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Neurocognitive and Psychiatric Issues Post Cardiac Surgery
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Heart, Lung and Circulation (2017) xx, 1–7 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2016.12.010
Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery
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Ben Elias Indja a,b,c, Michael Seco, MBBS a[2_TD$IF],b,d, Richard Seamark, MBBS, FRANZCP e[2_TD$IF], Jason Kaplan, MBBS, FRACP f, Paul G. Bannon, MBBS, PhD, FRACS a,b,d,g, Stuart M. Grieve, FRANZCR, DPhil (Oxon) a,c,h, Michael P. Vallely, MBBS, PhD, FRACS a,b,d,f,g* a
Sydney Medical School, The University of Sydney, Sydney, NSW, Australia The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, NSW, Australia c Sydney Translational Imaging Laboratory, Heart Research Institute, Charles Perkins Centre, University of Sydney, NSW, Australia d Royal Prince Alfred Institute of Academic Surgery, Sydney, NSW, Australia e Sunshine Coast Mental Health and Addiction Services, Nambour, NSW, Australia f Macquarie University Hospital, Sydney, NSW, Australia g Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia h Department of Radiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia b
Received 24 November 2016; accepted 14 December 2016; online published-ahead-of-print xxx
[14_TD$IF]Neurocognitive and psychiatric complications are common following cardiac surgery and impact on patient quality of life, recovery from surgery, participation in rehabilitation and long-term mortality. Postoperative cognitive decline, depressive disorders, post-traumatic stress disorder and neurocognitive impairment related to silent brain infarcts have all been linked to the perioperative period of cardiac surgery, and potentially have serious consequences. The accurate assessment of these conditions, particularly in determining the aetiology, and impact on patients is difficult due to the poorly recognised nature of these complications as well as similarities in presentation with postoperative delirium. This review aims to summarise current understanding surrounding psychiatric disturbances following cardiac surgery including the impact on patient quality of life and long-term outcomes. Keywords
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Introduction
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Cardiac surgical procedures Mental disorders Neuropsychiatry Postoperative cognitive dysfunction
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Neurologic injury, including stroke and transient ischaemic attack are important complications of cardiac surgery. A number of techniques have developed with the aim of reducing neurologic injury during cardiac surgical procedures. These include off-pump coronary artery bypass grafting, antegrade cerebral perfusion and hypothermia during aortic arch surgery, and distal aortic perfusion and cerebrospinal fluid drainage in thoracoabdominal aortic surgery [1].
These techniques have positively impacted on overt neurologic outcomes, and the focus has begun to shift towards less well-understood and often subtle neuro-psychiatric complications such as postoperative cognitive dysfunction (POCD), depression, dementia, and post-traumatic stress disorder (PTSD). These disorders have a significant impact on postoperative quality of life, and potentially negate the expected improvement in quality of life following successful surgery [2]. They may also affect functional independence, resulting in an increase in care requirements, reduction in workforce participation, and increased reliance on social
*Corresponding author [3_TD$IF]at: The Baird Institute of Applied Heart & Lung Surgical Research, 305/100 Carillon Ave, Newtown NSW 2042, Australia[4_TD$IF]. Tel.: +61295503714, Fax: +61295197584 Email: [email protected] © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Indja BE, et al. Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery. Heart, Lung and Circulation (2017), http://dx.doi.org/10.1016/j.hlc.2016.12.010
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welfare [3]. Furthermore, there is some evidence that POCD may be associated with an increased mortality long-term [3]. The precise aetiology of these conditions is not entirely clear but likely involves a number of mechanisms including cerebral hypoperfusion and oxygenation, microemboli causing silent brain infarcts or a systemic inflammatory response [4]. Known patient risk factors include age, preoperative cognitive function and cognitive reserve [5], and premorbid psychiatric disorders [6]. This review discusses the possible aetiology of these conditions and their effect on patient outcomes.
[15_TD$IF]Postoperative Cognitive Dysfunction Cognitive dysfunction after cardiac surgery, while well known to occur, is less clearly understood with regards to the true incidence, causative factors involved, extent of the damage, and long-term implications and prognosis. Similar to clinically apparent stroke, embolic injury is likely to be a dominant mechanism of injury, however as demonstrated by an inconsistent correlation between POCD and new diffusion weighted imaging (DWI) cerebral ischaemic lesions [7], there are likely other factors involved. Cerebral hypoperfusion [8], systemic inflammatory response, CPB circuit [9], and cerebral hyperthermia [10] are all recognised as potential mechanisms of brain injury in the perioperative period. The definition of POCD is subject to considerable variation, which has made the true extent of this often sub-clinical brain injury difficult to determine. A 1995 statement of consensus for the diagnosis of POCD [11] recommended a core battery of tests, which included assessment of specific core cognitive domains including motor skill, verbal memory, attention and concentration, as well as assessing for effects of anxiety and depression, IQ testing, neurologic examination and accounting for learning effects and additional follow-up testing at least three months post procedure were all advocated. However in a review of POCD after cardiac surgery, which included 62 studies, high heterogeneity was found between the assessment batteries applied [12]. Further adding to heterogeneity was the finding that the statistical definition of POCD varied widely between studies with more than nine definitions (most notably including: percentage decline, standard deviation decline, factor analysis, individual test analysis) seen across the 62 studies with the threshold for cognitive decline being inconsistent between each [12]. Although heterogeneity in the definition of POCD remains, it can be generally described as a reduction in any cognitive domain following surgery [6_TD$IF]– typically thinking and memory, without an obvious state of confusion [13]. This is important so as to distinguish POCD from postoperative delirium, which can best be described as an acute and fluctuating confusional state, with reduced attention, disorientation, and additional symptoms such as hallucinations and inappropriate behaviour [14]. The reported incidence of POCD is highly variable, as would be expected with the
inconsistent definitions. A standard deviation (reduction of 1 SD) definition by Newman et al. has reported the incidence of POCD to be as high as 70% in the first week and 40% at 12 months [15]. Diagnosis of POCD early in the preoperative period is difficult due to many variables which may overestimate the diagnoses such as effects of anaesthetic drugs, narcotics and benzodiazepines [15] as well as misinterpretation of POCD in the presence of postoperative delirium [16]. Similarly, diagnosing POCD in the long-term has its own challenges, largely due to reduced cognition and associated increased incidence of silent brain infarcts (SBIs) with increasing age, potentially overestimating the effect of cognitive dysfunction actually related to the surgical procedure [17]. Cognitive dysfunction is a serious morbidity that can impact significantly on social function and independence. In a non-cardiac surgery study of POCD, in which 701 patients were followed up for 8.5 years, POCD present at one week postoperatively was associated with increased time receiving social welfare payments and earlier withdrawal from the labour market [3]. Self-care is an important factor of patient independence and their clinical outcomes [18] and in a study of patients with congestive heart failure, those who had cognitive impairment demonstrated difficulty in recognising symptom changes and thus had an impaired ability to make adequate self-care decisions over time [19]. Further to this, impairment of the executive function cognitive domain has been linked to a reduction in the ability to perform activities of daily living, specifically medication management [20], negatively impacting patient outcomes. In a long-term study of a median 11-year follow-up of patients following cardiac surgery, cognitive dysfunction present at six months was associated with increased long-term mortality [21], further demonstrating that the consequences of POCD are likely to have long-term implications that are more significant than just a transient postoperative state.
