing TKA is associated with an increased risk of POD, worsened postoperative functional status, and discharge to non-home facility.

Electroconvulsive therapy awareness as approach for psychology students

Electroconvulsive therapy (ECT) generated many controversies over time. The clinical literature establishing the efficacy of ECT is among the most solid for any medical treatment, and has been extensively reviewed; however, both practitioners and patients seem to be still reluctant on this issue. In the following review we are aiming at raising the level of awareness among the interested parties regarding ECT. Epidemiological evidence shows that there are a growing number of cases in which ECT has a great benefit, among the most notable being pharmacological resistant depressive disorder, bipolar disorder, schizophrenia, catatonia and others. Current guidelines seem to be overly-prudent regarding ECT indications, in spite of a growing body of research attesting to its importance. Side effects of ECT range from somatic to cognitive and, with a careful prior examination, most are acute and can be managed in a few minutes. An exception to this is the cognitive impairment, which can last from a few hours to a few weeks and presents a reason to reconsider ECT in elderly patients with an important preexisting cognitive impairment.

Depression and the apathy symptom are associated with poorer cognitive functioning in very old men

AbstractBackgroundOlder adults (65+) are among the fastest growing segments of the population, projected to double by 2050. Oldest‐old (85+) manifest the greatest relative increase in population and have the greatest risk of developing Alzheimer’s Disease (AD). Depression is a chronic, debilitating condition in older adults. Depressive symptoms, particularly apathy—and poor concentration—have been associated with poor cognitive functioning and dementia. However, some associations depend upon gender, age of depression onset, and preexisting cognitive impairment; other studies find no association. Associations have been primarily in relatively young samples, and apathy has infrequently been studied in the very old. We investigated the cross‐sectional associations of depressive symptoms and apathy with cognitive functioning in cognitively normal very old men.MethodsParticipants consisted of 74 cognitively intact male veterans (age = 86 ±5.1 [mean ± SD], range = 76‐98; 81.1 % White, 18.9% Black; 15‐item Geriatric Depression Scale [GDS] = 2.6 ±2.7, range = 0‐12; 13.5% depressed [GDS ≥ 6]) enrolled in the Cardiovascular Risk Factors and Successful Cognitive Aging in Very Old Male Veterans study. The predictors were the GDS‐15 and the apathy item “Have you dropped many of your activities and interests?” Cognitive outcomes, from factor analysis of 11 neuropsychological test scores, were three Varimax factor cognitive domains (Episodic Memory, Attention, Executive Function), and the first principal component (global cognition). Linear regression analyses adjusted for age and education.ResultsDepressive symptoms were significantly associated with poorer global cognition (r = ‐.274, p = .020). Apathy was significantly associated with poorer Attention (r = ‐.403, p &lt; .001) and global cognition (r = ‐.377, p = .001). Apathy remained significant after controlling for the sum of other depressive symptoms.ConclusionThese results extend others’ findings by showing that depressive symptoms, and specifically apathy, are associated with poorer cognitive functioning in very old men. This study highlights the relevance of examining depressive symptoms as predictors of cognitive functioning. The small effect sizes (r ≤ .097) for memory, the hallmark cognitive symptom of AD, suggest possible non‐AD biological involvement. Future studies with larger and more demographically and ethnically diverse samples are warranted.

Delirium.

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.

The Association of a Frailty Index and Incident Delirium in Older Hospitalized Patients: An Observational Cohort Study.

