Preoperative Vitamin D Level is Associated with Postoperative Delirium After Cardiac Surgery in Patients Over 65 Years of Age
Keywords:Delirium, Vitamin D, Open Heart Surgery
Introduction: Delirium after cardiac surgery is a devastating and important complication. Delirium is defined as “disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).” In this study, we analyzed the association of preoperative vitamin D levels and postoperative delirium after cardiac surgery in patients over 65 years.
Materials and methods: We retrospectively reviewed the data of 212 adult patients above 65 years of age who underwent isolated coronary artery bypass graft surgery from
January 2016 to January 2018. The mean age for Group I was 69.7 ± 7.4 and Group II was 70.6 ± 4.8 years. There were 112 female patients in Group I and 46 female patients in Group II. The patient population was divided into 2 groups based on preoperative serum vitamin D (25-hydroxyvitamin D [25-OHD]) levels (normal range of 25-75nmol/L). Group I included patients with preoperative serum 25-OHD level<25nmol/L. Group II included patients with preoperative serum 25-OHD level ≥25nmol/L.
Results: The incidence of delirium in this study was 30.2%. In this study, 138 patients (65.1%) had preoperative serum 25-OHD levels <25 nmol/L, and 74 patients (34.9%) had preoperative serum 25-OHD levels ≥25 nmol/L.
Preoperative serum 25-OHD levels were associated with postoperative delirium after coronary artery bypass graft surgery. Our retrospective study illustrated that a lower preoperative serum level of 25-OHD was associated with postoperative delirium. Our results showed that 65.1% of patients had preoperative serum 25-OHD levels <25 nmol/L, and this was associated with postoperative delirium.
Conclusion: Vitamin D deficiency exacerbates delirium after coronary artery bypass surgery with cardiopulmonary bypass. Whether the effects of vitamin D deficiency during this event represent separate or interrelated activities with cardiopulmonary bypass is an important question to address and prospective randomized studies are necessary to confirm these results.
American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. 2015. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg 220:136-148.
Annweiler C, Allali G, Allain P, et al. 2009. Vitamin D and cognitive performance in adults: a systematic review. Eur J Neurol. 16:1083–1089.
Bakker RC, Osse RJ, Tulen JH, et al. 2012. Preoperative and operative predictors of delirium after cardiac surgery in elderly patients. Eur J Cardiothorac Surg 41:544-549.
Balion C, Griffith LE, Strifler L, et al. 2012. Vitamin D, cognition, and dementia: a systematic review and meta-analysis. Neurology. 79:1397–1405.
Bokeriia LA, Golukhova EZ, Poluninia AG. 2009. Postoperative delirium in cardiac operations: Microembolic load is an important factor. Ann Thorac Surg 88: 348-354.
Borgermann J, Lazouski K, Kuhn J, Dreier J, Schmidt M, Gilis-Januszewski T, et al. 2012. 1,25-dihydroxy vitamin D fluctuations in cardiac surgery are related to age and clinical outcome. Crit Care Med 40(7):2073e81.
Bowman K, Jones L, Pilling LC, Delgado J, Kuchel GA, Ferrucci L, Fortinsky RH, Melzer D. 2019. Vitamin D levels and risk of delirium: A mendelian randomization study in the UK Biobank. Neurology 92(12): e1387-e1394.
Braun LA, Spitzer O, Levkovich B, Bailey M, Stanguts C, Hose L, Rosenfeldt F. 2014. Prevalence of vitamin D deficiency prior to cardiothoracic surgery. Heart Lung Circ 23(10):978-80.
Cropsey C, Kennedy J, Han J, Pandharipande P. 2015. Cognitive Dysfunction, Delirium, and Stroke in Cardiac Surgery Patients. Semin Cardiothorac Vasc Anesth 19:309-17.
Demirdas E, Atilgan K. 2019. Addition of Vitamin B Complex to Prime Solution in Cobalamin-Deficient Patients to Prevent Postoperative Delirium. Heart Surg Forum. 25;22(2): E082-E087.
Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus R. 2001. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 286:2703-10.
European Delirium Association and American Delirium Society. 2014. The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer. BMC Medicine 12:141.
Ford J, Hategan A, Bourgeois JA, Tisi DK, Xiong GL. 2013. Hypovitaminosis D in delirium: a retrospective cross-sectional study. Can Geriatr J 16:186-91.
Glade MJ. 2012. A 21st-century evaluation of the safety of oral vitamin D. Nutrition. 28:344–356.
Gosselt AN, Slooter AJ, Boere PR, Zaal IJ. 2015. Risk factors for delirium after on-pump cardiac surgery: a systematic review. Crit Care 19:346.
Grover S, Kate N. 2012. Assessment scales for delirium: A review. World J Psychiatr 2:58-70.
Hilger J, Friedel A, Herr R, et al. 2014. Br. J. Nutr. 111, 23–45; Palacios C, Gonzalez L, 2014. J. Steroid Biochem. Mol. Biol. 144, 138–145.
Ibi M, Sawada H, Nakanishi M, et al. 2001. Protective effects of 1 alpha,25-(OH)2D3 against the neurotoxicity of glutamate and reactive oxygen species in mesencephalic culture. Neuropharmacol 40(6):761–71.
Järvelä K, Porkkala H, Karlsson S, Martikainen T, Selander T, Bendel S. 2018. Postoperative Delirium in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 32:1597-1602.
Lin Y, Chen J, Wang Z. 2012. Meta-analysis of factors which influence delirium following cardiac surgery. J Card Surg 27:481-492.
Lundström M, Edlund A, Karlsson S, et al. 2005. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc 53: 622-628.
Mangusan RF, Hooper V, Denslow SA, Travis L. 2015. Outcomes associated with postoperative delirium after cardiac surgery. Am J Crit Care 24:156–63.
McCann JC, Ames BN. 2008. Is there convincing biological or behavioral evidence linking vitamin D deficiency to brain dysfunction? FASEB J. 22:982–1001.
Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, et al. 2004. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 32:955–62.
Norkiene I, Ringaitiene D, Kuzminskaite V, Sipylaite J. 2013. Incidence and risk factors of early delirium after cardiac surgery. Biomed Res Int 323491.
Quraishi SA, Litonjua AA, Elias KM, Gibbons FK, Giovannucci E, Camargo CA Jr, Christopher KB. 2015. Association between prehospital vitamin D status and hospital-acquired new-onset delirium. Br J Nutr. 113(11):1753-60.
Roth DE, Abrams SA, Aloia J, Bergeron G, Bourassa MW, Brown KH, Calvo MS, Cashman KD, Combs G, De-Regil LM, Jefferds ME, Jones KS, Kapner H, Martineau AR, Neufeld LM, Schleicher RL, Thacher TD, Whiting SJ. 2018. Global prevalence and disease burden of vitamin D deficiency: a roadmap for action in low- and middle-income countries.Ann N Y Acad Sci 1430(1):44-79.
Zapatero A, Dot I, Diaz Y, Gracia MP, Pérez-Terán P, Climent C, et al. 2018. La hipovitaminosis D grave al ingreso en el paciente crítico se asocia a fracaso renal agudo y mal pronóstico. Med Intensiva 42:216-224.
Zhang Z, Pan L, and Ni H. 2013. Impact of delirium on clinical outcome in critically ill patients: a meta-analysis. General Hospital Psychiatry vol. 35, pp. 105–111.
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).