[7_TD$IF]Perioperative Depression Depression has been closely associated with cardiovascular disease, with major depressive disorder (MDD) reported to be present in up to 20% of patients [22]. It is not surprising, therefore, that depression is a notable comorbidity in patients undergoing cardiac surgery. Depression has been shown to be associated with extensive neural network abnormalities across the brain, hence both focal and global brain injuries may cause damage to these networks and predispose to increase risk of MDD [23]. Pre-morbid depressive disorders are the main risk factor for postoperative depression, with new postoperative depression relatively uncommon [24], so while cardiac surgery has not been shown to be a significant cause of depression it may be an important co-factor in inducing relapse as well as in contributing to postoperative morbidity and mortality. In a study of 309 patients undergoing CABG, 20% met the criteria for MDD prior to discharge; of this group 27% had a cardiac event within the first 12 months [25]. This was compared to 10% of the group without MDD [25]. Further to this,
Please cite this article in press as: Indja BE, et al. Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery. Heart, Lung and Circulation (2017), http://dx.doi.org/10.1016/j.hlc.2016.12.010
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depression scores assessed with Centre for Epidemiologic Studies Depression Scale (CES-D Scale) found a correlation between higher scores at one month, one year and five years to chest pain of cardiac origin in the five years following CABG [26]. Mortality is likely also affected with findings of new postoperative depressive symptoms being strongly associated with increased mortality and complications in the following two years [27]. This is not surprising as multiple studies have been able to show a link between preoperative depression and reduced postoperative mortality [28,29]. Depression may additionally be a risk factor for postoperative delirium, with Tully et al. [30] reporting that patients diagnosed with major depressive disorder had an odds ratio of 3.49 (95%CI 1.48–8.26, <0.01) for developing postoperative delirium after cardiac operations. This was further highlighted more recently in a cohort of CABG patients in which both delirium and reduced quality of life was correlated to preoperative depression [31]. With such evidence of the deleterious effects that MDD has following cardiac surgery, identification and appropriate management preoperatively may carry significant weight in reducing this population’s postoperative complications. However, more research is required regarding the efficacy and safety of antidepressants and psychological therapies with evidence currently conflicted in this area [32–35].
[8_TD$IF]Silent Brain Infarcts and Psychiatric Sequelae Silent brain infarcts (SBI) have been shown to be associated with cardiac surgery, evidenced by new ischaemic lesions detected by DWI postoperatively. The incidence of SBI after cardiac surgery is somewhat variably reported between 25– 50% [7] and appears associated with the type of procedure performed, with aortic valve replacement seemingly carrying the highest risk [36]. The sources of SBI associated with cardiac surgery, similar to stroke are multifactorial and likely include embolism, hypo-perfusion, systemic inflammatory response and microangiopathy [37]. While SBIs are not completely understood, there is growing evidence that with them comes increased risk of long- and short-term complications. The hypothesised link between SBIs and POCD has not been strongly established. Barber et al. demonstrated significant correlation between the burden of new DWI lesions and impairment of at least one cognitive domain at six weeks post operation [38], and Restrepo et al. were able to demonstrate a similar association [39]. In a study of cognitive dysfunction, SBIs in an elderly population were shown to correlate with a reduction in the attention domain, which was linked to disruption of the central cholinergic pathway [40]. However a number of studies of cardiac surgical procedures including CABG and AVR [41], transcatheter aortic valve implantation [42], and carotid revascularisation [43], have failed to show any significant correlation between the presence and number of new DWI lesions and POCD.
