The association between heatwave and heat-related outcomes in people with mental health conditions with and without psychotropics was unclear.

We identified people with severe mental illness (SMI) and depression, respectively, using Japanese claim data of Ibaraki prefecture during 1/1/2014–31/12/2021. We conducted self-controlled case series to estimate the incidence rate ratio (IRR) of heat-related illness, myocardial infarction and delirium, respectively, during 5-day pre-heatwave, heatwave, and 5-day post-heatwave periods v. all other periods (baseline) within an individual, stratified by periods prescribed psychotropics and periods not prescribed psychotropics, respectively.

Among people with SMI, heatwave was associated with an increased rate of heat-related illness v. baseline, with no evidence of a difference in the IRRs between those prescribed v. not prescribed antipsychotics (IRR: 1.48 [95% CI 1.40–1.56]; 1.45 [95% CI 1.35–1.56] respectively, p interaction: 0.53). Among people with depression, heatwave was similarly associated with heat-related illness, with no evidence of a difference in the IRRs between those prescribed v. not prescribed antidepressants (IRR: 1.54 [95% CI 1.46–1.64]; 1.64 [95% CI 1.57–1.71] respectively, p interaction: 0.33). Smaller increased rates of heat-related illness were also observed in pre- and post-heatwave periods, v. baseline in both cohorts. There was weak evidence of an increased risk of MI and delirium associated with heatwave v. baseline.

We showed an increased risk of heat-related illness, myocardial infarction and delirium associated with heatwave in people with mental health conditions regardless of whether being prescribed psychotropics. Risks of heat-related illness, myocardial infarction and delirium associated with heatwave might not be factors to influence decisions about the routine use of psychotropics.

Delirium is a severe neuropsychiatric syndrome caused by physical illness, associated with high mortality. Understanding risk factors for delirium is key to targeting prevention and screening. Whether severe mental illness (SMI) predisposes people to delirium is not known. We aimed to establish whether pre-existing SMI diagnosis is associated with higher risk of delirium diagnosis and mortality following delirium diagnosis.

A retrospective cohort and nested case–control study using linked primary and secondary healthcare databases from 2000–2017. We identified people diagnosed with SMI, matched to non-SMI comparators. We compared incidence of delirium diagnoses between people with SMI diagnoses and comparators, and between SMI subtypes; schizophrenia, bipolar disorder and ‘other psychosis’. We compared 30-day mortality following a hospitalisation involving delirium between people with SMI diagnoses and comparators, and between SMI subtypes.

We identified 20 566 people with SMI diagnoses, matched to 71 374 comparators. Risk of delirium diagnosis was higher for all SMI subtypes, with a higher risk conferred by SMI in the under 65-year group, (aHR:7.65, 95% CI 5.45–10.7, ⩾65-year group: aHR:3.35, 95% CI 2.77–4.05). Compared to people without SMI, people with an SMI diagnosis overall had no difference in 30-day mortality following a hospitalisation involving delirium (OR:0.66, 95% CI 0.38–1.14).

We found an association between SMI and delirium diagnoses. People with SMI may be more vulnerable to delirium when in hospital than people without SMI. There are limitations to using electronic healthcare records and further prospective study is needed to confirm these findings.

Children with prolonged hospital admissions for CHD often develop delirium. Antipsychotic medications (APMs) have been used to treat delirium but are known to prolong the QTc duration. There is concern for prolongation of the QTc interval in cardiac patients who may be more vulnerable to electrocardiogram (ECG) changes and may have postoperative QTc prolongation already. The goal of this study was to determine the effect of APM on QTc duration in postoperative paediatric cardiac patients and determine the effect of quetiapine and risperidone in treating delirium and QTc prolongation.

Retrospective study, July 1, 2017–May 31, 2022.

Tertiary children’s hospital.

Included were patients admitted to the paediatric cardiac ICU at Children’s Healthcare of Atlanta.

None.

ECGs, delirium scores, and drug information were collected. Delirium was defined as Cornell Assessment of Pediatric Delirium (CAPD) score >9. Mixed effect models were performed to evaluate the effect of surgery on QTc change and the effect of antipsychotics on QTc and CAPD changes. There were 139 children, 55% male and 67% surgical admissions. Median age was 5.9 months. Mean QTc increased after cardiac surgery by 18 ms (p = 0.014, 95% CI 3.65–32.4). There was no significant change in QTc after antipsychotic administration (p = 0.064). The mean CAPD score decreased (12.5–7.2; p < 0.001). Quetiapine had the most improvement in delirium, and risperidone had the least improvement (77.8%, n = 14; 37.8%, n = 34, respectively; p = 0.002).

