J Neuropsychiatry Clin Neurosci. 2015 Winter;27(1):69-71. doi: 10.1176/appi.neuropsych.13060121.

Delirium and hypovitaminosis D: neuroimaging findings.

Bourgeois JA1, Hategan A, Ford J, Tisi DK, Xiong GL.
  • 1From the Dept. of Psychiatry/Langley Porter Psychiatric Institute, Consultation-Liaison Service, University of California San Francisco Medical Center, San Francisco, CA (JAB); Dept. of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada (AH, JF); St. Joseph’s Healthcare Hamilton, West 5th Campus, Hamilton, Ontario, Canada (AH, DKT); and Dept. of Psychiatry and Behavioral Sciences, University of California, Davis, CA (GLX).

 

Abstract

The authors examined the frequency of neuroimaging findings of cortical atrophy and/or cerebrovascular disease in patients with delirium with hypovitaminosis D and normal vitamin D levels. Of 32 patients with delirium with hypovitaminosis D who were neuroimaged, 91.4% had neuroimaging findings, despite only five cases having a comorbid diagnosis of dementia. Similar frequencies of cortical atrophy and/or cerebrovascular disease were found in patients with delirium with normal vitamin D levels. Further research with a larger sample size is needed to compare neuroimaging findings between normal patients and patients with hypovitaminosis D with delirium.

PMID: 25111282

 

Supplement

Delirium and major/mild neurocognitive disorder (NCD)/dementia are the most important psychiatric illnesses in medically ill, especially older, patients.  NCD/dementia is well understood as the most important psychiatric illness rendering the patient vulnerable to the subsequent development of episodic delirium when experiencing an acute systemic medical illness or drug toxicity/withdrawal state, and/or post-surgically.  NCD/dementia is associated with both structural (e.g., cortical and subcortical atrophy, white matter disease) and functional (e.g., effective decrease in function of cholinergic neural pathways) deficits that confer greater risk for acute delirium, a concept understood as “the vulnerable brain” or “delirium proneness.”

 

As delirium is a major public health problem and an independent risk factor for accelerated functional decline, increased morbidity/mortality, and institutional placement for individual patients, current research endeavors are addressing identifiable systemic risk factors for delirium.  This is especially important if readily ascertained clinical risk factors for delirium lead to opportunities for clinical intervention, which may offer the opportunity to mitigate delirium risk and (inferentially) improve clinical outcomes. There is a similar imperative to look for identifiable and potentially remediable systemic medical conditions in dementia as well.  More broadly, the evaluation and management of other psychiatric illnesses leads one to seek systemic medical risk factors that may be associated. This point of reference led our group to examine the possible role for vitamin D deficiency states in other psychiatric illness more broadly defined, and delirium in particular.

 

In our group’s first paper on vitamin D status and psychiatric illness, 25-hydroxyvitamin D (25-OHD) samples were obtained from nine consecutive geriatric psychiatric inpatients. All subjects showed vitamin D insufficiency (25-OHD ≤ 75 nmol/L) (1). In our group’s second paper, we completed a retrospective cross-sectional analysis of hospitalized patients with a diagnosis of delirium. Seventy-one (5.8%) out of 1,232 delirium inpatients had vitamin D levels obtained. Thirty-nine of these patients (55%) had vitamin D insufficiency (25-OHD of 25-75 nmol/L), while 8 (11%) showed vitamin D deficiency (25-OHD < 25 nmol/L), suggesting that vitamin D deficiency may be associated with delirium, even if vitamin D levels were rarely obtained as part of delirium evaluations (2).

 

In the current study, of the 51 delirium patients with all the characteristics to allow for statistical analysis, 35 (68%) had decreased vitamin D levels. Though this is a small sample size, this finding suggests that vitamin D deficiency may be relatively common in delirium cases, and is consistent with our prior work on vitamin D and delirium (2).  This suggests that physicians consider ascertainment of vitamin D status as part of delirium workups; whether vitamin D supplementation in such cases modifies the course of delirium remains unknown and would require a prospective design intervention study.

 

Also notable in the current study, despite the small sample sizes, was the very high rate of positive neuroimaging findings among the hypovitaminosis D group (91%), despite a small percentage (16%) that had an established diagnosis of dementia premorbidly.  Similar results were seen (not statistically significantly different from the hypovitaminosis group) for the normal range vitamin D group. Therefore, the hypovitaminosis D condition among delirium patients did not per se discriminate regarding the likelihood of neuroimaging findings.  The main neuroimaging finding therefore is that, among delirium patients, positive neuroimaging was far more common than an established diagnosis of NCD/dementia (a well-appreciated risk factor for delirium).

 

Inferentially, the positive neuroimaging findings in the majority of these patients may serve as a marker for “delirium proneness” and could thus lead to an eventual diagnosis of NCD/dementia after evaluation for/management of delirium.  This further argues for a practice, particularly in the elderly, for routine noncontrast CT head in all delirium cases, with positive results being consistent with risk for dementia as well as plausibly contributing to delirium.  Imaging evidence of “the vulnerable brain” or “delirium proneness” may further guide the clinician towards greater caution in medical management after recovery from delirium, to include assiduous attention to vascular disease management, regular cognitive examination, trials of cholinesterase inhibitors, close monitoring of reversible metabolic risk factors for cognitive impairment (e.g., hypothyroidism, B12 deficiency, perhaps vitamin D deficiency states) and avoidance of cognitively toxic medication (e.g., anticholinergics, opioids, benzodiazepines, other sedatives) with continued clinical surveillance for recurrence of delirium.

 

References

  1. Ford J, Hategan A, Bourgeois JA, Tisi DK: Hypovitaminosis D: a contributor to psychiatric disorders in elderly? Canadian Geriatrics Journal 2012; 15:80-84.
  2. Ford J, Hategan A, Bourgeois JA, Tisi DK, Xiong GL: Hypovitaminosis D in delirium: a retrospective cross-sectional study. Canadian Geriatrics Journal 2013; 16:186-191.

 

 

 

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