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Biomedical subjects

James C Jackson

Publications and source records attributed to James C Jackson.

16 recordsLinked to original sources
PubMed2007

Apolipoprotein E4 polymorphism as a genetic predisposition to delirium in critically ill patients.

OBJECTIVE: To test for an association between apolipoprotein E (APOE) genotypes and duration of intensive care unit delirium. DESIGN: Prospective, observational cohort study. SETTING: A 541-bed, community-based teaching hospital. PATIENTS: Fifty-three mechanically ventilated intensive care unit patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patients were managed with standardized sedation and ventilator weaning protocols as part of an ongoing clinical trial and were evaluated prospectively for delirium with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). DNA was extracted from whole blood samples obtained on enrollment, and APOE genotype was determined using polymerase chain reaction followed by restriction enzyme digestion by investigators blinded to the clinical information. Delirium occurred in 47 (89%) patients at some point during the intensive care unit stay. Of the 53 patients, 12 (23%) had an APOE4 allele (APOE4+) and 41 (77%) had only APOE2 or APOE3 alleles (APOE4-). APOE4+ patients were younger (53.2 +/- 21.9 vs. 65.4 +/- 13.4, p = .08) and less often admitted for pneumonia (0% vs. 29.3%, p = .05) compared with APOE4- patients, yet they had a duration of delirium that was twice as long: median (interquartile range), 4 (3, 4.5) vs. 2 (1, 4) days (p = .05). No other clinical outcomes were significantly different between the APOE4+ and APOE4- patients. Using multivariable regression analysis to adjust for age, admission diagnosis of sepsis or acute respiratory distress syndrome or pneumonia, severity of illness, and duration of coma, the presence of APOE4 allele was the strongest predictor of delirium duration (odds ratio, 7.32; 95% confidence interval, 1.82-29.51, p = .005). CONCLUSIONS: APOE4 allele represents the first demonstrated genetic predisposition to longer duration of delirium in humans.

Aged↗
PubMed2007

Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage.

BACKGROUND: Trauma patients without intracranial hemorrhage or focal neurologic deficits are typically considered low risk for lasting neuropsychological and emotional deficits, and such sequela may be overlooked, especially in those with skull fractures and concussions. We undertook this study to determine the prevalence of and risk factors for persistent cognitive impairment and emotional and functional difficulties in a sample of adult trauma intensive care unit survivors without intracranial hemorrhage. METHODS: We queried the Vanderbilt University Trauma Registry for all patients admitted during 2003 with an Injury Severity Score >25 and a head computed tomography scan showing no intracranial hemorrhage. Of the 97 patients identified, 58 were evaluated, in person between 12 to 24 months after hospital discharge, with a comprehensive battery of cognitive, emotional, and functional instruments. The Informant Questionnaire of Cognitive Decline in the Elderly-Short Form (IQCODE-SF) was used to evaluate for pre-existing cognitive deficits in patients suspected of having cognitive impairment before their trauma. RESULTS: A total of 33 (57%) patients were determined to have cognitive impairment, which was most pronounced in the domains of attention and executive functioning/verbal fluency. Of these patients, one (3%) was determined by the IQCODE-SF to be cognitively impaired before trauma intensive care unit hospitalization. Of the 58 patients studied, 21 (36.2%) had a concussion or skull fracture and 37 (63.8%) had neither. Cognitive impairment was significantly more likely to occur in patients who sustained a concussion or skull fracture than in trauma patients who did not (81% versus 43%; p = 0.006). Patients reported significant depressive symptoms (56%), significant symptoms of posttraumatic stress disorder (38%), and significant symptoms of anxiety (29%). Quality of life scores were lower than in the general United States population and employment difficulties were widespread. A total of 34% of patients reported being unemployed at follow-up, and cognitive impairment was more common among these patients compared with patients in the workforce (p = 0.03). Neither cognitive impairment nor emotional dysfunction was associated with age, sex, race, Injury Severity Score, blood loss, ventilatory days, or intramedullary nailing of long-bone fractures. CONCLUSIONS: The majority of trauma survivors without intracranial hemorrhage display persistent cognitive impairment, which is nearly twice as likely in those with skull fractures or concussions. This cognitive impairment was associated with functional defects, poor quality of life, and an inability to return to work. Future research must delineate modifiable risk factors for these poor outcomes, especially in patients with skull fractures and concussions, to help improve long-term cognitive and functional status.