The QTc interval did not have a statistically significant change after the administration of antipsychotics, while there was improvement in the CAPD score. APMs may be administered safely without significant prolongation of the QTc and are an effective treatment for delirium.

There is concern that hydroxyzine exacerbates delirium, but a recent preliminary study suggested that the combination of haloperidol and hydroxyzine was effective against delirium. This study examined whether the concomitant use of hydroxyzine and haloperidol worsened delirium in patients with cancer.

This retrospective, observational study was conducted at 2 general hospitals in Japan. The medical records of patients with cancer who received haloperidol for delirium from July to December 2020 were reviewed. The treatments for delirium included haloperidol alone or haloperidol combined with hydroxyzine. The primary outcome was the duration from the first day of haloperidol administration to the resolution of delirium, defined as its absence for 2 consecutive days. The time to delirium resolution was analyzed to compare the haloperidol group and hydroxyzine combination group using the log-rank test with the Kaplan–Meier method. Secondary outcomes were (1) the total dose of antipsychotic medications, including those other than haloperidol (measured in chlorpromazine-equivalent doses), and (2) the frequencies of detrimental incidents during delirium, specifically falls and self-removal of drip infusion lines. The unpaired t-test and Fisher’s exact test were used to analyze secondary outcomes.

Of 497 patients who received haloperidol, 118 (23.7%) also received hydroxyzine. No significant difference in time to delirium resolution was found between the haloperidol group and the hydroxyzine combination group (log-rank test, P = 0.631). No significant difference between groups was found in either chlorpromazine-equivalent doses or the frequency of detrimental incidents.

This study showed that the concomitant use of hydroxyzine and haloperidol did not worsen delirium in patients with cancer.

Cognitive Reserve (CR) developed from observation that several individuals show fewer cognitive impairment compared to others with the same brain injuries or neuropathology. Cognitive reserve is a potentially modifiable characteristic. Most of studies on cognitive reserve were conducted on chronic progressive diseases such as dementia. This study aims to define the role of cognitive reserve in geriatric delirium cases.

This case-control study was conducted in the acute geriatric inpatient of Cipto Mangunkusumo Hospital, Jakarta, Indonesia on June to September 2019 that consisted of 33 subjects with delirium and 33 controls. The measurement of cognitive reserve was done using the Indonesian adaptation of Cognitive Reserve Index questionnaire (CRIq) with 3 subscales, i.e. Education, Work Activity and Leisure Time.

We found that the CRIq scores of delirium patients were lower compared to the non-delirium controls both on total and each subscores, with a statistically significant mean difference (p<0,01). Patients with low-medium cognitive reserve also more likely to develop delirium compared to those with medium-high cognitive reserve (OR 9; 95% CI 2.86 to 28.22).

Low cognitive reserve may serve as a risk factor for delirium in the elderly. The measure of CRI in the geriatric inpatients unit can be used to determine those at risk of developing delirium. Further research are warranted to elaborate potentially modifiable variables of cognitive reserve to minimize the risk of delirium.

Postoperative neurocognitive disorder is common after all forms of surgery in older adults. The mechanisms are multifactorial, and probably require pre-existing neuropathology, whether the patient is symptomatic or not. In Alzheimer's disease (AD) and other tauopathies, the microtubule-associated protein tau can undergo aberrant hyperphosphorylation potentially leading to the development of neurofibrillary pathology, one of the neuropathological hallmarks of the disease. Preclinical and human CSF studies suggest that anesthesia and surgery elicits an increment in CNS tauopathy, which may accelerate any preexisting neuropathology and produce a risk of delirium and the commonly reported changes in cognition.

In this session, the author will present a bench to beside review of how tau protein is altered by perioperative factors and its potential relationship to the impairment of cognition after surgery and anesthesia. Published and ongoing studies will be reviewed to result in a discussion as to why changes in tau protein are concerning in perioperative disorders of cognition.

