Delirium is a manifestation of acute brain dysfunction that occurs in up to 80% of patients who are critically ill and is associated with higher mortality and long-term cognitive impairment (LTCI), which is akin to a dementia-like cognitive disability. [1][2][3][4][5][6][7] This acquired cognitive impairment-critical illness brain injury-has important public health implications for both younger and older patients (the latter an increasingly larger proportion of the population), threatening the functional independence and quality of life of millions of ICU survivors in the coming decades. Given that delirium in the ICU represents early brain dysfunction during critical illness and can be easily assessed using validated bedside instruments, 1,8 novel therapies that prevent or treat delirium may prevent its associated immediate and long-term sequelae.Findings from animal and human studies suggest a neuroinfl ammatory pathogenesis of delirium and longterm brain dysfunction associated with critical illness. We propose a testable hypothesis, based on existing data, that the pleiotropic effects of statin medications can mitigate the mechanisms of delirium and LTCI associated with critical illness. Specifi cally, that statins may modify two processes leading to brain injury: neuroinfl ammation and activation of proinfl ammatory microglia.
Effects on Neuroinflammation During Critical IllnessAn intense systemic infl ammatory response to illness or injury is a key mediator of organ dysfunction during critical illness. Several conditions that often lead to an ICU admission are examples of the deleterious effects of systemic infl ammation (eg, severe sepsis, trauma, acute respiratory distress syndrome).
Proinfl ammatory cytokines (eg, tumor necrosis factor [TNF]-a and IL-1 b ) and chemokines (eg, monocytic chemoattractant protein [MCP]-1) activate leukocytes and endothelial cells (which express leukocyteDelirium is a frequent form of acute brain dysfunction in patients who are critically ill and is associated with poor clinical outcomes, including a critical illness brain injury that may last for months to years. Despite widespread recognition of signifi cant adverse outcomes, pharmacologic approaches to prevent or treat delirium during critical illness remain unproven. We hypothesize that commonly prescribed statin medications may prevent and treat delirium by targeting molecular pathways of infl ammation (peripheral and central) and microglial activation that are central to the pathogenesis of delirium. Systemic infl ammation, a principal mechanism of injury, for example, in sepsis, acute respiratory distress syndrome, and other critical illnesses, can cause neuronal apoptosis, blood-brain barrier injury, brain ischemia, and microglial activation. We hypothesize that the known pleiotropic effects of statins, which attenuate such neuroinfl ammation, may redirect microglial activation and promote an antiinfl ammatory phenotype, thereby offering the potential to reduce the public health burden of delirium and its associated l...