Cortisol levels and neuropsychiatric diagnosis as markers of postoperative delirium: a prospective cohort study

Abstract

IntroductionThe pathophysiology of delirium after cardiac surgery is largely unknown. The purpose of this study was to investigate whether increased concentration of preoperative and postoperative plasma cortisol predicts the development of delirium after coronary artery bypass graft surgery. A second aim was to assess whether the association between cortisol and delirium is stress related or mediated by other pathologies, such as major depressive disorder (MDD) or cognitive impairment.MethodsThe patients were examined 1 day preoperatively with the Mini International Neuropsychiatric Interview and the Montreal Cognitive Assessment and the Trail Making Test to screen for depression and for cognitive impairment, respectively. Blood samples for cortisol levels were collected both preoperatively and postoperatively. The Confusion Assessment Method for the Intensive Care Unit was used within the first 5 days postoperatively to screen for a diagnosis of delirium.ResultsPostoperative delirium developed in 36% (41 of 113) of participants. Multivariate logistic regression analysis revealed two groups independently associated with an increased risk of developing delirium: those with preoperatively raised cortisol levels; and those with a preoperative diagnosis of MDD associated with raised levels of cortisol postoperatively. According to receiver operating characteristic analysis, the most optimal cutoff values of the preoperative and postoperative cortisol concentration that predict the development of delirium were 353.55 nmol/l and 994.10 nmol/l, respectively.ConclusionRaised perioperative plasma cortisol concentrations are associated with delirium after coronary artery bypass graft surgery. This may be an important pathophysiological consideration in the increased risk of postoperative delirium seen in patients with a preoperative diagnosis of MDD.

Anesthesia, surgical stress, and “long-term” outcomes

“…18 It has been found that alterations in the endocrine response to surgery can influence the risk of developing POCD. Higher cortisol levels postoperatively have been shown to be associated with a higher chance of developing POCD, 19 along with suppression of the growth hormone axis. 20 Increased presence of proinflammatory cytokines associated with the surgical stressinduced immune response, such as interleukin (IL)-6, IL-1b, 21 and tumor necrosis factor-alpha, 22 has been shown within the hippocampus postoperatively and is associated with the development of POCD in murine models.…”

Mild Cognitive Impairment with Associated Inflammatory and Cortisol Alterations as Independent Risk Factor for Postoperative Delirium

“…Moreover, cortisol has been implicated as a potential biomarker for AD in the Australian Imaging Biomarker and Lifestyle Study [54]. Cortisol levels are potentially of a similar importance in delirium; raised levels may play a role in the development of delirium, with the further suggestion that cortisol may be an appropriate biomarker for postoperative delirium [35,36]. …”

“…The study was approved by the Ethics Committee of the Medical University of Lodz, Poland, and was performed in accordance with the ethical standards of the Declaration of Helsinki. The subjects included in this study have been previously reported in a paper regarding the role of cortisol in delirium development [36]. …”

“…Interestingly, both interleukins and glucocorticoids are potentially involved in the pathophysiology of delirium [24,35,36]. However, the association between homocysteine and cobalamin concentrations and delirium has not been investigated to date.…”

Yokukansan, a traditional Japanese medicine, decreases head-twitch behaviors and serotonin 2A receptors in the prefrontal cortex of isolation-stressed mice

“…Exposure to stress is a key factor in the precipitation of symptoms and in subsequent exacerbation of symptoms (Nuechterlein et al, 1992;Miller et al, 2001;Dawson et al, 2010;Cerejeira et al, 2013;Kazmierski et al, 2013), and chronic stress-induced alterations of prefrontal cortical function have been suggested to be associated with the precipitation and exacerbation of these symptoms (Mizoguchi et al, 2000;Cerqueira et al, 2007;Arnsten, 2011). On the other hand, the main approach for treatment of these symptoms involves the use of atypical and typical antipsychotics (e.g., olanzapine and haloperidol).…”