Numerous psychiatric conditions have been linked to SBIs including depression, mania and dementia. In a study of 194 patients with a variety of psychiatric conditions, SBIs were seen in 42.8% of patients receiving treatment for a depressive disorder [44], which supported previous findings by Yamashita et al. who reported the prevalence of SBI in major depression to be 48.6% [45]. For some time an association between depression and SBI has been known, which has largely been linked to depression onset with increasing age. In patients with pre-senile onset depression 51.4% have been observed to have SBIs, with this rate increasing to 97.3% of patients with senile onset depression [46]. Comparatively, only 22.6% of patients (mean age 56.7) with juvenile onset depression were shown to have SBIs present on MRI [46]. Further supporting this hypothesis was a finding from the Rotterdam study demonstrating that reduced cerebral blood flow velocity was predictive of depressive symptoms and disorders [47]. An important mechanism for the development of SBIs is thought to be due to impaired vasomotor reactivity of cerebral vessels leading to ischaemic injury [48]. Bipolar disorder is a growing concern in elderly patients and similar to late-onset depression, has been associated with vascular risk factors and white matter ischaemic lesions. Silent brain infarcts have been associated with mania, which have been seen in approximately half of patients diagnosed with bipolar disorder after the age of 50 [49]. Vascular risk factors, which are thought to be the cause of sub-clinical cerebral ischaemic lesions, have also been demonstrated to be an important cause of late-onset mania [50]. In a study comparing elderly patients who either had early onset or late onset bipolar disorder and age-matched controls, the lateonset group had the highest rate of silent white matter lesions on MRI, particularly in regions which have been associated with mood disorders [6_TD$IF]– the deep frontal and parietal regions, and the putamen [51]. In a meta-analysis, Beyer et al. found that 38.9% of bipolar patients had ischaemic lesions, compared to 18% of healthy controls [52]. The mean age of patients was around 34, which may account for this lower prevalence as compared to the previous studies of elderly populations. Interestingly, four of the studies were of child and adolescent populations, which reported an odds ratio of having SBIs of 5.7 for the bipolar disorder population as compared to healthy controls [52]. This meta-analysis also further supported the association of SBIs with unipolar depression and schizophrenia which both had similar rates of white matter hyper-intensities [52]. Silent brain infarcts have also been implicated in the development of dementia. The Rotterdam study reported that the presence of SBIs in the general population doubles the risk of dementia, and furthermore, patients with dementia accompanied by SBIs also had a quicker decline in cognitive function as compared to those without [53]. Further reported from the Rotterdam study was that an association between the location of the white matter lesions and the development of dementia may exist [6_TD$IF]– periventricular lesion severity was correlated with a higher risk of dementia, while lesions in the subcortical region did not [54]. Debette et al., who reviewed
Please cite this article in press as: Indja BE, et al. Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery. Heart, Lung and Circulation (2017), http://dx.doi.org/10.1016/j.hlc.2016.12.010
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17 studies looking at SBIs and dementia, found that, comparable to the Rotterdam study, white matter lesions in the general population contributed to a higher risk of developing dementia, although this correlation was not seen in a high-risk population such as those with mild cognitive impairment or stroke [55]. There is obviously much overlap between patients undergoing cardiac surgical procedures and patients with vascular risk factors which lead to SBIs, thus studies specifically focussed on the incidence of these psychiatric conditions post-surgery associated with new infarct load are required for validation of this link. With new SBIs closely linked to cardiac procedures, the longer-term cognitive and psychiatric complications of these clinically silent lesions present a possible important cause of increased morbidity and mortality for patients following cardiac surgery.
[7_TD$IF]PTSD, Chronic Perioperative Stress and HRQL Exposure to a high level of stress occurs in the perioperative period surrounding cardiac procedures, particularly in the ICU environment. Highlighted by Schelling et al., who found that notwithstanding successful cardiac procedures, up to 20% of patients did not have improvement in the HRQL scores [56]. Of 148 patients, 20 had new PTSD six months after their surgery and this was strongly correlated to preoperative stress levels and CPB time (150 vs 120 minutes, median values, p[9_TD$IF]<0.01) [56]. Overall, the total study population showed significant improvement in HRQL scores (almost exclusively related to physical function scores), however the patients with new postoperative PTSD did not show the same improvement due to reduced mental health function. Critical illness related corticosteroid insufficiency (CIRCI) is a corticosteroid insufficiency that is seen in acute illness, including septic shock and post cardiac surgery [57]. This is a poorly understood condition; during critical illness states the normal cortisol response is maintained, and there are even decreased levels of corticosteroid-binding globulin leading to an increase in plasma free corticosteroid available [58]. However, at some point, an impaired response or signalling occurs and likely factors thought to be involved include inadequate corticosteroid release as well as tissue resistance to both corticosteroids and ACTH [59]. In the early postoperative period after cardiac surgery, patients with prolonged reduction in circulating corticosteroids have been found to have a higher incidence of PTSD and chronic stress [60]. Weis et al. demonstrated that hydrocortisone administration in the perioperative period (initial dose prior to anaesthesia induction, followed by a gradually reduced infusion over the first four postoperative days) was able to reduce chronic stress symptoms, improve HRQL scores and reduce incidence of PTSD at a six-month follow-up [61]. Improvements in both physical and mental health functions were seen on the HRQL questionnaire in the hydrocortisone group suggesting that stressors may have an impact on patient physical health. There is no clear explanation for these findings, however,
contributing factors may include: [1] stress masking the physical benefits of the successful operation; [2] stress increasing allostatic load [62]; [3] stress resulting in decreased compliance with medications resulting in actual physical impairment [63]. In addition to the long-term benefits, the hydrocortisone group also demonstrated short-term benefits as compared to the control group [6_TD$IF]– reduced ICU stay, lower TISS score, reduced norepinephrine requirements and lower concentrations of pro-inflammatory cytokine IL-6 [60]. Schelling et al. supported these findings by similarly demonstrating the protective benefit of perioperative hydrocortisone administration in reducing chronic stress symptoms and PTSD at six months following cardiac surgery [60].
