Association of obesity, diabetes and hypertension with cognitive impairment in older age

Background: Age-related cognitive impairment is rising in prevalence but is not yet fully characterized in terms of its epidemiology. Here, we aimed to elucidate the role of obesity, diabetes and hypertension as candidate risk factors. Methods: Original baseline data from 3 studies (OCTOPUS, DECS, SuDoCo) were obtained for secondary analysis of cross-sectional associations of diabetes, hypertension, blood pressure, obesity (body mass index [BMI] ≥30 kg/m²) and BMI with presence of cognitive impairment in log-binomial regression analyses. Cognitive impairment was defined as scoring more than 2 standard deviations below controls on at least one of 5–11 cognitive tests. Underweight participants (BMI<18.5 kg/m2 ) were excluded. Results were pooled across studies in fixed-effects inverse variance models. Results: Analyses totaled 1545 participants with a mean age of 61 years (OCTOPUS) to 70 years (SuDoCo). Cognitive impairment was found in 29.0% of participants in DECS, 8.2% in SuDoCo and 45.6% in OCTOPUS. In pooled analyses, after adjustment for age, sex, diabetes and hypertension, obesity was associated with a 1.29-fold increased prevalence of cognitive impairment (risk ratio [RR] 1.29; 95% CI 0.98, 1.72). Each 1 kg/m² increment in BMI was associated with 3% increased prevalence (RR 1.03; 95% CI 1.00, 1.06). None of the remaining risk factors were associated with impairment. Conclusion: Our results show that older people who are obese have higher prevalence of cognitive impairment compared with normal weight and overweight individuals, and independently of co-morbid hypertension or diabetes. Prospective studies are needed to investigate the temporal relationship of the association

The Delphi Delirium Management Algorithms. A practical tool for clinicians, the result of a modified Delphi expert consensus approach

Delirium is common in hospitalised patients, and there is currently no specific treatment. Identifying and treating underlying somatic causes of delirium is the first priority once delirium is diagnosed. Several international guidelines provide clinicians with an evidence-based approach to screening, diagnosis and symptomatic treatment. However, current guidelines do not offer a structured approach to identification of underlying causes. A panel of 37 internationally recognised delirium experts from diverse medical backgrounds worked together in a modified Delphi approach via an online platform. Consensus was reached after five voting rounds. The final product of this project is a set of three delirium management algorithms (the Delirium Delphi Algorithms), one for ward patients, one for patients after cardiac surgery and one for patients in the intensive care unit.</p

Detection and prevention of postoperative delirium

Sowohl im Aufwachraum als auch auf der Intensivstation und peripheren Station stellt das postoperative Delir eine der häufigsten psychiatrischen Erkrankungen dar. Der Beginn dieser akuten Störung ist plötzlich, die Symptomatik schwankt jedoch im Tagesverlauf. Die zwei häufigsten Formen sind das hyperaktive und hypoaktive Delir. Letzteres bietet dabei mehr diagnostische Schwierigkeiten. Delir ist kein binäres Phänomen. Die Erfassung ist abhängig vom jeweils verwendeten Goldstandart und jedes in der klinischen Routine zu verwendene Delir- Messinstrument sollte einfach und praktikabel in der Anwendung sein. Die von uns durchgeführten Studien zur Detektion und Prävention des Delirs tragen dazu bei, dass besonders im deutschsprachigen Raum sowohl perioperative Messinstrumente und Implementierungsmethodiken als auch präventive Optionen zur Vermeidung des Delirs bereitgestellt wurden. Die wichtigsten modifizierbaren Faktoren in der perioperativen Versorgung sind der operative Eingriff und die Anästhesie. Da nur wenige therapeutische Maßnahmen für das postoperative Delir verfügbar sind, bleibt die Prävention die beste Option. Die präoperative Flüssigkeits- Karenz und die Wahl des intraoperativen Opioids zeigten sich als prinzipiell modifizierbare unabhängige Prädiktoren für das postoperative Delir. Dabei zeigten kontinuierliche analgetische Verfahren im Vergleich zu der intermittierenden Verabreichung von Analgetika sich als protektiv in Hinsicht auf die postoperative Delir-Inzidenz .Postoperative delirium represents one of the most common psychiatric illnesses in the recovery room, the intensive care unit as well as on ward. Delirium is defined as an acute disturbance of consciousness with signs of inattention, typically a fluctuating course and a change in cognition. Despite its importance delirium is often under recognized in the hospital setting. The two most common forms are the hyperactive and hypoactive delirium. Delirium, especially the hypoactive subtype, often remains undetected without standardized delirium monitoring. Monitoring to detect delirium however is a basic prerequisite for early intervention. We have researched methods in regard to detection, prevention as well as implementation of screening instruments for postoperative delirium. Major modifiable risk factors in the perioperative setting are the surgical procedure as well as provided anesthesia. Since few therapeutic measures for postoperative delirium are available, prevention remains the best option. Preoperative fluid and the choice of intraoperative opioid appeared to be in principle modifiable independent predictors of postoperative delirium. The continuous application of analgesic compared to intermittent administration of analgesics as being protective with respect to the incidence of postoperative delirium

