Objective: Delirium is a frequent complication after surgery with important negative outcomes for affected patients and society. However, it is still largely unknown why some patients have a... Show moreObjective: Delirium is a frequent complication after surgery with important negative outcomes for affected patients and society. However, it is still largely unknown why some patients have a predisposition for delirium and others not. To increase our understanding of the neural substrate of postoperative delirium, we studied the association between preoperative brain MRI features and the occurrence of delirium after major surgery.Methods: A group of 413 patients without dementia (Mean 72 years, SD: 5) was included in a prospective observational two-center study design. The study was conducted at Charite Universitatsmedizin (Berlin, Germany) and the University Medical Center Utrecht (Utrecht, The Netherlands). We measured preoperative brain volumes (total brain, gray matter, white matter), white matter hyperintensity volume and shape, brain infarcts and cerebral perfusion, and used logistic regression analysis adjusted for age, sex, intracranial volume, study center and type of surgery.Results: Postoperative delirium was present in a total of 70 patients (17%). Preoperative cortical brain infarcts increased the risk of postoperative delirium, although this did not reach statistical significance (OR (95%CI): 1.63 (0.84-3.18). Furthermore, we found a trend for an association of a more complex shape of white matter hyperintensities with occurrence of postoperative delirium (OR (95%CI): 0.97 (0.95-1.00)). Preoperative brain volumes, white matter hyperintensity volume, and cerebral perfusion were not associated with occurrence of postoperative delirium.Conclusion: Our study suggests that patients with preoperative cortical brain infarcts and those with a more complex white matter hyperintensity shape may have a predisposition for developing delirium after major surgery. Show less
Montfort, S.J.T. van; Slooter, A.J.C.; Kant, I.M.J.; Leur, R.R. van der; Spies, C.; Bresser, J. de; ... ; Dellen, E. van 2020
Delirium, the clinical expression of acute encephalopathy, is a common neuropsychiatric syndrome that is related to poor outcomes, such as long-term cognitive impairment. Disturbances of functional... Show moreDelirium, the clinical expression of acute encephalopathy, is a common neuropsychiatric syndrome that is related to poor outcomes, such as long-term cognitive impairment. Disturbances of functional brain networks are hypothesized to predispose for delirium. The aim of this study in non-delirious elderly individuals was to investigate whether predisposing risk factors for delirium are associated with fMRI network characteristics that have been observed during delirium. As predisposing risk factors, we studied age, alcohol misuse, cognitive impairment, depression, functional impairment, history of transient ischemic attack or stroke, and physical status. In this multicenter study, we included 554 subjects and analyzed resting-state fMRI data from 222 elderly subjects (63% male, age range: 65-85 year) after rigorous motion correction. Functional network characteristics were analyzed and based on the minimum spanning tree (MST). Global functional connectivity strength, network efficiency (MST diameter) and network integration (MST leaf fraction) were analyzed, as these measures were altered during delirium in previous studies. Linear regression analyses were used to investigate the relation between predisposing delirium risk factors and delirium-related fMRI characteristics, adjusted for confounding and multiple testing. Predisposing risk factors for delirium were not associated with delirium-related fMRI network characteristics. Older age within our elderly cohort was related to global functional connectivity strength (beta = 0.182, p < 0.05), but in the opposite direction than hypothesized. Delirium-related functional network impairments can therefore not be considered as the common mechanism for predisposition for delirium. Show less
Het aantal heupfracturen zal de komende jaren stijgen. Bovendien zijn de morbiditeit en mortaliteit na een heupfractuur groot. Het eerste deel van het proefschrift gaat over prothesiologie bij... Show moreHet aantal heupfracturen zal de komende jaren stijgen. Bovendien zijn de morbiditeit en mortaliteit na een heupfractuur groot. Het eerste deel van het proefschrift gaat over prothesiologie bij heupfractuurpatiënten. Uit eerder onderzoek is gebleken dat een prothese de voorkeur heeft ten opzichte van osteosynthese. Hoofdstuk drie beschrijft een multicenter trail waarbij we 201 patiënten hebben gerandomiseerd tussen een gecementeerde en een ongecementeerde kophalsprothese. De patiënten met een gecementeerde prothese kregen minder complicaties (minder periprothetische fracturen en luxaties). In hoofdstuk twee beschrijven we de 22.675 patiënten die de afgelopen 10 jaar na een heupfractuur in het landelijk register zijn opgenomen. Uit dit hoofdstuk blijkt dat er minder re-operaties worden uitgevoerd na een gecementeerde prothesesteelfixatie en een niet-posterolaterale benadering. Het tweede deel van het proefschrift toont dat een heupfractuur een enorme impact heeft op het leven van de patiënt. Het percentage delier na de fractuur was hoog (27%) evenals het percentage mensen dat overleed binnen 30 dagen (8%). Kwaliteit van leven en dagelijks functioneren gingen fors achteruit en herstelden niet volledig. De patiënten die het meest achteruit gingen waren jong en mobiel voorafgaand aan de fractuur. We adviseren dan ook meer aandacht te hebben voor deze groep. Show less
