Transcript Cortisol, Insulin & Glucose and the Risk of Delerium in

Cortisol, Insulin & Glucose
and the Risk of Delirium in
Older Adults with Hip Fracture
Peter H. Bisschop, MD, PhD; Sophia E. de
Rooij, MD, PhD; Aeilko H. Zwinderman,
PhD; Hannah E. van Oosten, MD; and
Barbara C. van Munster, MD, PhD
The American Geriatrics Society 59:1692 - 1696
Lindsay Drevlow, PA-S2
November 28, 2011
Overview
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Delirium = severe neuropsychiatric syndrome
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Contributing factors:
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Acute onset
Fluctuating course of inattention
Preexisting functional/cognitive impairment, acute
medical illness, trauma, surgery or medications
30 - 50% older adults with hip fx experience
perioperative delirium
Overview
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Pathophysiology of Delirium
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Poorly understood
Physiologic stress response
metabolic
changes
Possible hypothalamic-pituitary-adrenal axis
activation
H-P-A Axis
Overview
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Cortisol = major stress hormone
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Functions:
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Increase blood sugar via gluconeogenesis
Suppress immune system
Aid in fat, protein and carbohydrate metabolism
Glucose and Insulin
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Counteracts insulin, causing hyperglycemia
Inhibits peripheral utilization of glucose
Objective
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To determine the relationship b/t
perioperative delirium and cortisol, glucose
and insulin in older patients acutely admitted
for hip fracture
Design and Setting
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Prospective cohort study
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Tertiary University Center
Participants
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Inclusion:
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Consecutive individuals
aged 65+ acutely
admitted for hip fx
May 2005 - October
2008
143 patients
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Exclusion:
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Lack of surrogate or
refusal to consent
Inability to speak or
understand
Dutch/English
170 patients
Methods
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Confusion Assessment Scale
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Delirium Observation Screening Scale
Delirium Symptom Interview
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Subtyping
Delirium Rating Scale-98
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Presence vs. Absence of delirium
Severity
Charleston Comorbidity Index
Informant Questionnaire on Cognitive Decline-short
form
Katz ADL Index
Methods
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Blood Samples
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1 pre-op, 1 - 3 post-op
All collected around 11 am
Kept on ice
Centrifuged to separate plasma & serum
Cortisol, Glucose and Insulin measured
Statistical Analyses
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T-tests and Mann-Whitney Tests
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Logistic Regression
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Log transformation used to fulfill normality
4 separate analyses used to look at relationship b/t C,
logG, logI and logI:G
Random effect = participant #
Fixed effects = day of sample, delirious state, age, sex,
preexisting cognitive & functional impairment
Dependent variable = delirium
Independent variables = C, G, I, I:G
Samples of participants with preexisiting DM taken
before/after delirium were excluded
Results
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143 individuals
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49% with delirium
51% without delirium
457 samples
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196 with delirium
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28 before
137 during
60 after
232 without delirium
Results
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Pre-admission cognitive/functional impairment more
prevalent in pts WITH delirium
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Pre-operative cortisol related to cognitive impairment
Delirium a/w higher cortisol and lower insulin in
univariate analysis
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Not significant after correction for pre-existing
cognitive/functional impairment in multivariate analysis
No difference in insulin w/ or w/o delirium in either analysis
Odds Ratio (95% CI) p-value
Results
Factor
Univariate Analysis
Multivariate
Analysis
Cortisol, nmol/L
1.003 (1.001 1.004) 0.004
Glucose, mmol/L
0.98 (0.83 - 1.16)
0.81
Insulin, pmol/L
1.00 (1.00 - 1.00)
0.61
Insulin:Glucose
0.99 (0.96 - 1.02)
0.61
Sex (F:M)
2.63 (1.03 - 6.75)
0.04
Age
1.07 (1.01 - 1.14)
0.02
Preexisiting
Cognitive
Impairment
7.34 (2.88 - 18.7)
<0.001
4.49 (1.46 - 13.8)
0.009
Preexisiting
Functional
Impairment
17.2 (6.2 - 47.8)
<0.001
11.2 (3.76 - 33.2) <
0.001
3.00 (1.01 - 8.93)
0.05
Conclusion
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Negative study for cortisol, insulin and
glucose & the risk of delirium in people with
hip fracture
Limitations
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Results are not generalizable
Abnormal glucose levels are only “defined”
for diabetes
Would suspect a correlation b/t cortisol and
insulin
Level of Evidence: 2B
References
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Bisschop, P. H., de Rooij, S. E., Zwinderman, A. H., van Oosten, H. E. and
van Munster, B. C. (2011), Cortisol, Insulin, and Glucose and the Risk of
Delirium in Older Adults with Hip Fracture. Journal of the American
Geriatrics Society, 59: 1692–1696. doi: 10.1111/j.1532-5415.2011.03575.x