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Postoperative delirium is a well-known complication of cardiac surgery [64]. Reported incidence varies widely according to age, population, type of operation and the diagnostic criteria used. Similar to POCD, clinical diagnostic tests vary in their structure as well as selected threshold for diagnosis, thus all these factors result in a wide reported incidence from 6% to over 50% [65]. Similarities also exist between hypothesised aetiology of delirium and POCD [6_TD$IF]– duration of CPB [66], postoperative systemic inflammatory response, history of stroke and micro-emboli [67]. However, there is mixed evidence, with Rudolph et al. showing that an intraoperative micro-emboli load of the middle cerebral artery detected by transcranial Doppler (TCD) had no association with postoperative delirium in patients undergoing CABG, nor did they find an association with CPB time [68]. Similarly, in a systematic review of studies which examined the relationship between intraoperative micro-emboli and cognitive impairment, there was no definitive causal link with the authors concluding that micro emboli may only play a small role at best [69]. And in a separate systematic review looking at risk factors for postoperative delirium following cardiac surgery, CPB time was not found to have an association [70]. In this same review a number of risk factors were found to have a strong level of evidence toward postoperative delirium, notably age, pre-existing cognitive or psychiatric conditions, previous stroke, complexity of cardiac surgery and mechanical ventilation time [70]. Length of aortic cross clamp time has also been shown to have a positive correlation to patients developing severe delirium [71]. Furthermore, in non-cardiac surgery, delirium has been associated with intraoperative hypotension, blood loss and number of blood transfusions and hypothermia [72], all of which are common factors associated with cardiac surgery [68]. Postoperative delirium negatively impacts patient shortand long-term outcomes. Short-term outcomes include increased recovery time, which can be separated into longer intensive care stay, and increased hospital stay [67] as well as prolonging the required time for mechanical ventilation [73]. Longer term, there is a potential association between delirium in the intensive care postoperatively and cognitive impairment [74]. Additionally, higher 12-month mortality is significantly associated with delirium, particularly in
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Please cite this article in press as: Indja BE, et al. Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery. Heart, Lung and Circulation (2017), http://dx.doi.org/10.1016/j.hlc.2016.12.010
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elderly patients. Martin et al. were able to demonstrate a strong link between delirium and perioperative stroke and separately to this, a higher stroke rate in the preceding 10 years [75]. Also significantly affected was a notable lack in increase of HRQL scores following CABG in patients who suffered delirium compared to the significant increase seen in non-delirious patients at 18 months follow-up [76]. Health care costs are also significantly increased due to postoperative delirium, which includes costs of longer intensive care and overall hospital stay, and higher intensive care costs, regardless of length of stay [77]. Due to the multi-factorial mechanisms resulting in postoperative delirium, it is difficult to accurately predict patient risk prior to surgery. Additionally to this, the high heterogeneity in diagnostic criteria adds to the complexity. DSM-IV, ICD-10, and the Memorial Delirium Assessment Scale criteria, have all been shown to have different positive diagnostic rates across a single cohort [78]. In addition to this, the unavoidable subjective nature of these assessments adds to the heterogeneity of results. Prevention and management of postoperative delirium is therefore difficult with the present knowledge due to the highly variable aetiology.
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Neurologic injury has been the main focus of cardiac surgery complications, albeit in the more overt forms of stroke and transient ischaemic attacks. With improvements seen in these areas the focus has shifted towards the subtler neurocognitive and psychiatric complications such as POCD, depression, dementia and PTSD for which similar mechanisms have been proposed, yet current understanding and evidence is not adequate. Psychiatric sequelae following cardiac surgery have a clear impact on patient quality of life, and potential to impact long-term outcomes. Thus, improved understanding is required to more accurately assess the prevalence, understand causative factors and develop potential preventative measures.
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[51] Tamashiro JH, Zung S, Zanetti MV, de Castro CC, Vallada H, Busatto GF, et al. Increased rates of white matter hyperintensities in late-onset bipolar disorder. Bipolar Disorders 2008;10(7):765–75. [52] Beyer JL, Young R, Kuchibhatla M, Krishnan KR. Hyperintense MRI lesions in bipolar disorder: A meta-analysis and review. International Review of Psychiatry 2009;21(4):394–409. [53] Vermeer SE, Prins ND, den Heijer T, Hofman A, Koudstaal PJ, Breteler MM. Silent brain infarcts and the risk of dementia and cognitive decline. The New England Journal of Medicine 2003;348(13):1215–22. [54] Prins ND, van Dijk EJ, den Heijer T, Vermeer SE, Koudstaal PJ, Oudkerk M, et al. Cerebral white matter lesions and the risk of dementia. Archives of Neurology 2004;61(10):1531–4. [55] Debette S, Markus HS. The clinical importance of white matter hyperintensities on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2010;341:c3666. [56] Schelling G, Richter M, Roozendaal B, Rothenhausler HB, Krauseneck T, Stoll C, et al. Exposure to high stress in the intensive care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery. Critical Care Medicine 2003;31(7):1971–80. [57] Schelling G, Roozendaal B, Krauseneck T, Schmoelz M, D DEQ, Briegel J. Efficacy of hydrocortisone in preventing posttraumatic stress disorder following critical illness and major surgery. Annals of the New York Academy of Sciences 2006;1071:46–53. [58] Beishuizen A, Thijs LG, Vermes I. Patterns of corticosteroid-binding globulin and the free cortisol index during septic shock and multitrauma. Intensive Care Medicine 2001;27(10):1584–91. [59] Cooper MS, Stewart PM. Corticosteroid insufficiency in acutely ill patients. The New England Journal