Prevention of post-operative delirium

Ziel einer erfolgreichen Prävention des postoperativen Delirs ist es, bei Patient*innen die Beeinträchtigung des funktionellen Status durch eine Operation so gering wie möglich zu halten. Dies kann durch allgemeine Präventionsmaßnahmen geschehen. Als zusätzlicher Ansatz eignen sich ergänzende individualisierte Maßnahmen. Geeignete Screening- und Assessment-Instrumente werden eingesetzt, um das individuelle Risikoprofil älterer Patient*innen zu erfassen und entsprechende präventive Maßnahmen einzuleiten. Postoperative delirium (POD) is an adverse but often preventable complication of surgery and surgery-related anaesthesia, and increasingly prevalent. This article provides an overview on non-pharmacological preventive measures, divided into individualized and non-individualized measures. Non-individualized measures, such as the most minimally invasive surgical procedure, avoidance of unnecessary fasting before surgery, and the most tolerable anaesthesia are used to minimize the risk of POD in all patients. Based on the results of preoperative screenings for risk factors such as frailty or cognitive impairment, individualized measures may encompass prehabilitation, treatment of specific risk factors, operation room companionship or cognitive, motor, and sensory stimulation as well as social support. This article additionally lists several examples of best practice approaches already implemented in German-speaking countries and websites for further readings

Data_Sheet_1_Desflurane is risk factor for postoperative delirium in older patients’ independent from intraoperative burst suppression duration.pdf

BackgroundPostoperative Delirium (POD) is the most frequent neurocognitive complication after general anesthesia in older patients. The development of POD is associated with prolonged periods of burst suppression activity in the intraoperative electroencephalogram (EEG). The risk to present burst suppression activity depends not only on the age of the patient but is also more frequent during propofol anesthesia as compared to inhalative anesthesia. The aim of our study is to determine, if the risk to develop POD differs depending on the anesthetic agent given and if this correlates with a longer duration of intraoperative burst suppression.MethodsIn this secondary analysis of the SuDoCo trail [ISRCTN 36437985] 1277 patients, older than 60 years undergoing general anesthesia were included. We preprocessed and analyzed the raw EEG files from each patient and evaluated the intraoperative burst suppression duration. In a logistic regression analysis, we assessed the impact of burst suppression duration and anesthetic agent used for maintenance on the risk to develop POD.Results18.7% of patients developed POD. Burst suppression duration was prolonged in POD patients (POD 27.5 min ± 21.3 min vs. NoPOD 21.4 ± 16.2 min, p ConclusionWe found a significantly increased risk to develop POD after desflurane anesthesia in older patients, even though burst suppression duration was shorter under desflurane anesthesia as compared to propofol anesthesia. Our finding might help to explain some discrepancies in studies analyzing the impact of burst suppression duration and EEG-guided anesthesia on the risk to develop POD.</p

Delirium, sedation and analgesia in the intensive care unit: a multinational, two-part survey among intensivists.

