Cognitive functioning, mental health, and quality of life in ICU survivors: an overview

Quality of life in ICU survivors and their relatives with post-intensive care syndrome: A systematic review

BACKGROUND

Post-intensive care syndrome (PICS) is characterized by all three adverse survivorship dimensions: physical function, cognitive function and mental health status.

AIM

This review aimed to describe the quality of life (QoL) of Intensive Care Unit (ICU) survivors with PICS after discharge and of their relatives with Family Post-intensive care syndrome (PICS-F) and to report anxiety, depression and Post-Traumatic Stress Disorders (PTSD) in studies investigating PICS.

STUDY DESIGN

A systematic review was carried out. We searched PubMed, Scopus, Web of Science and the Cumulative Index to Nursing and Allied Health Literature. This review was registered in the PROSPERO database (CRD42022382123).

RESULTS

We included 19 studies of PICS and PICS-F in this systematic review. Fourteen observational studies report the effects of PICS on depression, 12 studies on anxiety and nine on post-traumatic stress disorder and 10 on QoL. Mobility, personal care, usual activities and pain/discomfort in QoL were the domains most affected by PICS. A significant association was demonstrated between a high level of ICU survivors' anxiety and high levels of ICU relatives' burden. Strain-related symptoms and sleep disorders were problems encountered by ICU relatives with PICS-F.

CONCLUSION

PICS and PICS-F were widespread experiences among ICU survivors and their ICU relatives, respectively. The results of this review showed the adverse effects of PICS and PICS-F on QoL.

RELEVANCE TO CLINICAL PRACTICE

PICS and PICS-F strongly impact the rehabilitation process and are measured in terms of health costs, financial stress and potentially preventable readmission.

New-onset mental illness and long-term survival in survivors of critical illness: population-based cohort study in South Korea

BACKGROUND

Critical care unit (CCU) survivors have a high risk of developing mental illness.

AIMS

We aimed to examine the incidence and associated factors of newly developed mental illness among CCU survivors of critical illness. Moreover, we examined the association between newly developed mental illness and 2-year all-cause mortality.

METHOD

All adult patients (≥20 years) who were admitted to the CCU during hospitalisation between 2010 and 2018 and survived for 1 year were defined as CCU survivors and were included in this nationwide population-based cohort study. CCU survivors with a history of mental illness before CCU admission were excluded from the study.

RESULTS

A total of 1 353 722 CCU survivors were included in the analysis; of these, 33 743 survivors (2.5%) had newly developed mental illness within 1 year of CCU admission. Old age, longer CCU stay, hospital admission through the emergency room, increased total cost of hospitalisation, mechanical ventilatory support, extracorporeal membrane oxygenation support and continuous renal replacement therapy were associated with an increased incidence of newly developed mental illness. Moreover, the newly developed mental illness group showed a 2.36-fold higher 2-year all-cause mortality rate than the no mental illness group (hazard ratio: 2.36; 95% CI: 2.30-2.42; P < 0.001).

CONCLUSIONS

In South Korea, 2.5% of CCU survivors had newly developed mental illness within 1 year of CCU admission. Moreover, newly developed mental illness was associated with an increased 2-year all-cause mortality.

Cognitive impairment in critically ill patients and former critically ill patients: A concept analysis

OBJECTIVES

This concept analysis aimed to clarify the meaning of the concept of cognitive impairment in critically ill patients throughout the trajectory of their rehabilitation during and after an intensive care unit admission.

REVIEW METHODS USED

This study used concept analysis based on Rodgers' evolutionary method.

DATA SOURCES

A systematic search was conducted in Cumulative Index to Nursing and Allied Health Literature, Public MEDLINE, and American Psychological Associations PsycINFO. The web was searched for grey literature.

REVIEW METHODS

Overall search terms used were "patients with cognitive impairments" AND "intensive care unit". Literature published between 2008 and 2022 was included and screened by title and abstract using systematic review software. The descriptive analysis focussed on surrogate terms/related concepts, attributes, and contextual basis.

RESULTS

Thirty studies were included, representing variability in study design and country of origin. The analysis uncovered descriptions of the general terminology and the temporal trajectory of the concept, spanning from the acute phase to a long-term perspective. Attributes of the concept were described as delirium and domains of cognition. Antecedents were juxtaposed to risk factors, which were multifactorial. Consequences of cognitive impairment related to patients' quality of life, such as a decline in their ability to function independently, return to work, and manage everyday life. Also, cognitive impairment was identified as a significant public health problem.

CONCLUSION

Cognitive impairment is a complex concept with many surrogate and related terms. Furthermore, the concept is inextricably intertwined with the concepts of delirium and post-intensive care syndrome. Cognitive impairment may manifest as symptoms that can be challenging to identify and assess due to limitations in current screening tools and the absence of a consensus on timing. In relation to assessment and preventive strategies, the findings underline the need to distinguish between acute and long-term cognitive impairment.

REGISTRATION

There is no study registration number.

Mental health up to 12 months following SARS-CoV-2 infection: A prospective cohort study

OBJECTIVE

To investigate to what extent individuals report clinically relevant levels of depression, anxiety, post-traumatic stress disorder (PTSD) symptoms and concentration problems up to 12 months following COVID-19 symptom onset, using validated questionnaires.

METHODS

RECoVERED, a prospective cohort study in Amsterdam, the Netherlands, enrolled both hospitalized and community-dwelling adult participants diagnosed with SARS-CoV-2. Symptoms of depression and anxiety were assessed with the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 1, 3, 6 and 12 months following illness onset. The DSM-V PTSD checklist was administered at month 3 and 9. Concentration problems were assessed using the Checklist Individual Strength concentration subscale at month 1 and 12. Generalized Estimating Equations were used to determine factors related with clinically relevant levels of depression-, anxiety- and PTSD-symptoms and concentration problems over time.

RESULTS

In 303 individuals, the prevalence of clinically relevant symptoms of depression, anxiety and concentration problems was 10.6% (95%CI = 7.2-15.4), 7.0% (95%CI = 4.4-11.2) and 33.6% (95%CI = 27.7-40.1), respectively, twelve months after infection. Nine months after illness onset, 4.2% (95%CI = 2.3-7.7) scored within the clinical range of PTSD. Risk factors for an increased likelihood of reporting mental health problems during follow up included initial severe/critical COVID-19, non-Dutch origin, psychological problems prior to COVID-19 and being infected during the first COVID-19 wave.

CONCLUSION

Our findings highlight that a minority of patients with COVID-19 face clinically relevant symptoms of depression, anxiety or PTSD up to 12 months after infection. The prevalence of concentration problems was high. This study contributes to the identification of specific groups for which support after initial illness is indicated.

PM2.5 can help adjust building's energy consumption

Long- or short-term exposure to air pollution would distort human's cognitive function which has aroused widespread concern in interdisciplinary fields. It furtherly seems rational to assume that air pollution may affect energy use in public buildings. However, the overlooks of the potential impacts of air pollution on energy use would result in substantially higher energy saving cost. By matching the real-time energy consumption of public buildings to indoor and outdoor PM_2.5, we construct a panel containing 193,226 data items. Based on this, we conduct the first preliminary exploration to try to reveal the impact of PM_2.5 on energy use at the building-hourly level. Results show that the increase of energy intensity caused by PM_2.5 is subtle, it indeed exists significantly. When indoor PM_2.5 is 1 μg/m³, the marginal effect is minimum. After indoor PM_2.5 exceeding 1 μg/m³, the marginal effect began to increase and the maximum is 0.3224 when PM_2.5 is 1114 μg/m³. However, given the sorting and contrast effect, the practical relationship between indoor PM_2.5 and energy use is possible inverted-U shaped. Furtherly, we find long term exposure to outdoor PM_2.5 would not make people adapt to air pollution and instead cumulative the impact on energy use. Besides, centralized office could be an economical and feasible measure to achieve energy saving goal. Finally, we propose that it is promising for achieving the synergy between air pollution control and energy consumption reduction.