of Medicine 2003;348(8):727–34. [60] Schelling G, Kilger E, Roozendaal B, de Quervain DJ, Briegel J, Dagge A, et al. Stress doses of hydrocortisone, traumatic memories, and symptoms of posttraumatic stress disorder in patients after cardiac surgery: a randomized study. Biological Psychiatry 2004;55(6):627–33. [61] Weis F, Kilger E, Roozendaal B, de Quervain DJ, Lamm P, Schmidt M, et al. Stress doses of hydrocortisone reduce chronic stress symptoms and improve health-related quality of life in high-risk patients after cardiac surgery: a randomized study. The Journal of Thoracic and Cardiovascular Surgery 2006;131(2):277–82. [62] McEwen BS. Mood disorders and allostatic load. Biological Psychiatry 2003;54(3):200–7. [63] Shemesh E, Yehuda R, Milo O, Dinur I, Rudnick A, Vered Z, et al. Posttraumatic stress, nonadherence, and adverse outcome in survivors of a myocardial infarction. Psychosomatic Medicine 2004;66(4):521–6. [64] Blachy PH, Starr A. Post-Cardiotomy Delirum. The American Journal of Psychiatry 1964;121:371–5. [65] Lin Y, Chen J, Wang Z. Meta-analysis of factors which influence delirium following cardiac surgery. Journal of Cardiac Surgery 2012;27(4):481–92. [66] Rolfson DB, McElhaney JE, Rockwood K, Finnegan BA, Entwistle LM, Wong JF, et al. Incidence and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery. The Canadian Journal of Cardiology 1999;15(7):771–6. [67] Guenther U, Theuerkauf N, Frommann I, Brimmers K, Malik R, Stori S, et al. Predisposing and precipitating factors of delirium after cardiac surgery: a prospective observational cohort study. Annals of Surgery 2013;257(6):1160–7. [68] Rudolph JL, Babikian VL, Treanor P, Pochay VE, Wigginton JB, Crittenden MD, et al. Microemboli are not associated with delirium after coronary artery bypass graft surgery. Perfusion 2009;24(6):409–15. [69] Martin KK, Wigginton JB, Babikian VL, Pochay VE, Crittenden MD, Rudolph JL. Intraoperative cerebral high-intensity transient signals and postoperative cognitive function: a systematic review. American Journal of Surgery 2009;197(1):55–63. [70] Gosselt AN, Slooter AJ, Boere PR, Zaal IJ. Risk factors for delirium after on-pump cardiac surgery: a systematic review. Critical Care 2015;19:346. [71] Andrejaitiene J, Sirvinskas E. Early post-cardiac surgery delirium risk factors. Perfusion 2012;27(2):105–12. [72] Marcantonio ER, Goldman L, Orav EJ, Cook EF, Lee TH. The association of intraoperative factors with the development of postoperative delirium. The American Journal of Medicine 1998;105(5):380–4. [73] Stransky M, Schmidt C, Ganslmeier P, Grossmann E, Haneya A, Moritz S, et al. Hypoactive delirium after cardiac surgery as an independent risk factor for prolonged mechanical ventilation. Journal of Cardiothoracic and Vascular Anesthesia 2011;25(6):968–74. [74] Jackson JC, Gordon SM, Hart RP, Hopkins RO, Ely EW. The association between delirium and cognitive decline: a review of the empirical literature. Neuropsychology Review 2004;14(2):87–98.
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[75] Martin BJ, Buth KJ, Arora RC, Baskett RJ. Delirium: a cause for concern beyond the immediate postoperative period. The Annals of Thoracic Surgery 2012;93(4):1114–20. [76] Loponen P, Luther M, Wistbacka JO, Nissinen J, Sintonen H, Huhtala H, et al. Postoperative delirium and health related quality of life after coronary artery bypass grafting. Scandinavian Cardiovascular Journal 2008;42(5):337–44.
[77] Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, et al. Costs associated with delirium in mechanically ventilated patients. Critical Care Medicine 2004;32(4):955–62. [78] Kazmierski J, Kowman M, Banach M, Fendler W, Okonski P, Banys A, et al. The use of DSM-IV and ICD-10 criteria and diagnostic scales for delirium among cardiac surgery patients: results from the IPDACS study. The Journal of Neuropsychiatry And Clinical Neurosciences 2010;22(4):426–32.
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Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery
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Ben Elias Indja a,b,c, Michael Seco, MBBS a[2_TD$IF],b,d, Richard Seamark, MBBS, FRANZCP e[2_TD$IF], Jason Kaplan, MBBS, FRACP f, Paul G. Bannon, MBBS, PhD, FRACS a,b,d,g, Stuart M. Grieve, FRANZCR, DPhil (Oxon) a,c,h, Michael P. Vallely, MBBS, PhD, FRACS a,b,d,f,g* a
Sydney Medical School, The University of Sydney, Sydney, NSW, Australia The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, NSW, Australia c Sydney Translational Imaging Laboratory, Heart Research Institute, Charles Perkins Centre, University of Sydney, NSW, Australia d Royal Prince Alfred Institute of Academic Surgery, Sydney, NSW, Australia e Sunshine Coast Mental Health and Addiction Services, Nambour, NSW, Australia f Macquarie University Hospital, Sydney, NSW, Australia g Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia h Department of Radiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia b
Received 24 November 2016; accepted 14 December 2016; online published-ahead-of-print xxx
[14_TD$IF]Neurocognitive and psychiatric complications are common following cardiac surgery and impact on patient quality of life, recovery from surgery, participation in rehabilitation and long-term mortality. Postoperative cognitive decline, depressive disorders, post-traumatic stress disorder and neurocognitive impairment related to silent brain infarcts have all been linked to the perioperative period of cardiac surgery, and potentially have serious consequences. The accurate assessment of these conditions, particularly in determining the aetiology, and impact on patients is difficult due to the poorly recognised nature of these complications as well as similarities in presentation with postoperative delirium. This review aims to summarise current understanding surrounding psychiatric disturbances following cardiac surgery including the impact on patient quality of life and long-term outcomes. Keywords
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Cardiac surgical procedures Mental disorders Neuropsychiatry Postoperative cognitive dysfunction
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Neurologic injury, including stroke and transient ischaemic attack are important complications of cardiac surgery. A number of techniques have developed with the aim of reducing neurologic injury during cardiac surgical procedures. These include off-pump coronary artery bypass grafting, antegrade cerebral perfusion and hypothermia during aortic arch surgery, and distal aortic perfusion and cerebrospinal fluid drainage in thoracoabdominal aortic surgery [1].