Activities of Daily Living↗
PubMed2006

Fruit and vegetable juices and Alzheimer's disease: the Kame Project.

BACKGROUND: Growing evidence suggests that oxidative damage caused by the beta-amyloid peptide in the pathogenesis of Alzheimer's disease may be hydrogen peroxide mediated. Many polyphenols, the most abundant dietary antioxidants, possess stronger neuroprotection against hydrogen peroxide than antioxidant vitamins. METHODS: We tested whether consumption of fruit and vegetable juices, containing a high concentration of polyphenols, decreases the risk of incident probable Alzheimer's disease in the Kame Project cohort, a population-based prospective study of 1836 Japanese Americans in King County, Washington, who were dementia-free at baseline (1992-1994) and were followed through 2001. RESULTS: After adjustment for potential confounders, the hazard ratio for probable Alzheimer's disease was 0.24 (95% confidence interval [CI], 0.09-0.61) comparing subjects who drank juices at least 3 times per week with those who drank less often than once per week with a hazard ratio of 0.84 (95% CI, 0.31-2.29) for those drinking juices 1 to 2 times per week (P for trend < .01). This inverse association tended to be more pronounced among those with an apolipoprotein Eepsilon-4 allele and those who were not physically active. Conversely, no association was observed for dietary intake of vitamins E, C, or beta-carotene or tea consumption. CONCLUSIONS: Fruit and vegetable juices may play an important role in delaying the onset of Alzheimer's disease, particularly among those who are at high risk for the disease. These results may lead to a new avenue of inquiry in the prevention of Alzheimer's disease.

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PubMed2006

Assessing neurocognitive outcomes after critical illness: are delirium and long-term cognitive impairments related?

PURPOSE OF REVIEW: Critically ill patients have a high risk of developing neurologic dysfunction including delirium and long-term cognitive impairment. In this paper we examine possible relationships between delirium and long-term cognitive impairments and explore this in the context of critical illness. RECENT FINDINGS: Critical illness and its treatment can lead to neurologic morbidity including neuropathological abnormalities, delirium, and cognitive impairments. The association between delirium and long-term cognitive impairments has been shown in a number of populations. Among intensive care unit cohorts, delirium appears to be one of many possible causes of cognitive impairments and may be a leading modifiable cause. The mechanisms of both delirium and intensive care unit related cognitive impairment remain unclear, although a variety of common mechanisms have been proposed. SUMMARY: Potential neurologic consequences of critical illness include delirium and long-term cognitive impairments. Defining the extent of their association in intensive care unit cohorts is an important research priority due to the high prevalence of delirium and persistent cognitive impairments in critically ill patients. Future research should focus on strategies for the early identification of delirium and cognitive impairments, elucidating mechanisms of brain injury, and the development and implementation of therapeutic modalities designed to prevent or decrease delirium and cognitive morbidity.

Cognition Disorders↗
PubMed2006

Delirium and its motoric subtypes: a study of 614 critically ill patients.

OBJECTIVES: To describe the motoric subtypes of delirium in critically ill patients and compare patients aged 65 and older with a younger cohort. DESIGN: Prospective cohort study. SETTING: The medical intensive care unit (MICU) of a tertiary care academic medical center. PARTICIPANTS: Six hundred fourteen MICU patients admitted during a process improvement initiative to monitor levels of sedation and delirium. MEASUREMENTS: MICU nursing staff assessed delirium and level of consciousness in all MICU patients at least once per 12-hour shift using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale. Delirium episodes were categorized as hypoactive, hyperactive, and mixed type. RESULTS: Delirium was detected in 112 of 156 (71.8%) subjects aged 65 and older and 263 of 458 (57.4%) subjects younger than 65. Mixed type was most common (54.9%), followed by hypoactive delirium (43.5%) and purely hyperactive delirium (1.6%). Patients aged 65 and older experienced hypoactive delirium at a greater rate than younger patients (41.0% vs 21.6%, P<.001) and never experienced hyperactive delirium. Older age was strongly and independently associated with hypoactive delirium (adjusted odds ratio=3.0, 95% confidence interval=1.7-5.3), compared with no delirium in a model that adjusted for other important determinants of delirium including severity of illness, sedative medication use, and ventilation status. CONCLUSION: Older age is a strong predictor of hypoactive delirium in MICU patients, and this motoric subtype of delirium may be missed in the absence of active monitoring.