Optimizing Sleep and Circadian Health in the NeuroICU

Purpose of Review

This article introduces fundamental concepts in circadian biology and the neuroscience of sleep, reviews recent studies characterizing circadian rhythm and sleep disruption among critically ill patients and potentially links to functional outcomes, and draws upon existing literature to propose therapeutic strategies to mitigate those harms. Particular attention is given to patients with critical neurologic conditions and the unique environment of the neuro-intensive care unit.

Recent Findings

Circadian rhythm disruption is widespread among critically ill patients and sleep time is reduced and abnormally fragmented. There is a strong association between the degree of arousal suppression observed at the bedside and the extent of circadian disruption at the system (e.g., melatonin concentration rhythms) and cellular levels (e.g., core clock gene transcription rhythms). There is a paucity of electrographically normal sleep, and rest-activity rhythms are severely disturbed. Common care interventions such as neurochecks introduce unique disruptions in neurologic patients. There are no pharmacologic interventions proven to normalize circadian rhythms or restore physiologically normal sleep. Instead, interventions are focused on reducing pharmacologic and environmental factors that perpetuate disruption.

Summary

The intensive care environment introduces numerous potent disruptors to sleep and circadian rhythms. Direct neurologic injury and neuro-monitoring practices likely compound those factors to further derange circadian and sleep functions. In the absence of direct interventions to induce normalized rhythms and sleep, current therapy depends upon normalizing external stimuli.

Epidemiology of delirium in hospitalized patients in Latin America: A systematic review

BACKGROUND

Accurate epidemiological data are essential for the planning of policies aimed at the identification, prevention, and management of delirium. The reported occurrence of delirium in hospitalized patients varies widely among studies, ranging between 5% to more than 80% in the international literature. The exact occurrence in Latin America is not well described.

OBJECTIVE

The aim of this study is to conduct a systematic analysis of the published data on the epidemiology of delirium in hospitalized patients in Latin America.

METHODS

We conducted a systematic review following PRISMA guidelines. Both MEDLINE and LILACS databases were searched for original research articles reporting the occurrence of delirium among adult hospitalized patients in Latin American countries. Studies including pediatric populations were excluded from this analysis. Two authors independently applied eligibility criteria, assessed quality, and extracted data. The corresponding authors of the original articles were contacted to obtain relevant information about the study when this was not present in the published manuscripts.

RESULTS

Seven hundred and eighteen original articles were identified. After screening titles and abstracts, 149 studies were included in the final analysis. The occurrence of delirium varied depending on the clinical scenario: (1) in the general medico-surgical wards, it ranged from 2.1% to 60.4%, (2) in the Intensive Care Units (ICUs), from 9.6% to 94.8%, (3) in the post-operatory population, from 5.45% and 52.3%, and (4) it was found to be between 10.7% and 62% in the emergency department setting. The most used delirium assessment tools were the "Confusion Assessment Method" (CAM; in the general population), and the "Confusion Assessment Method for the ICU" (CAM-ICU). Fourteen out of 149 studies were conducted in clinical settings who actively implemented some form of non-pharmacological delirium prevention bundles, most of them as part of ICU sedation-analgesia protocols.

CONCLUSION

Delirium occurs frequently in hospitalized patients in Latin America throughout a variety of clinical scenarios, including ICU, general wards, post-operatory populations, and among the emergency department setting. The CAM and the CAM-ICU are the most used delirium assessment tools. Bundles of non-pharmacological interventions to prevent delirium are not universally implemented.

Psychiatric Outcomes in ICU Patients With Family Visitation: A Population-Based Retrospective Cohort Study

BACKGROUND

Lack of family visitation in the ICU can have long-term consequences on patients in the ICU after discharge. The effect of family visitation on the incidence of patient psychiatric disorders is unknown.

RESEARCH QUESTION

What is the association between family visitation in the ICU and incidence of psychiatric outcomes in patients in the ICU 1 year after hospital discharge?

STUDY DESIGN AND METHODS

This study assessed a population-based retrospective cohort of adult patients admitted to the ICU from January 1, 2014, through May 30, 2017, surviving to hospital discharge with ICU length of stay of ≥ 3 days. To be eligible, patients needed to have minimum of 5 years of administrative data before ICU admission and a minimum of 1 year of follow-up data after hospital discharge. An internally validated algorithm that interpreted natural language in health records determined patients with or without in-person family (ie, relatives, friends) visitation during ICU stay. The primary outcome was risk of an incidence of psychiatric disorder (composite outcome), including anxiety, depressive, trauma- and stressor-related, psychotic, and substance use disorders, identified using coding algorithms for administrative databases. Propensity scores were used in inverse probability weighted logistic regression models, and average treatment effects were converted to risk ratios (RRs) with 95% CIs. Secondary outcomes were incidences of diagnoses by type of psychiatric disorder.

RESULTS

We included 14,344 patients with (96% [n = 13,771]) and without (4.0% [n = 573]) in-person family visitation who survived hospital discharge. More than one-third of patients received a diagnosis of any psychiatric disorder within 1 year after discharge (34.9%; 95% CI, 34.1%-35.6%). Patients most often received diagnoses of anxiety disorders (17.5%; 95% CI, 16.9%-18.1%) and depressive disorders (17.2%; 95% CI, 16.6%-17.9%). After inverse probability weighting of 13,731 patients, in-person family visitation was associated with a lower risk of received a diagnosis of any incident psychiatric disorder within 1 year after discharge (RR, 0.79; 95% CI, 0.68-0.92).

INTERPRETATION

ICU family visitation is associated with a decreased risk of psychiatric disorders in critically ill patients up to 1 year after hospital discharge.

Intensive Care-Related Cognitive Impairment: A Biopsychosocial Overview

Advancements in critical care medicine have improved survival rates for patients experiencing critical illness in intensive care units (ICUs). While mortality has declined, more than half of ICU survivors experience functional impairments that persist beyond discharge. Of particular concern is ICU-related cognitive impairment, which can extend across the care continuum, ranging from acute and transient presentations in the ICU (eg, delirium) to long-term impairments years after discharge. ICU-related cognitive impairment has received increased attention in the literature, particularly as it relates to ICU survivors who have received and survived critical care in the context of SARS-CoV-2 pandemic and are now experiencing post-acute sequelae of SARS-CoV-2 infection. The medical complexity and heterogeneity of ICU survivors, coupled with the multifactorial etiology of ICU-related cognitive impairments, lead to challenges in how to optimize care for ICU survivors at various stages of recovery. This review aims to provide an overview of cognitive outcomes associated with critical illness by integrating recent literature focused on etiology, assessment, and interventions in the context of ICU-related cognitive impairments. The narrative review employs a biopsychosocial framework to comprehensively evaluate the multifactorial nature of ICU-related cognitive outcomes. Authors also highlight multidisciplinary teams composed of key rehabilitation providers are likely best suited for optimizing recovery trajectories of ICU survivors. This article is protected by copyright. All rights reserved.

Understanding the Barriers in Delirium Care in an Intensive Care Unit: A Survey of Knowledge, Attitudes, and Current Practices among Medical Professionals Working in Intensive Care Units in Teaching Hospitals of Central Province, Sri Lanka

Background

Delirium is a common, underdiagnosed, and undertreated condition that increases morbidity and mortality in ICU patients which has an incidence up to 80%. Barriers that hinder optimum care of delirium include inadequate knowledge, poor attitudes, and low perceived importance of delirium care.