The presenter will initially review pre-clinical studies focusing on the impact of anesthetics and surgery-induced inflammation on tau pathology and how the impairment of resolution of surgery-induced inflammation, notably decreased lipoxin A4 signaling, is altered by aging, gender, or an increase in the tau pathology burden. These preclinical studies have partially informed a multi-center federally funded observational clinical study, currently in progress, involving neuroimaging to determine whether pre-operative CNS tauopathy, as reflected by PET imaging, predicts delirium and other cognitive and functional outcomes. This translational study will also examine whether anesthesia and spine surgery produces a longitudinal change in the brain tau burden in older adults, as compared to control, nonoperative patients.

Bench to bedside research is needed in order to promote evidence-based care for patients at risk for ADRD.

Cognitive change affecting patients after anesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterward. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. This study aimed to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anesthesia and surgery.

A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions. Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anesthesia and surgery and may be useful for the inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature.

The working group recommends that 'perioperative neurocognitive disorders (PND)' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of the acute event (postoperative delirium) and cognitive and functional decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery (dNCR)) and up to 12 months (postoperative neurocognitive disorder (postoperative NCD).1 Further, the working group has undergone a further Delphi process to expand these recommendations for research purposes which will also be covered.

Perioperative neurocognitive disorders are the most common complication for patients aged 65y or more undergoing anesthesia and surgery. Moreover, they are associated with significant morbidity, mortality, loss of functional independence and extreme economic costs. A multi-disciplinary approach to PND, including neuropsychologists, is critical to reducing and preventing these disorders. Evered L, Silbert B, Knopman DS, et al. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018. Br J Anaesth 2018; 121: 1005-12

Older adults represent 50% of surgical patients and are disproportionately at risk of poor cognitive outcomes after surgery including delirium, accelerated cognitive decline, and dementia. Delirium alone is estimated to occur in up to 50% of older adults postoperatively, while research indicates it is preventable in 30-40% of cases. Individuals with pre-existing cognitive impairments or neurodegenerative diseases are at the highest risk of such outcomes, but (1) cognitive diagnoses are grossly underrepresented in patients' medical records, and (2) routine preoperative cognitive clearance remains rare. The purpose of this presentation is to demonstrate the extent and nature of cognitive vulnerability in older adults preparing for elective surgery within a tertiary care hospital. A case series is also reviewed to illustrate varying surgical outcomes with and without consideration of preoperative cognitive risk.

This presentation incorporated IRB-approved and data honest broker management to assess diagnoses and cognitive profiles of adults age 65 and older electing surgery with anesthesia between January 2018 and December 2019. Data were assessed across two phases of the Perioperative Cognitive Anesthesia Network (PeCAN) program within the University of Florida and UF Health. First, data from the preoperative anesthesia clinic were reviewed for the percentage of patients with cognitive difficulties within the patient problem list. Second, based on neuropsychological domains, the cognitive profiles of patients assessed by neuropsychologists within the preoperative anesthesia clinic were divided into primary attention, primary memory, or combined memory attention. From these patients, the presenter highlight cases to demonstrate how individuals with cognitive difficulties can be provided care by a multidisciplinary team to mitigate the presence of postoperative complications.

Of 14,794 older adults entering the tertiary care medical center for surgical procedures, 4% (n=591) of the sample had ICD cognitive or neurodegenerative codes in the record. When a comprehensive neurobehavioral assessments were conducted on 1,363 of these presurgical patients, 70% had confirmed cognitive deficits on neuropsychological testing. These deficits included primary attention and executive deficits (12%), primary memory impairment (27%), or both attention and memory impairment (31%). Cases from these patients are reviewed and highlight how preoperative cognitive risk status can inform conservative perioperative practices including opioid-sparing analgesia, depth of anesthesia monitoring, and postoperative inpatient geriatric medicine consultation.

Medical records listed cognitive diagnoses in 4% of hospital preoperative medical records, yet neuropsychological assessment of a subset of cases revealed a markedly higher rate of impairment. Patients with preoperative cognitive assessment show cognitive symptoms consistent with known neurological disorders of aging including Alzheimer's disease and cerebrovascular disease. Appreciation of pre-existing neurocognitive disorders can alter perioperative practices to prevent or reduce the risk of delirium and other postoperative neurocognitive changes. These data and cases reviewed will highlight how neuropsychology can be involved in perioperative care and champion perioperative interventions for perioperative "rescues".