Age Factors↗
PubMed2006

Long-term neurocognitive function after critical illness.

BACKGROUND: Until relatively recently, critical care practitioners have focused on the survival of their patients and not on long-term outcomes. The incidence of chronic neurocognitive dysfunction has been underestimated and underreported, and only recently has it been studied in critically ill patients. However, neurocognitive outcomes have been the subject of extensive investigation in other medical populations for many years. METHODS: Review of the current literature regarding long-term neurocognitive outcomes following critical illness. RESULTS: Data from studies to date indicate that critical illness can lead to significant neurocognitive impairments. The neurocognitive impairments persist for months and years, and may have important consequences for quality of life, the ability to return to work, overall functional ability, and substantial economic costs. The mechanisms of the neurocognitive impairments are not fully understood but likely include delirium, hypoxia, glucose dysregulation, metabolic derangements, inflammation, and the effects of sedatives and narcotics among other factors. The contributions of these factors may be particularly significant in patients with preexisting vulnerabilities for the development of cognitive impairments such as mild cognitive impairment, dementia, prior traumatic brain injury, or other comorbid disorders associated with neurocognitive impairments. CONCLUSIONS: Current research indicates that neurocognitive sequelae following critical illness are common, may be permanent, and are associated with impairments in daily function, decreased quality of life, and an inability to return to work. Research needs to be done to better understand the prevalence, nature, risk factors, and nuances of the neurocognitive impairments observed in ICU survivors.

Central Nervous System↗
PubMed2005

Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients.

INTRODUCTION: Delirium occurs in most ventilated patients and is independently associated with more deaths, longer stay, and higher cost. Guidelines recommend monitoring of delirium in all intensive care unit (ICU) patients, though few data exist in non-ventilated patients. The study objective was to determine the relationship between delirium and outcomes among non-ventilated ICU patients. METHOD: A prospective cohort investigation of 261 consecutively admitted medical ICU patients not requiring invasive mechanical ventilation during hospitalization at a tertiary-care, university-based hospital between February 2002 and January 2003. ICU nursing staff assessed delirium and level of consciousness at least twice per day using the Confusion Assessment Method for the ICU (CAM-ICU) and Richmond Agitation-Sedation Scale (RASS). Cox regression with time-varying covariates was used to determine the independent relationship between delirium and clinical outcomes. RESULTS: Of 261 patients, 125 (48%) experienced at least one episode of delirium. Patients who experienced delirium were older (mean +/- SD: 56 +/- 18 versus 49 +/- 17 years; p = 0.002) and more severely ill as measured by Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (median 15, interquartile range (IQR) 10-21 versus 11, IQR 6-16; p < 0.001) compared to their non-delirious counterparts. Patients who experienced delirium had a 29% greater risk of remaining in the ICU on any given day (compared to patients who never developed delirium) even after adjusting for age, gender, race, Charlson co-morbidity score, APACHE II score, and coma (hazard ratio (HR) 1.29; 95% confidence interval (CI) 0.98-1.69, p = 0.07). Similarly, patients who experienced delirium had a 41% greater risk of remaining in the hospital after adjusting for the same covariates (HR 1.41; 95% CI 1.05-1.89, p = 0.023). Hospital mortality was higher among patients who developed delirium (24/125, 19%) versus patients who never developed delirium (8/135, 6%), p = 0.002; however, time to in-hospital death was not significant the adjusted (HR 1.27; 95% CI 0.55-2.98, p = 0.58). CONCLUSION: Delirium occurred in nearly half of the non-ventilated ICU patients in this cohort. Even after adjustment for relevant covariates, delirium was found to be an independent predictor of longer hospital stay.

Cohort Studies↗
PubMed2005

Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers.