Aim

To assess attitudes, knowledge, and current practices related to delirium care among medical professionals working in intensive care units (ICUs) in all teaching hospitals in Central Province, Sri Lanka, as there are no Sri Lankan studies on this regard.

Method

A descriptive cross-sectional study was carried out among all medical professionals working in nine ICUs in all (n = 5) teaching hospitals in Central Province. Data were collected using a pretested self-administered questionnaire. Responses to questions were compared between postgraduate trainee medical officers (PG-MOs) and non-postgraduate-trainee medical officers (non-PG-MOs).

Results

Eighty-eight questionnaires were analyzed. More than 80% of PGs and non-PG-MOs regarded ICU delirium as significant problem that should be screened and prevented. Forty-one percent stated confidence in diagnosing delirium. However, more than 75% of non-PG-MOs failed to recognize features of hypoactive delirium. Only 30–50% subjects in incorporated preventive methods in usual practice and more than 60% non-PG-MOs had poor knowledge and experience on delirium screening. More than 80% of the participants did not routinely screen their patients. More than 90% non-PG-MOs (p <0.05) had no recent educational exposure.

Conclusion

A positive attitude toward the importance of management of delirium was observed. However, there is a discrepancy between the perceived importance and the current practice related to screening and prevention. Participants, especially non-PG-MOs, lacked knowledge on delirium screening, diagnosis, and identification of risk factors, probably related to a lack of educational exposure.

How to cite this article

Arachchi TMJ, Pinto V. Understanding the Barriers in Delirium Care in an Intensive Care Unit: A Survey of Knowledge, Attitudes, and Current Practices among Medical Professionals Working in Intensive Care Units in Teaching Hospitals of Central Province, Sri Lanka. Indian J Crit Care Med 2021;25(12):1413–1420.

Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review

Current achievements in medical science and technological advancements in intensive care medicine have allowed better support of critically ill patients in intensive care units (ICUs) and have increased survival probability. Post-intensive care syndrome (PICS) is a relatively new term introduced almost 10 years ago, defined as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization". A significant percentage of critically ill patients suffer from PICS for a prolonged period of time, with physical problems being the most common. The exact prevalence of PICS is unknown, and many risk factors have been described well. Coronavirus disease 2019 (COVID-19) survivors seem to be at especially high risk for developing PICS. The families of ICU survivors can also be affected as a response to the stress suffered during the critical illness of their kin. This separate entity is described as PICS family (PICS-F). A multidisciplinary approach is warranted for the treatment of PICS, involving healthcare professionals, clinicians, and scientists from different areas. Improving outcomes is both challenging and imperative for the critical care community. The review of the relevant literature and the study of the physical, cognitive, and mental sequelae could lead to the prevention and timely management of PICS and the subsequent improvement of the quality of life for ICU survivors.

The impact of patient delirium in the intensive care unit: patterns of anxiety symptoms in family caregivers

BACKGROUND

The purpose of this study was to examine the association of patient delirium in the intensive care unit (ICU) with patterns of anxiety symptoms in family caregivers when delirium was determined by clinical assessment and family-administered delirium detection.

METHODS

In this cross-sectional study, consecutive adult patients anticipated to remain in the ICU for longer than 24 h were eligible for participation given at least one present family caregiver (e.g., spouse, friend) provided informed consent (to be enrolled as a dyad) and were eligible for delirium detection (i.e., Richmond Agitation-Sedation Scale score ≥ - 3). Generalized Anxiety Disorder-7 (GAD-7) was used to assess self-reported symptoms of anxiety. Clinical assessment (Confusion Assessment Method for ICU, CAM-ICU) and family-administered delirium detection (Sour Seven) were completed once daily for up to five days.

RESULTS

We included 147 family caregivers; the mean age was 54.3 years (standard deviation [SD] 14.3 years) and 74% (n = 129) were female. Fifty (34% [95% confidence interval [CI] 26.4-42.2]) caregivers experienced clinically significant symptoms of anxiety (median GAD-7 score 16.0 [interquartile range 6]). The most prevalent symptoms of anxiety were "Feeling nervous, anxious or on edge" (96.0% [95%CI 85.2-99.0]); "Not being able to stop or control worrying" (88.0% [95%CI 75.6-94.5]; "Worrying too much about different things" and "Feeling afraid as if something awful might happen" (84.0% [95%CI 71.0-91.8], for both). Family caregivers of critically ill adults with delirium were significantly more likely to report "Worrying too much about different things" more than half of the time (CAM-ICU, Odds Ratio [OR] 2.27 [95%CI 1.04-4.91]; Sour Seven, OR 2.28 [95%CI 1.00-5.23]).

CONCLUSIONS

Family caregivers of critically ill adults with delirium frequently experience clinically significant anxiety and are significantly more likely to report frequently worrying too much about different things. Future work is needed to develop mental health interventions for the diversity of anxiety symptoms experienced by family members of critically ill patients.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03379129 ).

A Modified Delphi Process to Prioritize Experiences and Guidance Related to ICU Restricted Visitation Policies During the Coronavirus Disease 2019 Pandemic

To create evidence-based consensus statements for restricted ICU visitation policies to support critically ill patients, families, and healthcare professionals during current and future pandemics.

DESIGN

Three rounds of a remote modified Delphi consensus process.

SETTING

Online survey and virtual polling from February 2, 2021, to April 8, 2021.

SUBJECTS

Stakeholders (patients, families, clinicians, researchers, allied health professionals, decision-makers) admitted to or working in Canadian ICUs during the coronavirus disease 2019 pandemic.

MEASUREMENTS AND MAIN RESULTS

During Round 1, key stakeholders used a 9-point Likert scale to rate experiences (1-not significant, 9-significant impact on patients, families, healthcare professionals, or patient- and family-centered care) and strategies (1-not essential, 9-essential recommendation for inclusion in the development of restricted visitation policies) and used a free-text box to capture experiences/strategies we may have missed. Consensus was achieved if the median score was 7-9 or 1-3. During Round 2, participants used a 9-point Likert scale to re-rate experiences/strategies that did not meet consensus during Round 1 (median score of 4-6) and rate new items identified in Round 1. During Rounds 2 and 3, participants ranked items that reached consensus by order of importance (relative to other related items and experiences) using a weighted ranking system (0-100 points). Participants prioritized 11 experiences (e.g., variability of family's comfort with technology, healthcare professional moral distress) and developed 21 consensus statements (e.g., communicate policy changes to the hospital staff before the public, permit visitors at end-of-life regardless of coronavirus disease 2019 status, creating a clear definition for end-of-life) regarding restricted visitation policies.

CONCLUSIONS

We have formulated evidence-informed consensus statements regarding restricted visitation policies informed by diverse stakeholders, which could enhance patient- and family-centered care during a pandemic.

Mental Health Interventions to Improve Psychological Outcomes in Informal Caregivers of Critically Ill Patients: A Systematic Review and Meta-Analysis

Supplemental Digital Content is available in the text.

Determine effect of mental health interventions on psychologic outcomes in informal caregivers of critically ill patients.

General practitioners' views and experiences in caring for patients after sepsis: a qualitative interview study

BACKGROUND

Patients surviving critical illnesses, such as sepsis, often suffer from long-term complications. After discharge from hospital, most patients are treated in primary care. Little is known how general practitioners (GPs) perform critical illness aftercare and how it can be improved. Within a randomised controlled trial, an outreach training programme has been developed and applied.

OBJECTIVES

The aim of this study is to describe GPs' views and experiences of caring for postsepsis patients and of participating a specific outreach training.

DESIGN

Semistructured qualitative interviews.