Introduction/BackgroundFrailty identifies patients that have vulnerability to stress. Acute illness and hospitalization are stressors that may result in delirium and further accelerate the negative consequences of frailty.PurposeThe purpose of this study was to determine whether frailty, identified at hospital admission and as measured by a frailty index, is associated with incident delirium.MethodsA retrospective, observational, cohort study was done at a Veterans hospital between January 2013 and March 2014. English-speaking patients over 55 years were eligible. Exclusion criteria included inability to complete baseline assessments due to pre-existing cognitive impairment, emergent surgery; and/or admission from a nursing home, pre-existing delirium, and those with psychiatric disease or substance use disorder.Main Outcomes and MeasuresFrailty index (FI) variables included cognitive screening, physical function and comorbidities. The FI was calculated as a proportion of possible deficits (range 0 to 1; higher scores indicate increased frailty). Incident delirium was measured daily by an expert clinician interview.ResultsA total of 247 patients were admitted and 218 met inclusion/exclusion criteria, with a mean age of 71.54 years (SD = 9.53 years) and were predominantly white (92.7%) and male (91.7%). Participants were grouped using FI ranges as non-frail (FI <0.25, n=56 (26%)), pre-frail (FI =0.25–0.35, n=86 (39%)), and frail (FI >0.35, n=76 (35%)). Pre-frailty and frailty were associated with incident delirium (non-frail: 3.6% vs pre-frail: 20.9% vs frail: 29.3%, p=0.001) and total delirium days (mean day =non-frail 0.04 vs pre-frail 0.35 vs frail 0.57, p=0.003). After adjustment for sociodemographic factors, pre-frail (adjusted OR=5.64, 95% CI: 1.23, 25.99) and frail status (adjusted OR=6.80, 95% CI: 1.38, 33.45) were independently associated with delirium.ConclusionThis study demonstrates that a frailty index is independently associated with incident delirium and suggests that admission assessments for frailty may identify patients at high risk of developing delirium.

Current characteristics and early functional outcome of older stroke patients: a population-based study (Dijon Stroke Registry).

the ongoing growing and ageing population is associated with an increase in older patients suffering a stroke. We aimed to assess the current profile of these patients in a population-based setting. all patients with acute stroke were prospectively identified among residents of Dijon, France, between 2013 and 2017, using a population-based registry. Characteristics and early outcome of patients were compared according to age groups. 1,288 stroke cases were recorded (median age: 81.1years, interquartile range: 66.1-86.7, 54% women). Patients aged 75-85years and those >85years accounted for 27.6 and 33.9% of overall cases. Increasing age was associated with a greater prevalence of vascular risk factors, pre-existing cognitive impairment and handicap, higher initial severity, more frequent cardioembolic ischemic stroke, post-stroke pulmonary infection and delirium. Only 41% of patients aged 75-85years and 18% of those aged >85years had a good early recovery. Compared with patients aged <75years, patients aged 75-85years [adjusted odds ratio (OR) = 2.61; 95% confidence interval (CI): 1.74-3.93, P < 0.001] and those aged >85years (adjusted OR = 7.18; 95% CI: 4.58-11.3, P < 0.001) had an increased risk of poor post-stroke functional outcome. Among survivors, the proportion of patients discharged to home was 60% in age group <75years, compared with 49% in patients aged 75-85years and 29% in those aged >85years. Thirty per cent of patients >85years old required a long-term care institution. the increasing burden of stroke in older people has major implications for future treatment strategies and need for dedicated care facilities.

The impact of cognitive impairment on survival and medication adherence among older women with breast cancer.

The purpose of this study was to examine the impact of preexisting cognitive impairments on survival and medication adherence, and whether chronic medication adherence mediates or moderates the association between cognitive impairments and mortality in patients with breast cancer. This retrospective cohort study of older female patients diagnosed with breast cancer was conducted using the Surveillance, Epidemiology, and End Results Medicare Linked Database. We examined the risk of mortality from cancer and non-cancer causes in patients with and without a history of cognitive impairment. In addition, we examined if chronic medication adherence rates differ between these groups of patients and if medication adherence mediates or moderates the association between cognitive impairments and non-cancer mortality. Mortality from cancer-specific (HR 1.13, 95% CI 1.04-1.23) and non-cancer causes (HR 1.16, 95% CI 1.11-1.21) as well as all-cause mortality (HR 1.30, 95% CI 1.23-1.38) was significantly higher in patients with cognitive impairments compared to those without cognitive impairment. Both groups showed low adherence levels to chronic medication before and after the breast cancer diagnosis. Further analysis did not show that medication adherence mediates or moderates the relationship between cognitive impairment and non-cancer mortality (p value > 0.05). The results of this study indicate that older female patients with cognitive impairments and a breast cancer diagnosis have a heightened risk of cancer-specific and non-cancer mortality. Our findings do not indicate that chronic medication adherence plays a role in the association between a history of cognitive impairment and mortality, it is still necessary to further investigate this issue.