OBJECTIVE: To implement sedation and delirium monitoring via a process-improvement project in accordance with Society of Critical Care Medicine guidelines and to evaluate the challenges of modifying intensive care unit (ICU) organizational practice styles. DESIGN: Prospective observational cohort study. SETTING: The medical ICUs at two institutions: the Vanderbilt University Medical Center (VUMC) and a community Veterans Affairs hospital (York-VA). SUBJECTS: Seven hundred eleven patients admitted to the medical ICUs for >24 hrs and followed over 4,163 days during a 21-month study period. INTERVENTIONS: Unit-wide nursing documentation was changed to accommodate a sedation scale (Richmond Agitation-Sedation Scale) and delirium instrument (Confusion Assessment Method for the ICU). A 20-min introductory in-service was performed for all ICU nurses, followed by graded, staged educational interventions at regular intervals. Data were collected daily for compliance, and randomly 40% of nurses each day were chosen for accuracy spot-checks by reference raters. An implementation survey questionnaire was distributed at 6 months. MEASUREMENTS AND MAIN RESULTS: The implementation project involved 64 nurses (40 at VUMC and 24 at York-VA). Sedation and delirium monitoring data were recorded for 711 patients (614 at VUMC and 97 at York-VA). Compliance with the Richmond Agitation-Sedation Scale was 94.4% (21,931 of 23,220) at VUMC and 99.7% (5,387 of 5,403) at York-VA. Compliance with the Confusion Assessment Method for the ICU was 90% (7,323 of 8,166) at VUMC and 84% (1,571 of 1,871) at York-VA. The Confusion Assessment Method for the ICU was performed more often than requested on 63% of shifts (5,146 of 8,166) at VUMC and on 8% (151 of 1871) of shifts at York-VA. Overall weighted-kappa between bedside nurses and references raters for the Richmond Agitation-Sedation Scale were 0.89 (95% confidence interval, 0.88 to 0.92) at VUMC and 0.77 (95% confidence interval, 0.72 to 0.83) at York-VA. Overall agreement (kappa) between bedside nurses and reference raters using the Confusion Assessment Method for the ICU was 0.92 (95% confidence interval, 0.90-0.94) at VUMC and 0.75 (95% confidence interval, 0.68-0.81) at York-VA. The two most-often-cited barriers to implementation were physician buy-in and time. CONCLUSIONS: With minimal training, the compliance of bedside nurses using sedation and delirium instruments was excellent. Agreement of data from bedside nurses and a reference-standard rater was very high for both the sedation scale and the delirium assessment over the duration of this process-improvement project.

Adult↗
PubMed2004

Clinical identification of cognitive impairment in ICU survivors: insights for intensivists.

BACKGROUND: A growing body of research has demonstrated the presence of ongoing cognitive impairment in large numbers of ICU survivors. OBJECTIVE: This review offers a practical framework for practicing intensivists and those following patients after their ICU stay for the identification of cognitive impairment in ICU survivors. CONCLUSIONS: Early detection of cognitive impairment in critically ill patients is an important and achievable goal, but overt cognitive impairment remains unrecognized in most cases. However, it can be identified by objective (test scores) or subjective evidence (clinical judgment, patient observation, family interaction).

Cognition Disorders↗
PubMed2004

Research issues in the evaluation of cognitive impairment in intensive care unit survivors.

Neuropsychological assessment has been utilized extensively in the research of cognitive outcomes associated with medical illnesses, such as HIV, and post-surgical procedures, such as coronary artery bypass graft. However, few investigations of intensive care unit (ICU) survivors have examined cognitive function as a clinical outcome. Significant clinical questions exist regarding the impact of critical illness on long-term cognitive function. Many of these questions can be systematically evaluated through the use of standardized neuropsychological assessment instruments within the context of well designed, prospective research trials. This review will provide information for clinical researchers interested in the study of neuropsychological outcomes in intensive care unit survivors ( a comparison article in this issue will address clinical issues related to cognitive functioning).

Cognition Disorders↗
PubMed2004

The association between delirium and cognitive decline: a review of the empirical literature.

Delirium is a common neurobehavioral syndrome that occurs across health care settings which is associated with adverse outcomes, including death. There are limited data on long-term cognitive outcomes following delirium. This report reviews the literature regarding relationships between delirium and cognitive impairment. Psych Info and Medline searches and investigation of secondary references for all English language articles on delirium and subsequent cognitive impairment were carried out. Nine papers met inclusion criteria and documented cognitive impairment in patients following delirium. Four papers reported greater cognitive impairment among patients with delirium than matched controls. Four papers reported higher incidence of dementia in patients with a history of delirium. One study found 1 of 3 survivors of critical illness with delirium developed cognitive impairment. The evidence suggests a relationship between delirium and cognitive impairment, although significant questions remain regarding the nature of this association. Additional research on delirium-related effects on long-term cognitive outcome is needed.