SETTING

14 primary care practices in the metropolitan area of Berlin, Germany.

PARTICIPANTS

14 GPs who had participated in a structured sepsis aftercare programme in primary care.

RESULTS

Themes identified in sepsis aftercare were: continuity of care and good relationship with patients, GP's experiences during their patient's critical illness and impact of persisting symptoms. An outreach education as part of the intervention was considered by the GPs to be acceptable, helpful to improve knowledge of the management of postintensive care complications and useful for sepsis aftercare in daily practice.

CONCLUSIONS

GPs provide continuity of care to patients surviving sepsis. Better communication at the intensive care unit-GP interface and training in management of long-term complications of sepsis may be helpful to improve sepsis aftercare.

TRIAL REGISTRATION NUMBER

ISRCTN61744782.

Cognitive and Psychological Sequelae of COVID-19: Age Differences in Facing the Pandemic

Literature about the novel Coronavirus (COVID-19) is currently focusing on the potential cognitive and neuropsychiatric sequelae observed in individuals receiving intensive care unit (ICU) treatments. The aim of the present study is to evaluate the differences in cognitive and psychological sequelae of COVID-19 between younger and older adults, regardless of being admitted to the ICU or not. The study involved 299 recovered individuals (from 18 to 90 years old), who underwent a comprehensive cognitive and psychological assessment. Linear regression models were conducted separately for Montreal Cognitive Assessment (MoCA) test and Post-traumatic Stress Disorder Checklist (PCL) scores to investigate the effect of socio-demographic and clinical characteristics on them. Separate linear regression models were then applied sorting participants by age: younger adults (<65 years) and older adults (≥65 years). In the whole sample, PCL scores were predicted by the intensity of care received, by being intubated, and by the persistence of cough after 1 month after hospitalization. Only age had instead an effect on cognition. In younger adults, PCL scores were predicted by the presence of neurological symptoms, by the intensity of care received, and by being intubated; MoCA scores were only predicted by the intensity of care received. No significant associations were found in older adults. Psychological negative effects of the COVID-19 pandemic particularly affect individuals under 65 years old, who also subjectively report cognitive sequelae associated with the infection. Individuals over 65 years old, instead, seem to be free from psychological and cognitive difficulties due to COVID-19.

Neuropsychological functioning in severe acute respiratory disorders caused by the coronavirus: Implications for the current COVID-19 pandemic

Objective: The coronavirus class of respiratory viruses - including Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19) - has been associated with central nervous system (CNS) disease. In fact, multiple mechanisms of CNS involvement have been proposed, making it difficult to identify a unitary syndrome that can be the focus of clinical work and research. Neuropsychologists need to understand the potential cognitive and psychological sequelae of COVID-19 and the impact of the interventions (e.g., ICU, ventilation) that have been used in treating patients with severe forms of the illness.Method: We briefly review the literature regarding the neurological and neuropsychological effects of similar coronaviruses, the limited information that has been published to date on COVID-19, and the literature regarding the long-term cognitive and psychological effects of undergoing treatment in the intensive care unit (ICU).Results: We discuss the roles that neuropsychologists can play in assessing and treating the cognitive difficulties and psychiatric symptoms described.Conclusions: At this time, the mechanisms, correlates, and effects of COVID-19 are poorly understood, but information gleaned from the literature on similar viruses and utilized interventions should help inform neuropsychologists as they begin to work with this population.

Post-traumatic stress disorder: A differential diagnostic consideration for COVID-19 survivors

Objective: SARS-CoV-2 infection and its oft-associated illness COVID-19 may lead to neuropsychological deficits, either through direct mechanisms (i.e., neurovirulance) or indirect mechanisms, most notably complications caused by the virus (e.g., stroke) or medical procedures (e.g., intubation). The history of past human coronavirus outbreaks resulting in similar health emergencies suggests there will be a substantial prevalence of post-traumatic stress disorder (PTSD) among COVID-19 survivors. To prepare neuropsychologists for the difficult task of differentiating PTSD-related from neuropathology-related deficits in the oncoming wave of COVID-19 survivors, we integrate research across a spectrum of related areas.Methods: Several areas of literature were reviewed: psychiatric, neurologic, and neuropathological outcomes of SARS and MERS patients; neurological outcomes in COVID-19 survivors; PTSD associated with procedures common to COVID-19 patients; and differentiating neuropsychological deficits due to PTSD from those due to acquired brain injuries in other patient groups.Conclusions: Heightened risk of PTSD occurred in MERS and SARS survivors. While data concerning COVID-19 is lacking, PTSD is known to occur in patient groups who undergo similar hospital courses, including ICU survivors, patients who are intubated and mechanically ventilated, and those that experience delirium. Research with patients who develop PTSD in the context of mild traumatic brain injury further suggests that PTSD may account for some or all of a patient's subjective cognitive complaints and neuropsychological test performance. Recommendations are provided for assessing PTSD in the context of COVID-19.

Sleep and Circadian Rhythms in Survivors of Acute Respiratory Failure

Background: Little is known about sleep and circadian rhythms in survivors of acute respiratory failure (ARF) after hospital discharge. Objectives: To examine sleep and rest-activity circadian rhythms in ARF survivors 3 months after hospital discharge, and to compare them with a community-dwelling population. Methods: Sleep diary, actigraphy data, and insomnia symptoms were collected in a pilot study of 14 ARF survivors. Rest-activity circadian rhythms were assessed with wrist actigraphy and sleep diary for 9 days, and were analyzed by cosinor and non-parametric circadian rhythm analysis. Results: All participants had remarkable actigraphic sleep fragmentation, 71.5% had subclinical or clinical insomnia symptoms. Compared to community-dwelling adults, this cohort had less stable rest-activity circadian rhythms (p < 0.001), and weaker circadian strength (p < 0.001). Conclusion: Insomnia and circadian disruption were common in ARF survivors. Sleep improvement and circadian rhythm regularity may be a promising approach to improve quality of life and daytime function after ARF.

Preventing Chronic Emotional Distress in Stroke Survivors and Their Informal Caregivers

BACKGROUND/OBJECTIVE

Chronic emotional distress (e.g., depression, anxiety, post-traumatic stress) is common after stroke and interdependent between patients and their informal caregivers. We measured stroke survivors', caregivers', and neurocritical care nurses' views of primary drivers of distress during the stroke experience, and needs and preferences for the structure, topics, mode of delivery, and timing of an intervention to promote emotional recovery.

METHODS

We conducted semi-structured interviews with 24 patient-caregiver dyads within the Neuroscience Intensive Care Unit (Neuro-ICU). Additionally, we conducted two focus groups with 15 nurses. Interviews and focus groups were audio-recorded, transcribed, and coded using NVivo 11 (QSR International) software.

RESULTS AND CONCLUSIONS

The challenges and impacts of stroke most commonly reported by dyads were: uncertainty about future health, fear of recurrent strokes, negative emotions, and role changes post-stroke. Dyads and nurses agreed that resiliency skills such as mindfulness/focusing on the present, problem solving, gratitude/optimism, self-care, interpersonal communication and developing a supportive team of family, friends, and medical staff are beneficial to optimize recovery. The potential barrier to intervention delivery was accessibility, due to challenges of time and travel to appointments. Participants agreed that starting the intervention at hospitalization and continuing via live video after discharge is an ideal delivery modality. Stroke survivors, caregivers, and Neuro-ICU nurses believe that a resiliency skills-based intervention to prevent chronic emotional distress is necessary and urgent. This qualitative study provides valuable information on the challenges faced by dyads, intervention topics to prioritize, and strategies to maximize feasibility, acceptability, and effect.