These techniques have positively impacted on overt neurologic outcomes, and the focus has begun to shift towards less well-understood and often subtle neuro-psychiatric complications such as postoperative cognitive dysfunction (POCD), depression, dementia, and post-traumatic stress disorder (PTSD). These disorders have a significant impact on postoperative quality of life, and potentially negate the expected improvement in quality of life following successful surgery [2]. They may also affect functional independence, resulting in an increase in care requirements, reduction in workforce participation, and increased reliance on social
*Corresponding author [3_TD$IF]at: The Baird Institute of Applied Heart & Lung Surgical Research, 305/100 Carillon Ave, Newtown NSW 2042, Australia[4_TD$IF]. Tel.: +61295503714, Fax: +61295197584 Email: [email protected] © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Indja BE, et al. Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery. Heart, Lung and Circulation (2017), http://dx.doi.org/10.1016/j.hlc.2016.12.010
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welfare [3]. Furthermore, there is some evidence that POCD may be associated with an increased mortality long-term [3]. The precise aetiology of these conditions is not entirely clear but likely involves a number of mechanisms including cerebral hypoperfusion and oxygenation, microemboli causing silent brain infarcts or a systemic inflammatory response [4]. Known patient risk factors include age, preoperative cognitive function and cognitive reserve [5], and premorbid psychiatric disorders [6]. This review discusses the possible aetiology of these conditions and their effect on patient outcomes.
[15_TD$IF]Postoperative Cognitive Dysfunction Cognitive dysfunction after cardiac surgery, while well known to occur, is less clearly understood with regards to the true incidence, causative factors involved, extent of the damage, and long-term implications and prognosis. Similar to clinically apparent stroke, embolic injury is likely to be a dominant mechanism of injury, however as demonstrated by an inconsistent correlation between POCD and new diffusion weighted imaging (DWI) cerebral ischaemic lesions [7], there are likely other factors involved. Cerebral hypoperfusion [8], systemic inflammatory response, CPB circuit [9], and cerebral hyperthermia [10] are all recognised as potential mechanisms of brain injury in the perioperative period. The definition of POCD is subject to considerable variation, which has made the true extent of this often sub-clinical brain injury difficult to determine. A 1995 statement of consensus for the diagnosis of POCD [11] recommended a core battery of tests, which included assessment of specific core cognitive domains including motor skill, verbal memory, attention and concentration, as well as assessing for effects of anxiety and depression, IQ testing, neurologic examination and accounting for learning effects and additional follow-up testing at least three months post procedure were all advocated. However in a review of POCD after cardiac surgery, which included 62 studies, high heterogeneity was found between the assessment batteries applied [12]. Further adding to heterogeneity was the finding that the statistical definition of POCD varied widely between studies with more than nine definitions (most notably including: percentage decline, standard deviation decline, factor analysis, individual test analysis) seen across the 62 studies with the threshold for cognitive decline being inconsistent between each [12]. Although heterogeneity in the definition of POCD remains, it can be generally described as a reduction in any cognitive domain following surgery [6_TD$IF]– typically thinking and memory, without an obvious state of confusion [13]. This is important so as to distinguish POCD from postoperative delirium, which can best be described as an acute and fluctuating confusional state, with reduced attention, disorientation, and additional symptoms such as hallucinations and inappropriate behaviour [14]. The reported incidence of POCD is highly variable, as would be expected with the
inconsistent definitions. A standard deviation (reduction of 1 SD) definition by Newman et al. has reported the incidence of POCD to be as high as 70% in the first week and 40% at 12 months [15]. Diagnosis of POCD early in the preoperative period is difficult due to many variables which may overestimate the diagnoses such as effects of anaesthetic drugs, narcotics and benzodiazepines [15] as well as misinterpretation of POCD in the presence of postoperative delirium [16]. Similarly, diagnosing POCD in the long-term has its own challenges, largely due to reduced cognition and associated increased incidence of silent brain infarcts (SBIs) with increasing age, potentially overestimating the effect of cognitive dysfunction actually related to the surgical procedure [17]. Cognitive dysfunction is a serious morbidity that can impact significantly on social function and independence. In a non-cardiac surgery study of POCD, in which 701 patients were followed up for 8.5 years, POCD present at one week postoperatively was associated with increased time receiving social welfare payments and earlier withdrawal from the labour market [3]. Self-care is an important factor of patient independence and their clinical outcomes [18] and in a study of patients with congestive heart failure, those who had cognitive impairment demonstrated difficulty in recognising symptom changes and thus had an impaired ability to make adequate self-care decisions over time [19]. Further to this, impairment of the executive function cognitive domain has been linked to a reduction in the ability to perform activities of daily living, specifically medication management [20], negatively impacting patient outcomes. In a long-term study of a median 11-year follow-up of patients following cardiac surgery, cognitive dysfunction present at six months was associated with increased long-term mortality [21], further demonstrating that the consequences of POCD are likely to have long-term implications that are more significant than just a transient postoperative state.
[7_TD$IF]Perioperative Depression Depression has been closely associated with cardiovascular disease, with major depressive disorder (MDD) reported to be present in up to 20% of patients [22]. It is not surprising, therefore, that depression is a notable comorbidity in patients undergoing cardiac surgery. Depression has been shown to be associated with extensive neural network abnormalities across the brain, hence both focal and global brain injuries may cause damage to these networks and predispose to increase risk of MDD [23]. Pre-morbid depressive disorders are the main risk factor for postoperative depression, with new postoperative depression relatively uncommon [24], so while cardiac surgery has not been shown to be a significant cause of depression it may be an important co-factor in inducing relapse as well as in contributing to postoperative morbidity and mortality. In a study of 309 patients undergoing CABG, 20% met the criteria for MDD prior to discharge; of this group 27% had a cardiac event within the first 12 months [25]. This was compared to 10% of the group without MDD [25]. Further to this,
Please cite this article in press as: Indja BE, et al. Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery. Heart, Lung and Circulation (2017), http://dx.doi.org/10.1016/j.hlc.2016.12.010
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depression scores assessed with Centre for Epidemiologic Studies Depression Scale (CES-D Scale) found a correlation between higher scores at one month, one year and five years to chest pain of cardiac origin in the five years following CABG [26]. Mortality is likely also affected with findings of new postoperative depressive symptoms being strongly associated with increased mortality and complications in the following two years [27]. This is not surprising as multiple studies have been able to show a link between preoperative depression and reduced postoperative mortality [28,29]. Depression may additionally be a risk factor for postoperative delirium, with Tully et al. [30] reporting that patients diagnosed with major depressive disorder had an odds ratio of 3.49 (95%CI 1.48–8.26, <0.01) for developing postoperative delirium after cardiac operations. This was further highlighted more recently in a cohort of CABG patients in which both delirium and reduced quality of life was correlated to preoperative depression [31]. With such evidence of the deleterious effects that MDD has following cardiac surgery, identification and appropriate management preoperatively may carry significant weight in reducing this population’s postoperative complications. However, more research is required regarding the efficacy and safety of antidepressants and psychological therapies with evidence currently conflicted in this area [32–35].
