Diabetes Mellitus Increases Adverse Neurocognitive Outcome after Coronary Artery Bypass Grafting Surgery

Abstract

Background: Cognitive dysfunction is a well known problem in the postoperative period in cardiac surgery. We hypothesised that the incidence of postoperative cognitive dysfunction in patients with diabetes mellitus is higher than in the nondiabetic patient. Methods: Thirty-four patients (11 females, 23 males) with a mean age of 62.44 ± 7.52 undergoing on-pump CABG surgery were studied in a prospective manner. Fourteen patients had treated diabetes mellitus (Group I) and 20 were nondiabetic (Group II). All patients were operated upon by the same surgeon under standardised intra- and perioperative conditions. Patients with preoperative dementia (MMSE < 24) or advanced cerebrovascular disease were excluded. An extensive set of tests examining emotional and cognitive state, stress-coping and quality of life were performed preoperatively. Emotional and cognitive variables were assessed daily from day two to five postoperatively. Results: All tests showed comparable results between the groups preoperatively. The perfusion lasted considerably longer in Group I (102.5 ± 16.61 vs. 83.9 ± 14.1 min) as did the cross clamping (64.21 ± 18.31 vs. 51.75 ± 10.88 min). Postoperative cognitive outcome was significantly worse in Group I with regard to the Stroop Test (29.46 ± 8.6 vs. 24.01 ± 6.23, p = 0.02), the Abbreviated Mental Test (8.04 ± 0.71 vs. 8.68 ± 0.78, p = 0.02) and the Trial Making Test (35.72 ± 11.38 vs. 29.3 ± 7.77 p = 0.04). These differences persisted even after adjustment for perfusion- and cross-clamping time. Conclusion: The cognitive outcome in the early postoperative period is worse in diabetic patients compared to nondiabetics. Speed-related cognitive functions are mainly affected. Probably, this reflects a different physiology of cerebral perfusion during extracorporeal circulation. Optimising perfusion strategies to improve the outcome of diabetic patients should be the next topic of study.

Coronary bypass surgery complications - postoperative delirium - diabetes mellitus