Analgesia, sedation and delirium management are important parts of intensive care treatment as they are relevant for patients' clinical and functional long-term outcome. Previous surveys showed that despite this fact implementation rates are still low. The primary aim of the prospective, observational multicenter study was to investigate the implementation rate of delirium monitoring among intensivists. Secondly, current practice concerning analgesia and sedation monitoring as well as treatment strategies for patients with delirium were assesed. In addition, this study compares perceived and actual practice regarding delirium, sedation and analgesia management. Data were obtained with a two-part, anonymous survey, containing general data from intensive care units in a first part and data referring to individual patients in a second part. Questionnaires from 101 hospitals (part 1) and 868 patients (part 2) were included in data analysis. Fifty-six percent of the intensive care units reported to monitor for delirium in clinical routine. Fourty-four percent reported the use of a validated delirium score. In this respect, the survey suggests an increasing use of delirium assessment tools compared to previous surveys. Nevertheless, part two of the survey revealed that in actual practice 73% of included patients were not monitored with a validated score. Furthermore, we observed a trend towards moderate or deep sedation which is contradicting to guideline-recommendations. Every fifth patient was suffering from pain. The implementation rate of adequate pain-assessment tools for mechanically ventilated and sedated patients was low (30%). In conclusion, further efforts are necessary to implement guideline recommendations into clinical practice. The study was registered (ClinicalTrials.gov identifier: NCT01278524) and approved by the ethical committee

Morphology of roman, Islamic and medieval seismic design: pointed arch and ablaq

In ancient written sources earthquakes were mostly interpreted as a divine punishment for human sins, only few authors instead interpreted the seismic event as a phenomenon independent from human actions. Considering the built architectures as material documents, several examples can be found, suggesting that there was an empyrical knowledge of the consequences of earthquakes on buildings. Modern literature on the topic, mostly within engineering studies, lacking an historical approach, assumes that in ancient times science ignored the physical nature of seismic events and consequently declares that architects couldn’t consider dynamics in their projects. The close examination of some examples shows clearly that Roman, Islamic and Medieval architects had an empirical knowledge of dynamics, probably based on post-seismic reconstruction. This knowledge developed through history, so it is possible to outline a history of seismic design way before the Lisbon earthquake (1775), considered by many authors as the beginning of the history of seismic design

Diabetes, but Not Hypertension and Obesity, Is Associated with Postoperative Cognitive Dysfunction

BACKGROUND/AIMS: Older people undergoing surgery are at risk of developing postoperative cognitive dysfunction (POCD), but little is known of risk factors predisposing patients to POCD. Our objective was to estimate the risk of POCD associated with exposure to preoperative diabetes, hypertension, and obesity. METHODS: Original data from 3 randomised controlled trials (OCTOPUS, DECS, SuDoCo) were obtained for secondary analysis on diabetes, hypertension, baseline blood pressure, obesity (BMI ≥30 kg/m2), and BMI as risk factors for POCD in multiple logistic regression models. Risk estimates were pooled across the 3 studies. RESULTS: Analyses totalled 1,034 patients. POCD occurred in 5.2% of patients in DECS, in 9.4% in SuDoCo, and in 32.1% of patients in OCTOPUS. After adjustment for age, sex, surgery type, randomisation, obesity, and hypertension, diabetes was associated with a 1.84-fold increased risk of POCD (OR 1.84; 95% CI 1.14, 2.97; p = 0.01). Obesity, BMI, hypertension, and baseline blood pressure were each not associated with POCD in fully adjusted models (all p > 0.05). CONCLUSION: Diabetes, but not obesity or hypertension, is associated with increased POCD risk. Consideration of diabetes status may be helpful for risk assessment of surgical patients

Demographic and clinical characteristics of included patients.

<p>*Continuous variables are presented as medians with interquartile range [25th to 75th]. IMV, invasive mechanical ventilation.</p><p>Demographic and clinical characteristics of included patients.</p