Beyond the Intensive Care Unit: Posttraumatic Stress Disorder in Critically Ill Patients

Medical care progress has enabled more patients in the intensive care unit to survive critical illnesses and return to daily living. This shift in survival rates has shed new light on the emotional consequences this experience. For patients surviving an ICU stay, posttraumatic stress disorder has been identified in approximately 9% to 27% compared with 7% of the general US population. Practitioners have an important role to play in early identification of patients experiencing signs and symptoms of this disorder. Timely interventions and treatment may reduce the incidence of physical and psychological comorbid conditions.

Interventions for preventing intensive care unit delirium in adults

BACKGROUND

Delirium is defined as a disturbance in attention, awareness and cognition with reduced ability to direct, focus, sustain and shift attention, and reduced orientation to the environment. Critically ill patients in the intensive care unit (ICU) frequently develop ICU delirium. It can profoundly affect both them and their families because it is associated with increased mortality, longer duration of mechanical ventilation, longer hospital and ICU stay and long-term cognitive impairment. It also results in increased costs for society.

OBJECTIVES

To assess existing evidence for the effect of preventive interventions on ICU delirium, in-hospital mortality, the number of delirium- and coma-free days, ventilator-free days, length of stay in the ICU and cognitive impairment.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, BIOSIS, International Web of Science, Latin American Caribbean Health Sciences Literature, CINAHL from 1980 to 11 April 2018 without any language limits. We adapted the MEDLINE search for searching the other databases. Furthermore, we checked references, searched citations and contacted study authors to identify additional studies. We also checked the following trial registries: Current Controlled Trials; ClinicalTrials.gov; and CenterWatch.com (all on 24 April 2018).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of adult medical or surgical ICU patients receiving any intervention for preventing ICU delirium. The control could be standard ICU care, placebo or both. We assessed the quality of evidence with GRADE.

DATA COLLECTION AND ANALYSIS

We checked titles and abstracts to exclude obviously irrelevant studies and obtained full reports on potentially relevant ones. Two review authors independently extracted data. If possible we conducted meta-analyses, otherwise we synthesized data narratively.

MAIN RESULTS

The electronic search yielded 8746 records. We included 12 RCTs (3885 participants) comparing usual care with the following interventions: commonly used drugs (four studies); sedation regimens (four studies); physical therapy or cognitive therapy, or both (one study); environmental interventions (two studies); and preventive nursing care (one study). We found 15 ongoing studies and five studies awaiting classification. The participants were 48 to 70 years old; 48% to 74% were male; the mean acute physiology and chronic health evaluation (APACHE II) score was 14 to 28 (range 0 to 71; higher scores correspond to more severe disease and a higher risk of death). With the exception of one study, all participants were mechanically ventilated in medical or surgical ICUs or mixed. The studies were overall at low risk of bias. Six studies were at high risk of detection bias due to lack of blinding of outcome assessors. We report results for the two most commonly explored approaches to delirium prevention: pharmacologic and a non-pharmacologic intervention.Haloperidol versus placebo (two RCTs, 1580 participants)The event rate of ICU delirium was measured in one study including 1439 participants. No difference was identified between groups, (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.87 to 1.17) (moderate-quality evidence). Haloperidol versus placebo neither reduced or increased in-hospital mortality, (RR 0.98, 95% CI 0.80 to 1.22; 2 studies; 1580 participants (moderate-quality evidence)); the number of delirium- and coma-free days, (mean difference (MD) -0.60, 95% CI -1.37 to 0.17; 2 studies, 1580 participants (moderate-quality of evidence)); number of ventilator-free days (mean 23.8 (MD -0.30, 95% CI -0.93 to 0.33) 1 study; 1439 participants, (high-quality evidence)); length of ICU stay, (MD 0.18, 95% CI -0.60 to 0.97); 2 studies, 1580 participants; high-quality evidence). None of the studies measured cognitive impairment. In one study there were three serious adverse events in the intervention group and five in the placebo group; in the other there were five serious adverse events and three patients died, one in each group. None of the serious adverse events were judged to be related to interventions received (moderate-quality evidence).Physical and cognitive therapy interventions (one study, 65 participants)The study did not measure the event rate of ICU delirium. A physical and cognitive therapy intervention versus standard care neither reduced nor increased in-hospital mortality, (RR 0.94, 95% CI 0.40 to 2.20, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of delirium- and coma-free days, (MD -2.8, 95% CI -10.1 to 4.6, I² = 0; 1 study, 65 participants; very low-quality evidence); the number of ventilator-free days (within the first 28/30 days) was median 27.4 (IQR 0 to 29.2) and 25 (IQR 0 to 28.9); 1 study, 65 participants; very low-quality evidence, length of ICU stay, (MD 1.23, 95% CI -0.68 to 3.14, I² = 0; 1 study, 65 participants; very low-quality evidence); cognitive impairment measured by the MMSE: Mini-Mental State Examination with higher scores indicating better function, (MD 0.97, 95% CI -0.19 to 2.13, I² = 0; 1 study, 30 participants; very low-quality evidence); or measured by the Dysexecutive questionnaire (DEX) with lower scores indicating better function (MD -8.76, 95% CI -19.06 to 1.54, I² = 0; 1 study, 30 participants; very low-quality evidence). One patient experienced acute back pain accompanied by hypotensive urgency during physical therapy.

AUTHORS' CONCLUSIONS

There is probably little or no difference between haloperidol and placebo for preventing ICU delirium but further studies are needed to increase our confidence in the findings. There is insufficient evidence to determine the effects of physical and cognitive intervention on delirium. The effects of other pharmacological interventions, sedation, environmental, and preventive nursing interventions are unclear and warrant further investigation in large multicentre studies. Five studies are awaiting classification and we identified 15 ongoing studies, evaluating pharmacological interventions, sedation regimens, physical and occupational therapy combined or separately, and environmental interventions, that may alter the conclusions of the review in future.

Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial

IMPORTANCE

It remains uncertain whether invasive ventilation should use low tidal volumes in critically ill patients without acute respiratory distress syndrome (ARDS).

OBJECTIVE

To determine whether a low tidal volume ventilation strategy is more effective than an intermediate tidal volume strategy.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial, conducted from September 1, 2014, through August 20, 2017, including patients without ARDS expected to not be extubated within 24 hours after start of ventilation from 6 intensive care units in the Netherlands.

INTERVENTIONS

Invasive ventilation using low tidal volumes (n = 477) or intermediate tidal volumes (n = 484).

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of ventilator-free days and alive at day 28. Secondary outcomes included length of ICU and hospital stay; ICU, hospital, and 28- and 90-day mortality; and development of ARDS, pneumonia, severe atelectasis, or pneumothorax.

RESULTS

In total, 961 patients (65% male), with a median age of 68 years (interquartile range [IQR], 59-76), were enrolled. At day 28, 475 patients in the low tidal volume group had a median of 21 ventilator-free days (IQR, 0-26), and 480 patients in the intermediate tidal volume group had a median of 21 ventilator-free days (IQR, 0-26) (mean difference, -0.27 [95% CI, -1.74 to 1.19]; P = .71). There was no significant difference in ICU (median, 6 vs 6 days; 0.39 [-1.09 to 1.89]; P = .58) and hospital (median, 14 vs 15 days; -0.60 [-3.52 to 2.31]; P = .68) length of stay or 28-day (34.9% vs 32.1%; hazard ratio [HR], 1.12 [0.90 to 1.40]; P = .30) and 90-day (39.1% vs 37.8%; HR, 1.07 [0.87 to 1.31]; P = .54) mortality. There was no significant difference in the percentage of patients developing the following adverse events: ARDS (3.8% vs 5.0%; risk ratio [RR], 0.86 [0.59 to 1.24]; P = .38), pneumonia (4.2% vs 3.7%; RR, 1.07 [0.78 to 1.47]; P = .67), severe atelectasis (11.4% vs 11.2%; RR, 1.00 [0.81 to 1.23]; P = .94), and pneumothorax (1.8% vs 1.3%; RR, 1.16 [0.73 to 1.84]; P = .55).

