amaclullich.bsky.social
Physician & Professor of Geriatric Medicine @EdinburghUni.
Chair, Scottish Hip Fracture Audit.
Delirium, hip fracture.
www.the4AT.com
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CAM-ICU is best in ICU settings re validation studies. 4AT is well-validated outside of ICU.
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Yes that was our thinking - and could fit with some of the animal model studies that show an inflammation-mediated pathway.
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but more likely it is more than that - an indicator of acute brain injury that signals possible acute neurodegeneration with severe consequences for the person's future cognitive health.
It may be that we can intervene acutely - with good general care +/- other neuroprotective measures.
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I'll conclude by stating that regardless of the reasons underlying the clear delirium --> dementia link, I think we are obligated to take it seriously.
It is, at least, prognostic factor that should be considered with respect to follow-up.
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And this?? pubmed.ncbi.nlm.nih.gov/33320945/
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Okay!
Just not yet sure of why the evidence base is unconvincing to some.
I think it is more about the class of risk factor than the effect size or the plausibility - it is unconventional & doesn't fit readily into standard models of slow damage over time.
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The argument is that acute illness can cause acute brain injury leading to (a) delirium & (b) longer-term effects including dementia.
Delirium itself is a product of the injury, not likely a direct cause, but nevertheless when delirium is present the risks of future decline are higher.
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(b) studies showing that people with acute systemic illness have evidence of damage to the brain (e.g. in ICU studies)
(c) animal model studies showing that in prion models peripheral inflammatory stimuli cause both (i) acute cog change, & (ii) accelerated longer-term neurodegeneration
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Thanks - will reply properly tomorrow. In brief, maybe 3 types of evidence:
(a) studies looking baseline cognition to rule out existing dementia then showing that people who get delirium are at far higher risk of future dementia
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So the LC 14 risk factors all have incontrovertible mechanistic causal links demonstrated? With targeted interventions (of those factors that are amenable to intervention) showing reduced risk?
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Agreed - but the effect sizes are very large, and delirium is potentially preventable as well as potentially treatable.
I think we are missing a trick here - why not address both the longer-term risk factors as well as do what we can to understand how acute brain damage might also lead to dementia?
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Agree - so why the resistance? Honestly am puzzled!
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... and either dismiss it as spurious, using careful evidence-based argument, or say that it is possibility.
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The Lancet Commission have looked at longer term risk factors but not at delirium - not even mentioning the issue - it's an odd schism IMO.
Given the weight of associational evidence, it would seem reasonable to *consider* the issue, at least ...
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Is there a fundamental objection to the proposal that the brain might be damaged during significant acute illness, particularly in vulnerable people?
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Do you think that the dementia community haven't seen papers like these?
pubmed.ncbi.nlm.nih.gov/38537951/
pubmed.ncbi.nlm.nih.gov/32658246/
pubmed.ncbi.nlm.nih.gov/22879644/
Or ...
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Yes that's definitelye true as well, and in people with dementia, episodes of delirium may exacerbate the rate of decline.
pubmed.ncbi.nlm.nih.gov/19414723/
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It's not widely appreciated, even in the dementia research community - something that I think needs to be addressed because delirium is definitely a strong risk factor for dementia.
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I am sorry to hear about the delirium and the dementia.
Yes there is a lot of evidence showing that older people without dementia who experience dementia are at much higher risk of dementia in the future.
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I think it is effective - most delirium resolves, likely as a result of treating the triggers (whether the delirium was detected or not).
Detecting delirium has additional value - likely speeds up recovery, as well as reducing distress.
Also delirium can be the presenting sign of an acute illness.
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I've stopped saying both sorry for delay or thank you for patience; it feels like when stand up comics say 'I hope you find me funny' because the recipient's disappointment is pre-assumed. It's imposter syndrome talk, and I promised myself I'd shove it aside.
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I'm stealing these.
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Thank you so much for this subject. I'm a nurse in england and care for older people,and understanding delirium is essential. So thank you