[8_TD$IF]Silent Brain Infarcts and Psychiatric Sequelae Silent brain infarcts (SBI) have been shown to be associated with cardiac surgery, evidenced by new ischaemic lesions detected by DWI postoperatively. The incidence of SBI after cardiac surgery is somewhat variably reported between 25– 50% [7] and appears associated with the type of procedure performed, with aortic valve replacement seemingly carrying the highest risk [36]. The sources of SBI associated with cardiac surgery, similar to stroke are multifactorial and likely include embolism, hypo-perfusion, systemic inflammatory response and microangiopathy [37]. While SBIs are not completely understood, there is growing evidence that with them comes increased risk of long- and short-term complications. The hypothesised link between SBIs and POCD has not been strongly established. Barber et al. demonstrated significant correlation between the burden of new DWI lesions and impairment of at least one cognitive domain at six weeks post operation [38], and Restrepo et al. were able to demonstrate a similar association [39]. In a study of cognitive dysfunction, SBIs in an elderly population were shown to correlate with a reduction in the attention domain, which was linked to disruption of the central cholinergic pathway [40]. However a number of studies of cardiac surgical procedures including CABG and AVR [41], transcatheter aortic valve implantation [42], and carotid revascularisation [43], have failed to show any significant correlation between the presence and number of new DWI lesions and POCD.
Numerous psychiatric conditions have been linked to SBIs including depression, mania and dementia. In a study of 194 patients with a variety of psychiatric conditions, SBIs were seen in 42.8% of patients receiving treatment for a depressive disorder [44], which supported previous findings by Yamashita et al. who reported the prevalence of SBI in major depression to be 48.6% [45]. For some time an association between depression and SBI has been known, which has largely been linked to depression onset with increasing age. In patients with pre-senile onset depression 51.4% have been observed to have SBIs, with this rate increasing to 97.3% of patients with senile onset depression [46]. Comparatively, only 22.6% of patients (mean age 56.7) with juvenile onset depression were shown to have SBIs present on MRI [46]. Further supporting this hypothesis was a finding from the Rotterdam study demonstrating that reduced cerebral blood flow velocity was predictive of depressive symptoms and disorders [47]. An important mechanism for the development of SBIs is thought to be due to impaired vasomotor reactivity of cerebral vessels leading to ischaemic injury [48]. Bipolar disorder is a growing concern in elderly patients and similar to late-onset depression, has been associated with vascular risk factors and white matter ischaemic lesions. Silent brain infarcts have been associated with mania, which have been seen in approximately half of patients diagnosed with bipolar disorder after the age of 50 [49]. Vascular risk factors, which are thought to be the cause of sub-clinical cerebral ischaemic lesions, have also been demonstrated to be an important cause of late-onset mania [50]. In a study comparing elderly patients who either had early onset or late onset bipolar disorder and age-matched controls, the lateonset group had the highest rate of silent white matter lesions on MRI, particularly in regions which have been associated with mood disorders [6_TD$IF]– the deep frontal and parietal regions, and the putamen [51]. In a meta-analysis, Beyer et al. found that 38.9% of bipolar patients had ischaemic lesions, compared to 18% of healthy controls [52]. The mean age of patients was around 34, which may account for this lower prevalence as compared to the previous studies of elderly populations. Interestingly, four of the studies were of child and adolescent populations, which reported an odds ratio of having SBIs of 5.7 for the bipolar disorder population as compared to healthy controls [52]. This meta-analysis also further supported the association of SBIs with unipolar depression and schizophrenia which both had similar rates of white matter hyper-intensities [52]. Silent brain infarcts have also been implicated in the development of dementia. The Rotterdam study reported that the presence of SBIs in the general population doubles the risk of dementia, and furthermore, patients with dementia accompanied by SBIs also had a quicker decline in cognitive function as compared to those without [53]. Further reported from the Rotterdam study was that an association between the location of the white matter lesions and the development of dementia may exist [6_TD$IF]– periventricular lesion severity was correlated with a higher risk of dementia, while lesions in the subcortical region did not [54]. Debette et al., who reviewed
Please cite this article in press as: Indja BE, et al. Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery. Heart, Lung and Circulation (2017), http://dx.doi.org/10.1016/j.hlc.2016.12.010
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17 studies looking at SBIs and dementia, found that, comparable to the Rotterdam study, white matter lesions in the general population contributed to a higher risk of developing dementia, although this correlation was not seen in a high-risk population such as those with mild cognitive impairment or stroke [55]. There is obviously much overlap between patients undergoing cardiac surgical procedures and patients with vascular risk factors which lead to SBIs, thus studies specifically focussed on the incidence of these psychiatric conditions post-surgery associated with new infarct load are required for validation of this link. With new SBIs closely linked to cardiac procedures, the longer-term cognitive and psychiatric complications of these clinically silent lesions present a possible important cause of increased morbidity and mortality for patients following cardiac surgery.