CONCLUSIONS AND RELEVANCE

In patients in the ICU without ARDS who were expected not to be extubated within 24 hours of randomization, a low tidal volume strategy did not result in a greater number of ventilator-free days than an intermediate tidal volume strategy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02153294.

Frailty and the Association Between Long-Term Recovery After Intensive Care Unit Admission

Frailty is common, although infrequently screened for among patients admitted to intensive care. Frailty has been the focus of research in geriatric medicine; however, its epidemiology and interaction with critical illness have only recently been studied. Instruments to screen for and measure frailty require refinement in intensive care settings. Frail critically ill patients are at higher risk of poor outcomes. Frail survivors of critical illness are high users of health resources. Further research is needed to understand how frailty assessment can inform decision-making before and during an episode of critical illness and during an intensive care course for frail patients.

The future of UK healthcare: problems and potential solutions to a system in crisis

The UK's Health System is in crisis, central funding no longer keeping pace with demand. Traditional responses-spending more, seeking efficiency savings or invoking market forces-are not solutions. The health of our nation demands urgent delivery of a radical new model, negotiated openly between public, policymakers and healthcare professionals. Such a model could focus on disease prevention, modifying health behaviour and implementing change in public policy in fields traditionally considered unrelated to health such as transport, food and advertising. The true cost-effectiveness of healthcare interventions must be balanced against the opportunity cost of their implementation, bolstering the central role of NICE in such decisions. Without such action, the prognosis for our healthcare system-and for the health of the individuals it serves-may be poor. Here, we explore such a new prescription for our national health.

Delirium in the Critically Ill Child: Assessment and Sequelae

Delirium is a common and serious neuropsychiatric complication in critically ill patients of all ages. In the context of critical illness, delirium may emerge as a result of a cascade of underlying pathophysiologic mechanisms and signals organ failure of the brain. Awareness of the clinical importance of delirium in adults is growing as emerging research demonstrates that delirium represents a serious medical problem with significant sequelae. However, our understanding of delirium in children lags significantly behind the adult literature. In particular, our knowledge of how to assess delirium is complicated by challenges in recognizing symptoms of delirium in pediatric patients especially in critical and intensive care settings, and our understanding of its impact on acute and long-term functioning remains in its infancy. This paper focuses on (a) the challenges associated with assessing delirium in critically ill children, (b) the current literature on the outcomes of delirium including morbidity following discharge from PICU, and care-giver well-being, and (c) the importance of assessment in determining impact of delirium on outcome. Current evidence suggests that delirium is a diagnostic challenge for clinicians and may play a detrimental role in a child's recovery after discharge from the pediatric intensive care unit (PICU). Recommendations are proposed for how our knowledge and assessment of delirium in children could be improved.

Mild Cognitive Impairment and Risk of Critical Illness

OBJECTIVES

Approximately half of ICU admissions are comprised of patients older than 65 years old. Mild cognitive impairment is a common disorder affecting 10-20% of patients in the same age group. A need exists for exploring mild cognitive impairment and risk of critical illness. As mild cognitive impairment may be a contributor to poorer overall health or be a result of it, we sought to determine whether the presence of mild cognitive impairment independently increases the risk of critical illness admissions.

DESIGN

Data from the Mayo Clinic Study of Aging were analyzed. All study participants underwent prospective comprehensive cognitive testing and expert panel consensus diagnosis of both cognitive function and clinical state at baseline and subsequent visits. Comparisons were made between those with normal cognitive function and mild cognitive impairment regarding baseline health and frequency of critical illness.

SETTING

Single-center population-based cohort out of Olmsted County, MN.

PARTICIPANTS

All individuals 70-89 years old were screened for prospective enrollment in the Mayo Clinic Study of Aging. Patients with preexisting dementia and ICU admission within 3 years of entry to the study were excluded from this analysis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 2,425 patients analyzed from the Mayo Clinic Study of Aging, 1,734 patients (71%) were included in the current study. Clinical factors associated with baseline mild cognitive impairment included age, male gender, stroke, and poorer health self-rating. Using a Cox regression model adjusting for these and a priori variables of baseline health, the presence of mild cognitive impairment remained a significant predictor of ICU admission (hazard ratio, 1.50 [1.15-1.96]; p = 0.003).

CONCLUSIONS AND RELEVANCE

The presence of mild cognitive impairment is independently associated with increased critical illness admission. Further prospective studies are needed to analyze the impact of critical illness on cognitive function.

Posttraumatic stress syndrome associated with stays in the intensive care unit: importance of nurses' involvement

More patients in the intensive care unit are surviving their critical illnesses because of advances in medical care. This change in survival has led to an increased awareness of the emotional consequences of being critically ill. Posttraumatic stress disorder has been identified in approximately 9% to 27% of critically ill patients compared with 7% of the general US population. Risk factors such as treatment with mechanical ventilation, sedation, delusional memories, and agitation are associated with development of posttraumatic stress disorder in patients in the intensive care unit. Individuals with posttraumatic stress disorder are more likely to experience negative physical and psychiatric health outcomes and a lower quality of life than are patients without the disorder. Early identification and treatment of patients experiencing these signs and symptoms may reduce these physical and psychological comorbid conditions. Through careful monitoring of medications, early mobilization, sleep promotion, and pain management, nurses may be able to reduce signs and symptoms of posttraumatic stress disorder.

Epidemiology and Outcomes of Pediatric Multiple Organ Dysfunction Syndrome

OBJECTIVE

To summarize the epidemiology and outcomes of children with multiple organ dysfunction syndrome as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26-27, 2015).

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an experienced expert from the field, issues relevant to the epidemiology and outcomes of children with multiple organ dysfunction syndrome were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by the relevant literature.

CONCLUSIONS

A full understanding the epidemiology and outcome of multiple organ dysfunction syndrome in children is limited by inconsistent definitions and populations studied. Nonetheless, pediatric multiple organ dysfunction syndrome is common among PICU patients, occurring in up to 57% depending on the population studied; sepsis remains its leading cause. Pediatric multiple organ dysfunction syndrome leads to considerable short-term morbidity and mortality. Long-term outcomes of multiple organ dysfunction syndrome in children have not been well studied; however, studies of adults and children with other critical illnesses suggest that the risk of long-term adverse sequelae is high. Characterization of the long-term outcomes of pediatric multiple organ dysfunction syndrome is crucial to identify opportunities for improved treatment and recovery strategies that will improve the quality of life of critically ill children and their families. The workshop identified important knowledge gaps and research priorities intended to promote the development of standard definitions and the identification of modifiable factors related to its occurrence and outcome.

Evaluation and treatment of depression in adult trauma patients

A retrospective study examined in-hospital antidepressant medication (ADM) use in adult trauma patients with an intensive care unit stay of 5 or more days. One fourth of patients received an ADM, with only 33% of those patients having a documented history of depression. Of patients who received their first ADM from a trauma or critical care physician, only 5% were discharged with a documented plan for psychiatric follow-up. The study identified a need for standardized identification and management of depressive symptoms among trauma patients in the inpatient setting.

Assessment and predictors of physical functioning post-hospital discharge in survivors of critical illness

Background

Prior studies of physical functioning after critical illness have been mostly limited to survivors of acute respiratory distress syndrome. The purpose of this study was to objectively assess muscle strength and physical functioning in survivors of critical illness from a general ICU and the associations of these measures to health-related quality of life (HRQL), mental health and critical illness variables.