References

• 1 Dyer C, Ashton C, Teasdale T. Postoperative delirium. A review of 80 primary data-collection studies.  Arch Intern Med. 1995;  155 461-465
• 2 Murkin J. The role of CPB management in neurobehavioral outcomes after cardiac surgery.  Ann Thorac Surg. 1995;  59 1308-1311
• 3 Croughwell N, Lyth M, Quill T, Newman M, Greeley W, Smith L, Reves J. Diabetic patients have abnormal cerebral autoregulation during cardiopulmonary bypass.  Circul. 1990;  82 (Suppl IV) 407-412
• 4 Biondi-Zoccai G, Abbate A, Liuzzo G, Biasucci L. Atherothrombosis, inflammation, and diabetes.  J Am Coll Cardiol. 2003;  41 1071-1077
• 5 Moreno P, Murcia A, Palacios I, Leon M, Bernardi V, Fuster V, Fallon J. Coronary composition and macrophage infiltration in atherectomy specimens from patients with diabetes mellitus.  Circul. 2000;  102 2180-2184
• 6 Cerizza M, Minciotti G, Meregalli S, Garosi V, Crosti P, Frattola L. Central nervous system involvement in elderly patients with non-insulin-dependent diabetes mellitus.  Acta Diabetol Lat. 1990;  27 343-348
• 7 Helkala E, Koivisto K, Hanninen T, Vanhanen M, Kervinen K, Kuusisto J, Mykkanen L, Kesaniemi Y, Laakso M, Riekkinen Sr P. Memory functions in human subjects with different apolipoprotein E phenotypes during a 3-year population-based follow-up study.  Neurosci Lett. 1996;  204 177-180
• 8 Worrall G, Moulton N, Briffett E. Effect of type II diabetes mellitus on cognitive function.  J Fam Pract. 1993;  36 639-643
• 9 Mattlar C, Falck B, Ronnemaa T, Hyyppa M. Neuropsychological cognitive performance of patients with type-2 diabetes.  Scand J Rehabil Med. 1985;  17 101-105
• 10 Robertson-Tchabo E, Arenberg D, Tobin J, Plotz J. A longitudinal study of cognitive performance in noninsulin dependent (type II) diabetic men.  Exp Gerontol. 1986;  21 459-467
• 11 Folstein M, Folstein S, McHugh P. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.  J Psychiatr Res. 1975;  12 189-198
• 12 Buckberg G. Development of blood cardioplegia and retrograde techniques: the experimenter/observer complex.  J Card Surg. 1998;  13 163-170
• 13 Murkin J, Newman S, Stump D, Blumenthal J. Statement of consensus on assessment of neurobehavioral outcomes after cardiac surgery.  Ann Thorac Surg. 1995;  59 1289-1295
• 14 Hueppe M, Uhlig T, Vogelsang H, Schmucker P. Personality traits, coping styles, and mood in patients awaiting lumbar-disc surgery.  J Clin Psychol. 2000;  56 119-130
• 15 Bullinger M. German translation and psychometric testing of the SF‐36 Health Survey: preliminary results from the IQOLA Project. International Quality of Life Assessment.  Soc Sci Med. 1995;  41 1359-1366
• 16 Derogatis L. Die Symptom-Checkliste (SCL‐90-R). Göttingen; Hogrefe 2002
• 17 Oswald W, Fleischmann U. Nürnberger-Alters-Inventar (NAI). 3rd ed. Göttingen; Hogrefe 1995
• 18 Hüppe M, Schmidt-Atzert L. Leistungsbeeinflussung durch Aktivierung im Alter.  Z Exp Psychol. 1996;  43 69-84
• 19 Stroop J. Studies of interference in serial verbal reactions.  J Exp Psychol. 1935;  18 643-662
• 20 Hodkinson H. Evaluation of a mental test score for assessment of mental impairment in the elderly.  Age Ageing. 1972;  1 233-238
• 21 Jitapunkul S, Pillay I, Ebrahim S. The abbreviated mental test: its use and validity.  Age Ageing. 1991;  20 332-336
• 22 Ni Chonchubhair A, Valacio R, Kelly J, O'Keefe S. Use of the abbreviated mental test to detect postoperative delirium in elderly people.  Br J Anaesth. 1995;  75 481-482
• 23 Cohen J. Statistical Power Analysis for Behavioral Sciences. Hillsdale; Erlbaum 1988
• 24 Abt K. Descriptive data analysis: a concept between confirmatory and exploratory data analysis.  Methods Inf Med. 1987;  26 77-88
• 25 Derogatis L R. SCL‐90-R, Administration, Scoring and Procedures Manual-II for the Revised Version and Other Instruments of the Psychopathology Rating Scale Series. Towson; Clinical Psychometric Resarch Inc. 1992
• 26 Perlmuter L, Hakami M, Hodgson-Harrington C, Ginsberg J, Katz J, Singer D, Nathan D. Decreased cognitive function in aging non-insulin-dependent diabetic patients.  Am J Med. 1984;  77 1043-1048
• 27 Mooradian A, Perryman K, Fitten J, Kavonian G, Morley J. Cortical function in elderly non-insulin dependent diabetic patients. Behavioral and electrophysiologic studies.  Arch Intern Med. 1988;  148 2369-2372
• 28 Strachan M, Deary I, Ewing F, Frier B. Is type II diabetes associated with an increased risk of cognitive dysfunction? A critical review of published studies.  Diabetes Care. 1997;  20 438-445
• 29 Salomon N, Page U, Okies J, Stephens J, Krause A, Bigelow J. Diabetes mellitus and coronary artery bypass. Short-term risk and long-term prognosis.  J Thorac Cardiovasc Surg. 1983;  85 264-271
• 30 Resnick L, Gupta R, Barbagallo M, Laragh J. Is the higher incidence of ischemic disease in patients with hypertension and diabetes related to intracellular depletion of high energy metabolites?.  Am J Med Sci. 1994;  307 (Suppl 1) S66-S69
• 31 Caplan L R, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke.  Arch Neurol. 1998;  55 1475-1482