[7_TD$IF]PTSD, Chronic Perioperative Stress and HRQL Exposure to a high level of stress occurs in the perioperative period surrounding cardiac procedures, particularly in the ICU environment. Highlighted by Schelling et al., who found that notwithstanding successful cardiac procedures, up to 20% of patients did not have improvement in the HRQL scores [56]. Of 148 patients, 20 had new PTSD six months after their surgery and this was strongly correlated to preoperative stress levels and CPB time (150 vs 120 minutes, median values, p[9_TD$IF]<0.01) [56]. Overall, the total study population showed significant improvement in HRQL scores (almost exclusively related to physical function scores), however the patients with new postoperative PTSD did not show the same improvement due to reduced mental health function. Critical illness related corticosteroid insufficiency (CIRCI) is a corticosteroid insufficiency that is seen in acute illness, including septic shock and post cardiac surgery [57]. This is a poorly understood condition; during critical illness states the normal cortisol response is maintained, and there are even decreased levels of corticosteroid-binding globulin leading to an increase in plasma free corticosteroid available [58]. However, at some point, an impaired response or signalling occurs and likely factors thought to be involved include inadequate corticosteroid release as well as tissue resistance to both corticosteroids and ACTH [59]. In the early postoperative period after cardiac surgery, patients with prolonged reduction in circulating corticosteroids have been found to have a higher incidence of PTSD and chronic stress [60]. Weis et al. demonstrated that hydrocortisone administration in the perioperative period (initial dose prior to anaesthesia induction, followed by a gradually reduced infusion over the first four postoperative days) was able to reduce chronic stress symptoms, improve HRQL scores and reduce incidence of PTSD at a six-month follow-up [61]. Improvements in both physical and mental health functions were seen on the HRQL questionnaire in the hydrocortisone group suggesting that stressors may have an impact on patient physical health. There is no clear explanation for these findings, however,
contributing factors may include: [1] stress masking the physical benefits of the successful operation; [2] stress increasing allostatic load [62]; [3] stress resulting in decreased compliance with medications resulting in actual physical impairment [63]. In addition to the long-term benefits, the hydrocortisone group also demonstrated short-term benefits as compared to the control group [6_TD$IF]– reduced ICU stay, lower TISS score, reduced norepinephrine requirements and lower concentrations of pro-inflammatory cytokine IL-6 [60]. Schelling et al. supported these findings by similarly demonstrating the protective benefit of perioperative hydrocortisone administration in reducing chronic stress symptoms and PTSD at six months following cardiac surgery [60].
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Postoperative delirium is a well-known complication of cardiac surgery [64]. Reported incidence varies widely according to age, population, type of operation and the diagnostic criteria used. Similar to POCD, clinical diagnostic tests vary in their structure as well as selected threshold for diagnosis, thus all these factors result in a wide reported incidence from 6% to over 50% [65]. Similarities also exist between hypothesised aetiology of delirium and POCD [6_TD$IF]– duration of CPB [66], postoperative systemic inflammatory response, history of stroke and micro-emboli [67]. However, there is mixed evidence, with Rudolph et al. showing that an intraoperative micro-emboli load of the middle cerebral artery detected by transcranial Doppler (TCD) had no association with postoperative delirium in patients undergoing CABG, nor did they find an association with CPB time [68]. Similarly, in a systematic review of studies which examined the relationship between intraoperative micro-emboli and cognitive impairment, there was no definitive causal link with the authors concluding that micro emboli may only play a small role at best [69]. And in a separate systematic review looking at risk factors for postoperative delirium following cardiac surgery, CPB time was not found to have an association [70]. In this same review a number of risk factors were found to have a strong level of evidence toward postoperative delirium, notably age, pre-existing cognitive or psychiatric conditions, previous stroke, complexity of cardiac surgery and mechanical ventilation time [70]. Length of aortic cross clamp time has also been shown to have a positive correlation to patients developing severe delirium [71]. Furthermore, in non-cardiac surgery, delirium has been associated with intraoperative hypotension, blood loss and number of blood transfusions and hypothermia [72], all of which are common factors associated with cardiac surgery [68]. Postoperative delirium negatively impacts patient shortand long-term outcomes. Short-term outcomes include increased recovery time, which can be separated into longer intensive care stay, and increased hospital stay [67] as well as prolonging the required time for mechanical ventilation [73]. Longer term, there is a potential association between delirium in the intensive care postoperatively and cognitive impairment [74]. Additionally, higher 12-month mortality is significantly associated with delirium, particularly in
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Please cite this article in press as: Indja BE, et al. Neurocognitive and [1_TD$IF]Psychiatric Issues Post Cardiac Surgery. Heart, Lung and Circulation (2017), http://dx.doi.org/10.1016/j.hlc.2016.12.010
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elderly patients. Martin et al. were able to demonstrate a strong link between delirium and perioperative stroke and separately to this, a higher stroke rate in the preceding 10 years [75]. Also significantly affected was a notable lack in increase of HRQL scores following CABG in patients who suffered delirium compared to the significant increase seen in non-delirious patients at 18 months follow-up [76]. Health care costs are also significantly increased due to postoperative delirium, which includes costs of longer intensive care and overall hospital stay, and higher intensive care costs, regardless of length of stay [77]. Due to the multi-factorial mechanisms resulting in postoperative delirium, it is difficult to accurately predict patient risk prior to surgery. Additionally to this, the high heterogeneity in diagnostic criteria adds to the complexity. DSM-IV, ICD-10, and the Memorial Delirium Assessment Scale criteria, have all been shown to have different positive diagnostic rates across a single cohort [78]. In addition to this, the unavoidable subjective nature of these assessments adds to the heterogeneity of results. Prevention and management of postoperative delirium is therefore difficult with the present knowledge due to the highly variable aetiology.
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Neurologic injury has been the main focus of cardiac surgery complications, albeit in the more overt forms of stroke and transient ischaemic attacks. With improvements seen in these areas the focus has shifted towards the subtler neurocognitive and psychiatric complications such as POCD, depression, dementia and PTSD for which similar mechanisms have been proposed, yet current understanding and evidence is not adequate. Psychiatric sequelae following cardiac surgery have a clear impact on patient quality of life, and potential to impact long-term outcomes. Thus, improved understanding is required to more accurately assess the prevalence, understand causative factors and develop potential preventative measures.
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