Methods

This was a prospective cohort study of 56 patients admitted to a medical ICU (length of stay ≥4 days) from April 1, 2009, and March 31, 2010. Patients were assessed in clinic at 3 months post-hospital discharge. Muscle strength and physical functioning were measured using hand-held dynamometry and the 6-min walk test. HRQL was assessed using the short-form 36 (SF-36) and EuroQol-5D (EQ-5D) questionnaires.

Results

Three months post-hospital discharge, median age- and sex-matched muscle strength was reduced across all muscle groups. The median 6-min walk distance was 72 % of predicted. Physical functioning was associated with reductions in self-reported HRQL (SF-36, EQ-5D) and increased anxiety. Univariate regression modeling showed that reduced muscle strength and 6-min walk distance were associated with sepsis but not ICU length of stay. Multivariate regression modeling showed that sepsis and corticosteroid use were associated with a reduced 6-min walk distance, but again ICU length of stay was not.

Conclusions

Survivors of critical illness have reduced strength in multiple muscle groups and impaired exercise tolerance impacting both HRQL and mental health. These outcomes were worsened by sepsis and corticosteroid use in the ICU but not ICU length of stay. Interventions to minimizing the burden of sepsis in critically ill patients may improve long-term outcomes.

Physical declines occurring after hospital discharge in ARDS survivors: a 5-year longitudinal study

PURPOSE

Survivors of acute respiratory distress syndrome (ARDS) are at high risk for new or ongoing physical declines after hospital discharge. The objective of our study was to evaluate the epidemiology of physical declines over 5-year follow-up and identify patients at risk for decline.

METHODS

This multi-site prospective cohort study evaluated ARDS survivors who completed a physical status assessment at 3 or 6 months post-discharge. Three measures were evaluated: muscle strength (Medical Resource Council sumscore); exercise capacity [6-min walk test (6MWT)]; physical functioning [36-Item Short Form Health Survey (SF-36 survey)]. Patients were defined as "declined" if a comparison of their current and prior score showed a decrease that was greater than the Reliable Change Index-or if the patient died. Risk factors [pre-ARDS baseline status, intensive care unit (ICU) illness severity, and other intensive care variables] were evaluated using longitudinal, generalized linear regression models for each measure.

RESULTS

During the follow-up of 193 ARDS survivors (55 % male; median age 49 years), 166 (86 %) experienced decline in ≥1 physical measure (including death) and 133 (69 %) experienced a physical decline (excluding death). For all measures, age was a significant risk factor [odds ratios (OR) 1.34-1.69 per decade; p < 0.001]. Pre-ARDS comorbidity (Charlson Index) was independently associated with declines in strength and exercise capacity (OR 1.10 and 1.18, respectively; p < 0.02), and organ failure [maximum daily Sequential Organ Failure Assessment (SOFA) score in ICU] was associated with declines in strength (OR 1.06 per 1 point of SOFA score; p = 0.02).

CONCLUSIONS

Over the follow-up period, the majority of ARDS survivors experienced a physical decline, with older age and pre-ICU comorbidity being important risk factors for this decline.

Psychiatric Symptoms in Acute Respiratory Distress Syndrome Survivors: A 1-Year National Multicenter Study

OBJECTIVE

To evaluate prevalence, severity, and co-occurrence of and risk factors for depression, anxiety, and posttraumatic stress disorder symptoms over the first year after acute respiratory distress syndrome.

DESIGN

Prospective longitudinal cohort study.

SETTINGS

Forty-one Acute Respiratory Distress Syndrome Network hospitals across the United States.

PATIENTS

Six hundred ninety-eight acute respiratory distress syndrome survivors.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Psychiatric symptoms were evaluated by using the Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised at 6 and 12 months. Adjusted prevalence ratios for substantial symptoms (binary outcome) and severity scores were calculated by using Poisson and linear regression, respectively. During 12 months, a total of 416 of 629 patients (66%) with at least one psychiatric outcome measure had substantial symptoms in at least one domain. There was a high and almost identical prevalence of substantial symptoms (36%, 42%, and 24% for depression, anxiety, and posttraumatic stress disorder) at 6 and 12 months. The most common pattern of co-occurrence was having symptoms of all three psychiatric domains simultaneously. Younger age, female sex, unemployment, alcohol misuse, and greater opioid use in the ICU were significantly associated with psychiatric symptoms, whereas greater severity of illness and ICU length of stay were not associated.

CONCLUSIONS

Psychiatric symptoms occurred in two thirds of acute respiratory distress syndrome survivors with frequent co-occurrence. Sociodemographic characteristics and in-ICU opioid administration, rather than traditional measures of critical illness severity, should be considered in identifying the patients at highest risk for psychiatric symptoms during recovery. Given high co-occurrence, acute respiratory distress syndrome survivors should be simultaneously evaluated for a full spectrum of psychiatric sequelae to maximize recovery.

Epigenetics of Stress, Addiction, and Resilience: Therapeutic Implications

Substance use disorders (SUDs) are highly prevalent. SUDs involve vicious cycles of binges followed by occasional periods of abstinence with recurrent relapses despite treatment and adverse medical and psychosocial consequences. There is convincing evidence that early and adult stressful life events are risks factors for the development of addiction and serve as cues that trigger relapses. Nevertheless, the fact that not all individuals who face traumatic events develop addiction to licit or illicit drugs suggests the existence of individual and/or familial resilient factors that protect these mentally healthy individuals. Here, I give a brief overview of the epigenetic bases of responses to stressful events and of epigenetic changes associated with the administration of drugs of abuse. I also discuss the psychobiology of resilience and alterations in epigenetic markers that have been observed in models of resilience. Finally, I suggest the possibility that treatment of addiction should involve cognitive and pharmacological approaches that enhance resilience in at risk individuals. Similar approaches should also be used with patients who have already succumbed to the nefarious effects of addictive substances.

The effects of cognitive intervention on cognitive impairments after intensive care unit admission

Patients who survive critical illness commonly suffer cognitive impairments. We aimed to study the effects of cognitive intervention to treat the long-term impairments observed among different populations of intensive care unit (ICU) survivors. The results showed that the intervention significantly suppressed the deterioration of cognitive function in these patients. Medical and neurological ICU survivors were more susceptible than post-anaesthesia ICU patients to severe cognitive damage. In the former, the deterioration of impairments can be slowed by cognitive intervention. In comparison, intervention exerted significantly positive effects on the recovery of the cognitive functions of post-anaesthesia care unit patients. Furthermore, young populations were more likely than older populations to recover from acute cognitive impairments, and the impairment observed among the older population seemed to be multi-factorial and irreversible.

Sleep in the intensive care unit

Sleep is an important physiologic process, and lack of sleep is associated with a host of adverse outcomes. Basic and clinical research has documented the important role circadian rhythm plays in biologic function. Critical illness is a time of extreme vulnerability for patients, and the important role sleep may play in recovery for intensive care unit (ICU) patients is just beginning to be explored. This concise clinical review focuses on the current state of research examining sleep in critical illness. We discuss sleep and circadian rhythm abnormalities that occur in ICU patients and the challenges to measuring alterations in circadian rhythm in critical illness and review methods to measure sleep in the ICU, including polysomnography, actigraphy, and questionnaires. We discuss data on the impact of potentially modifiable disruptors to patient sleep, such as noise, light, and patient care activities, and report on potential methods to improve sleep in the setting of critical illness. Finally, we review the latest literature on sleep disturbances that persist or develop after critical illness.

