Dr Amanda Barugh BSc (Hons), MBChB, MRCP(UK) Delirium and long-term cognitive impairment after stroke: the role of dysregulation of the hypothalamic-pituitary-adrenal axis Dr Amanda Barugh BSc (Hons), MBChB, MRCP(UK) Clinical Research Fellow and Honorary Geriatric and General (Internal) Medicine Registrar

Delirium after stroke COMMON: 20 - 40% of patients SEVERE: mortality, dependency, length of hospital stay DISTRESSING NO TREATMENTS: major unmet medical need KNOWLEDGE GAPS: mechanisms, outcomes

A role for excess cortisol? Stressor homeostasis restored cortisol cortisol L normal feedback Normal stress response cortisol delirium sustainedcortisol Stressor abnormal feedback Dysregulated stress response

Sustained high cortisol after acute stroke is associated with delirium A role for excess cortisol? Stressor homeostasis restored cortisol cortisol L normal feedback Normal stress response cortisol delirium sustainedcortisol Stressor abnormal feedback Dysregulated stress response Hypothesis Sustained high cortisol after acute stroke is associated with delirium

Main research questions Is cortisol after stroke associated with delirium? Does cortisol after stroke predict long-term cognitive decline? Does delirium after stroke predict long-term cognitive decline?

Recruit 120 participants from Methodology Cognitive testing Salivary cortisol Screen for delirium Recruit 120 participants from acute stroke unit. (days 3, 28) Days 3,5,7,14,21,28 Months 4 and 12

Screening for delirium Confusion assessment method – intensive care unit (CAM-ICU) Delirium rating scale -revised-98 (DRS-R-98) Observational scale of level of alertness (OSLA) Edinburgh delirium test box (mark 2)

Screening for delirium

Cognitive testing At recruitment: Montreal cognitive assessment Digit span forwards and backwards National adult reading test Informant Questionnaire on Cognitive Decline in the Elderly -IQCODE (rated by a relative)

Cognitive testing At follow-up: Montreal cognitive assessment Digit span forwards and backwards (working memory) List learning (verbal learning) Verbal fluency (executive function) Visual reproduction (visuospatial memory) Victoria stroop (cognitive flexibility) Digit symbol substitution test (attention and processing)

Progress Recruitment commenced 15th October 2012 25 participants recruited to date Delirium rates approximately 25% Salivary cortisol samples await analysis…..

Acknowledgements

Acknowledgements Professor Gillian Mead Professor Alasdair MacLullich Dr Susan Shenkin Professor John Starr