The number of older people in the population is rising and so is the number of older patients in the Emergency Department (ED). Older patients often have complex problems which leads to an... Show moreThe number of older people in the population is rising and so is the number of older patients in the Emergency Department (ED). Older patients often have complex problems which leads to an increased change of repeat ED visits, longer length of stay, higher chance of hospital admission and higher chance of negative health outcomes. Cognitive impairment is a frequent problem in older ED patients but often remains unrecognized and little is known about the association between cognitive impairment and adverse outcomes in older ED patients. In this thesis we show that cognitive impairment is associated with adverse outcomes in acutely presenting older patients. Secondly, we show that routinely collected parameters in addition to cognitive impairment can be used to screen for high risk of adverse outcomes in older ED patients. We investigated two delirium screeners and showed the CAM-ICU might not be suitable for early detection of delirium in the ED. Finally, vital signs that associate with decreased brain perfusion and oxygenation, such as low systolic blood pressure, were associated with cognitive impairment in older ED patients. Next steps would be to investigate if optimal resuscitation might improve cognition and decrease risk of subsequent delirium and adverse outcomes. Show less
Westhoff, D.; Engelen-Lee, J.Y.; Hoogland, I.C.M.; Aronica, E.M.A.; Westerloo, D.J. van; Beek, D. van de; Gool, W.A. van 2019
Background: Although haloperidol is the most widely used drug in the treatment of delirium, evidence on the relevance of atypical antipsychotics (AAPs) is growing. Objective: To review the... Show moreBackground: Although haloperidol is the most widely used drug in the treatment of delirium, evidence on the relevance of atypical antipsychotics (AAPs) is growing. Objective: To review the literature on the efficacy and tolerability of AAPs in the treatment of delirium. Methods: A systematic search of the literature published before April 2018 was performed on PubMed using the following search strings: "Delirium" and "Atypical antipsychotics", "Novel antipsychotics", "New antipsychotics", "Quetiapine", "Olanzapine", "Aripiprazole", "Risperidone", "Paliperidone", "Clozapine", "Asenapine", "Iloperidone", "Amisulpiride", "Ziprasidone", "Zotepine", "Sertindole", "Lurasidone" or "Perospirone". Results: Twelve randomized controlled trials (RCTs) and 22 open trials were considered. Despite an overall lack of large-scale RCTs, there is some evidence supporting the efficacy of olanzapine and quetiapine in placebo controlled trials. In a recent and large RCT in elderly patients, risperidone and/or haloperidol were associated with a significantly worse outcome than placebo. While preliminary, the current comparative studies suggest that haloperidol and the AAPs olanzapine, quetiapine and risperidone are similarly effective, although treatment with AAPs is associated with a reduced incidence of extrapyramidal symptoms. Ziprasidone was not shown to be effective. No RCTs are available for other AAPs. Conclusions: Although the current evidence of the efficacy and tolerability of AAPs in the treatment of delirium is limited and the heterogeneity of the data precluded a meta-analysis, olanzapine and quetiapine seem to be adequate alternatives to haloperidol, especially in patients who are vulnerable for extrapyramidal symptoms, who require sedation or who have a history of haloperidol intolerance. Evidently, larger-scale RCTs are urgently required. Show less
Ettema, R.; Heim, N.; Hamaker, M.; Emmelot-Vonk, M.; Mast, R. van der; Schuurmans, M. 2018
In this thesis, clinical and functional outcomes of a large cohort of hip fracture patients are described, with regards to anemia, blood transfusion, concomitant fractures, loss of mobility and... Show moreIn this thesis, clinical and functional outcomes of a large cohort of hip fracture patients are described, with regards to anemia, blood transfusion, concomitant fractures, loss of mobility and place of residence. Secondly, risk factors for poor outcome, both in a clinical and a functional perspective were identified. Finally, specific risk scores for delirium and discharge to an alternative location have been developed and validated. Show less