Adult↗
PubMed2004

Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals.

OBJECTIVE: Recently published clinical practice guidelines of the Society of Critical Care Medicine recommend monitoring for the presence of delirium in all mechanically ventilated patients because of the potential for adverse outcomes associated with this comorbidity, yet little is known about healthcare professionals' opinions regarding intensive care unit delirium or how they manage this organ dysfunction. The aim of this survey was to assess the medical community's beliefs and practices regarding delirium in the intensive care unit. DESIGN: Survey administration was conducted both without a delirium definition (phase 1) and then with a definition of delirium (phase 2). SETTING: Critical care meetings and continuing medical education/board review courses from October 2001 to July 2002. PARTICIPANTS: A convenience sample of physicians (n = 753), nurses (n = 113), pharmacists (n = 13), physician assistants (n = 12), respiratory care practitioners (n = 8), and others (n = 13). INTERVENTIONS: Survey. MEASUREMENTS AND MAIN RESULTS: Participants completed 912 of the surveys. The majority (68%) of respondents thought that >25% of adult mechanically ventilated patients experience delirium. Delirium was considered a significant or very serious problem in the intensive care unit by 92% of healthcare professionals, yet underdiagnosis was acknowledged by 78%. Only 40% reported routinely screening for delirium, and only 16% indicated using a specific tool for delirium assessment. Delirium was considered important in the outcome of elderly and young patients by 89% and 60% of the respondents, respectively (p <.0001). The most serious complications these professionals associated with delirium were prolonged mechanical ventilation, self-injury, and respiratory difficulties. Delirium was treated with haloperidol by 66% of the respondents, with lorazepam by 12%, and with atypical antipsychotics by <5%. More than 55% administered haloperidol and lorazepam at daily doses of < or =10 mg, but some used >50 mg/day of either medication. CONCLUSIONS: Most healthcare professionals consider delirium in the intensive care unit a common and serious problem, although few actually monitor for this condition and most admit that it is underdiagnosed. Data from this survey point to a disconnect between the perceived significance of delirium in the intensive care unit and current practices of monitoring and treatment.

Aged↗
PubMed2003

Six-month neuropsychological outcome of medical intensive care unit patients.

OBJECTIVE: To examine neuropsychological function, depression, and quality of life 6 months after discharge in patients who received mechanical ventilation in the intensive care unit. DESIGN: Prospective cohort study. SETTING: Tertiary care, medical and coronary intensive care unit of a university-based medical center. STUDY POPULATION: A total of 275 consecutive, mechanically ventilated patients from a medical intensive care unit were prospectively followed. At 6 months, 157 were alive, of whom 41 (26%) returned for extensive follow-up testing. MEASUREMENT AND MAIN RESULTS: Neuropsychological testing and assessment of depression and quality of life were performed at 6-month follow-up. Seven of 41 patients were excluded from further analysis due to preexisting cognitive impairment determined via surrogate interviews using the Modified Blessed Dementia Rating Scale and a review of medical records. On the basis of strict criteria derived from normative data, we found that 11 of 34 patients (32%) were neuropsychologically impaired. Impairment was generally diffuse but occurred primarily in areas of psychomotor speed, visual and working memory, verbal fluency, and visuo-construction. The rate of neuropsychological deficits in the study population was markedly higher than population norms for mild dementia. Scores on the Geriatric Depression Scale-Short Form were significantly more abnormal in the neuropsychologically impaired group than in the nonimpaired group at hospital discharge (p =.04) and at 6-month follow-up (p =.02), and clinically significant depression was found in 27% of impaired subjects at hospital discharge and in 36% at 6-month follow-up. No differences were observed between groups in quality of life as measured with the Short Form Health Survey-12 at discharge or 6-month follow-up. CONCLUSIONS: Prolonged neuropsychological impairment is common among survivors of the medical intensive care unit and occurs with greater than anticipated frequency when compared with relevant normative data. Future investigations are warranted to elucidate the nature of the association between critical illness, neuropsychological impairment, depression, and decreased quality of life.

APACHE↗