Role of testosterone in cognition and mobility of aging men.

Cognitive decline and impairment of physical performance and mobility are age-related clinical problems with major negative impact on quality of life of elderly men. In how far the decline of testosterone production contributes to these problems in older men and whether testosterone therapy can contribute to slow down, prevent, or reverse their development remains subjects of debate. This narrative review presents the current knowledge on association of sex steroid status with cognitive decline and impairment of physical function and mobility in elderly men and on the effects of testosterone therapy on cognition and on physical performance and mobility in elderly men. The review is based on electronic database searches with primary focus on evidence from larger prospective observational studies and from controlled randomized trials, respectively. In most observational studies, testosterone levels do not predict cognitive decline or development of Alzheimer's disease. In randomized trials, testosterone therapy did not significantly affect cognition in men with low or low-to-normal serum testosterone, regardless of whether they have preexisting cognitive impairment. Overall, observational data indicate that the usually moderate decline of androgen exposure in older men cannot fully account for the parallel decline of physical performance and mobility. Trials of testosterone therapy in older men with low or low-normal serum testosterone, whether they were generally healthy or suffered from physical function impairments, either did not show any effect on mobility and physical performance or showed limited effects of uncertain clinical relevancy. The whole of the evidence tends to downplay the role of sex steroid status in the decline of cognitive function and impairment of physical function and mobility in older men. Based on the available evidence, prevention or treatment of cognitive decline or of impairment of mobility and physical function are not valid indications for testosterone treatment in older men with low or low-to-normal serum testosterone levels.

Mild cognitive impairment and receipt of procedures for acute ischemic stroke in older adults

Background and purposeOlder patients with pre-existing mild cognitive impairment (MCI) receive less evidence-based care after acute myocardial infarction, however, whether they receive less care after acute ischemic stroke (AIS) is unknown. We compared receipt of guideline-concordant procedures after AIS between older adults with pre-existing MCI and normal cognition. MethodsProspective study of 591 adults ≥65 hospitalized for AIS between 2000 and 2014, and followed through 2015 using data from the nationally representative Health and Retirement Study, Medicare and American Hospital Association. We assessed pre-existing MCI (modified Telephone Interview for Cognitive Status score of 7–11) and normal cognition (score of 12–27). Primary outcome was a composite quality measure representing the number of 4 procedures (carotid imaging, cardiac monitoring, echocardiogram, and rehabilitation assessment) received within 30 days after AIS (ordinal scale with values of 0, 1, 2, 3–4). ResultsAmong survivors of AIS, 26.9% had pre-existing MCI (62.9% were women, with a mean [SD] age of 82.4 [7.7] years), and 73.1% had normal cognition (51.4% were women, with a mean age of 78.4 [7.2] years). Patients with pre-existing MCI, compared to cognitively normal patients, had 39% lower cumulative odds of receiving the composite quality measure (unadjusted cumulative odds ratio, OR, 0.61 [95% CI, 0.43–0.87]; P=0.006). However, this association became non-significant after adjusting for patient and hospital factors (adjusted cumulative OR, 0.83 [95% CI, 0.56–1.24]; P=0.37). Lower cumulative odds of receiving the composite quality measure were associated with older patient age (adjusted cumulative OR per 1-year older age, 0.97 [95% CI, 0.95–0.99]; P=0.01) and Southern hospitals (adjusted cumulative OR for South vs North, 0.54 [95% CI, 0.31–0.94]; P=0.03). ConclusionsDifferences in receipt of guideline-concordant procedures after AIS exist between patients with pre-existing MCI and normal cognition. These differences were largely explained by patient and regional factors associated with receiving less AIS care.

This Month in Anesthesiology

This Month in Anesthesiology

Preoperative Altered Spontaneous Brain Activity and Functional Connectivity Were Independent Risk Factors for Delayed Neurocognitive Recovery in Older Adults Undergoing Noncardiac Surgery.

Objectives Recently, it has been demonstrated that patients with subtle preexisting cognitive impairment were susceptible to delayed neurocognitive recovery (DNR). This present study investigated whether preoperative alterations in gray matter volume, spontaneous activity, or functional connectivity (FC) were associated with DNR. Methods This was a nested case-control study of older adults (≥60 years) undergoing noncardiac surgery. All patients received MRI scan at least 1 day prior to surgery. Cognitive function was assessed prior to surgery and at 7-14 days postsurgery. Preoperative gray matter volume, amplitude of low-frequency fluctuation (ALFF), and FC were compared between the DNR patients and non-DNR patients. The independent risk factors associated with DNR were identified using a multivariate logistic regression model. Results Of the 74 patients who completed assessments, 16/74 (21.6%) had DNR following surgery. There were no differences in gray matter volume between the two groups. However, the DNR patients exhibited higher preoperative ALFF in the bilateral middle cingulate cortex (MCC) and left fusiform gyrus and lower preoperative FC between the bilateral MCC and left calcarine than the non-DNR patients. The multivariate logistic regression analysis showed that higher preoperative spontaneous activity in the bilateral MCC was independently associated with a higher risk of DNR (OR = 3.11, 95% CI, 1.30-7.45; P = 0.011). A longer education duration (OR = 0.57, 95% CI, 0.41-0.81; P = 0.001) and higher preoperative FC between the bilateral MCC and left calcarine (OR = 0.40, 95% CI, 0.18-0.92; P = 0.031) were independently correlated with a lower risk of DNR. Conclusions Preoperative higher ALFF in the bilateral MCC and lower FC between the bilateral MCC and left calcarine were independently associated with the occurrence of DNR. The present fMRI study identified possible preoperative neuroimaging risk factors for DNR. This trial is registered with Chinese Clinical Trial Registry ChiCTR-DCD-15006096.

Long-Term Cognitive Impairment Associated With Delirium in Acute Neurological Injury.

To characterize the risk of long-term cognitive impairment associated with delirium in acute neurologic injury patients. We 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. We 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. We 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. None. Among 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. Identification, management, and prevention of in-hospital delirium could potentially improve long-term cognitive outcomes in acute neurologic injury patients.

Prevalence and outcome of delirium among acute general medical inpatients in Cape Town, South Africa.

Delirium is a common, serious, underdiagnosed condition in medical and surgical inpatients with acute conditions. It is associated with increased risk of mortality and morbidity. Data of geriatric cohorts are largely limited to developed countries. To describe prevalence, risk factors and outcomes of delirium among general medical patients admitted to two hospitals in Cape Town, South Africa. This was a prospective cohort study of patients with acute conditions admitted to a general medical inpatient service in secondary- and tertiary-level public hospitals in the Metro West area of Cape Town. Patients ≥18 years of age were recruited daily from all acute medical admissions. Patients were excluded if they were aphasic or their Glasgow coma scale was &lt;8/15. Delirium was diagnosed using the validated confusion assessment method (CAM) tool and performed by trained neuropsychologists. Demographic data were collected by a clinical team and short- and long-term mortality data were obtained using linkage analysis of hospitalised patients and routinely collected provincial death certification records. The median age of inpatients was 51 (interquartile range 36 - 65) years, 29% were HIV-infected and the overall prevalence of delirium was 12.3%. Multivariate predictors of delirium included the presence of an indwelling urinary catheter (odds ratio (OR) 4.47; confidence interval (CI) 2.43 - 8.23), admission with a central nervous system disease (OR 4.34; CI 2.79 - 7.90), pre-existing cognitive impairment (OR 3.02; CI 1.22 - 7.43) and immobility (OR 1.88; CI 1.01 - 3.51). HIV infection was not associated with increased risk of delirium. Delirium was associated with an increased risk of inhospital (delirium v. no delirium: 29% v. 12%; p&lt;0.01) and 12-month (30% v. 20%; p&lt;0.01) mortality, as well as increased length of hospital stay (7 days v. 5 days; p&lt;0.01). In this cohort of medical inpatients (relatively young and with a high HIV prevalence) 1 of 8 (12.3%) patients was delirious. Delirium was associated with adverse outcomes. Delirium risk factors in this young cohort were similar to those in geriatric cohorts in developed countries, and neither HIV nor opportunistic infections increased risk.