Project Post Intensive Care eXercise (PIX): A qualitative exploration of intensive care unit survivors' perceptions of quality of life post-discharge and experience of exercise rehabilitation

Patients who survive critical illness often report deterioration in health related quality of life. This has not been shown to improve following post-intensive care unit (ICU) self-directed exercise. The Post Intensive Care eXercise (PIX) study demonstrated improved objectively measured fitness following a supervised exercise programme following critical illness and also suggested beneficial effects on physical and mental health. The qualitative arm of the PIX study reported here utilised focus groups to explore in more detail recovery from critical illness, quality of life following hospital discharge, perceptions of the exercise programme and it's impact on perceived well-being. Sixteen participants (eight of whom underwent the supervised exercise programme) were allocated to four psychologist lead focus groups. Themes identified after hospital discharge centred on social isolation, abandonment, vulnerability and reduced physical activity. However, patients in the exercise group described exercise training as motivating, increasing energy levels and sense of achievement, social interaction and confidence. This study adds to the sparse literature on the patient experience post critical illness. It supports the improvements in physical and mental health suggested with exercise in the PIX study and would support further research in relation to the effects of supervised exercise and rehabilitation programmes post critical illness. It recommends that future comparative outcome studies in this patient population also include interview-based assessment as part of assessment of quality of life and an individual's functional status.

The use, prevalence and potential benefits of a diary as a therapeutic intervention/tool to aid recovery following critical illness in intensive care: a literature review

AIMS AND OBJECTIVES

To critically appraise the available literature and summarise the evidence related to the use, prevalence, purpose and potential therapeutic benefits of intensive care unit diaries following survivors' discharge from hospital and identify areas for future exploration.

BACKGROUND

Intensive care unit survivorship is increasing as are associated physical and psychological complications. These complications can impact on the quality of life of survivors and their families. Rehabilitation services for survivors have been sporadically implemented and lack an evidence base. Patient diaries in intensive care have been implemented in Scandinavia and Europe with the intention of filling memory gaps, enable survivors to set realistic recovery goals and cement their experiences in reality.

DESIGN

A review of original research articles.

METHODS

The review used key terms and Boolean operators across a 34-year time frame in: CIHAHL, Medline, Scopus, Proquest, Informit and Google Scholar for research reports pertaining to the area of enquiry. Twenty-two original research articles met the inclusion criteria for this review.

RESULTS

The review concluded that diaries are prevalent in Scandinavia and parts of Europe but not elsewhere. The implementation and ongoing use of diaries is disparate and international guidelines to clarify this have been proposed. Evidence which demonstrates the potential of diaries in the reduction of the psychological complications following intensive care has recently emerged. Results from this review will inform future research in this area.

CONCLUSIONS

Further investigation is warranted to explore the potential benefits of diaries for survivors and improve the evidence base which is currently insufficient to inform practice. The exploration of prospective diarising in the recovery period for survivors is also justified.

RELEVANCE TO CLINICAL PRACTICE

Intensive care diaries are a cost effective intervention which may yield significant benefits to survivors.

Measuring functional recovery in older patients discharged from intensive care units: is advanced technology an option?

The purpose of this descriptive study was to determine if older patients discharged from intensive care units (ICU) would be willing to use mobile phone and sensor technology (aka "mobile monitoring") to measure their functional recovery in the posthospitalization period. Semistructured interviews were conducted with 22 older ICU patients and/or their surrogates 24 to 48 hr prior to hospital discharge. While 11 respondents reported they would agree to participate in a future study involving mobile monitoring, an equal number reported they would not participate. Numerous contextual factors were found to affect older adults' willingness to participate including the belief the research would ultimately benefit themselves or other older adults, concerns about loss of privacy, perception that the research is feasible and valuable, and lack of skills using the technology. Future studies using the mobile monitoring technique with older survivors of a serious illness will require substantial recruitment and educational efforts.

Managing hyperactive delirium and spinal immobilisation in the intensive care setting: a case study and reflective discussion of the literature

The management of ventilated patients on intensive care has, at its core, a care bundle; an evidence based group of actions designed to reduce the risk of ventilator-associated pneumonia. One of these is the daily cessation of sedation medication to expedite weaning from ventilatory support. A reflection-on-action exercise was carried out when a spinally injured patient became physically active during a sedation hold. This was attributed to hyperactive delirium. The concern was the conflict between providing evidence based Intensive Care Unit (ICU) therapy care and maintaining spinal immobility. Reflection on this incident led to a literature search for guidance on the likelihood of delirium causing secondary spinal injury in patients with unstable fractures. There was plentiful research on delirium and its consequences but very little examining the link between spinal injury and delirium. In order to be able to provide evidence-based care to future trauma patients the research supporting spinal immobilisation was also examined. The research showed that compliance with ventilator care bundles reduced the risks of acquiring ventilator-associated pneumonia. Research surrounding spinal immobilisation was conflicting and there were no studies linking the consequences of immobilised patients experiencing hyperactive delirium. Through a case study approach the research was reviewed in relation to a particular patient and although literature was lacking some implications for practice could be identified to promote the best possible outcomes. Sedation cessation episodes are an essential part of patient care on intensive care. For spinally injured patients' these may need to be modified to sedation reductions to prevent sudden wakening and uncontrolled movement should the patient be experiencing hyperactive delirium. This case study clearly highlights the need for further research in this area as the consequences of both ventilator associated pneumonia and extending spinal injuries is costly for both patients and hospitals.

Emotional sequelae among survivors of critical illness: a long-term retrospective study

CONTEXT

Treatment in an ICU can be stressful and traumatic for patients, and can lead to various physical, psychological and cognitive sequelae.

OBJECTIVES

The aim of the study was to assess the influence of the social, economic and working status of individuals in regard to long-term anxiety and depression among ICU convalescents.

DESIGN

Retrospective, cross-sectional, 5-year survey between 2005 and 2009.

SETTING

The general ICUs of two hospitals in Lublin (Poland): the Teaching Hospital, Medical University of Lublin and the District Hospital.

PATIENTS

All adults surviving an ICU stay of more than 24 h were eligible. In December 2010, 533 questionnaires were sent to discharged ICU survivors, and 195 (36.6%) were returned. One hundred and eighty-six patients were enrolled in the study. Patients with brain injuries were excluded.

MAIN OUTCOME MEASURES

The questionnaire consisted of the Hospital Anxiety and Depression Scale (HADS); questions defining social, economic and working status before and after intensive care stay, health status before intensive care stay, as well as questions about memories and readmissions to intensive care were included.

RESULTS

According to HADS, 34.4% patients had an anxiety disorder and 27.4% were depressed. There was a strong positive correlation between anxiety and depression (r = +0.726, P<0.001). Better material and housing conditions correlated with lower anxiety and depression rates. Acute Physiology and Chronic Health Evaluation II scores on admission positively correlated with both anxiety (r =+0.187; P=0.011) and depression (r = +0.239; P=0.001). A negative correlation between health status before intensive care admission and HADS scores was observed (anxiety rs = -0.193; P=0.008; depression rs = -0.227; P=0.002); better health resulted in less anxiety and depression disorders.

CONCLUSION

Adverse social and economic status is associated with higher rates of anxiety and depression following ICU stay.

Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis

OBJECTIVE

The purpose of this systematic review was to review the evidence base for exercise in critically ill patients.

DATA SOURCES AND STUDY SELECTION

Using keywords critical care and physical therapy and related synonyms, randomized controlled trials, meta-analyses, and systematic reviews were identified through electronic database searches and citation tracking. Clinical trials with outcomes of mortality, length of hospital and ICU stay, physical function and quality of life, muscle strength, and ventilator-free days were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers abstracted data and assessed quality independently. Effect sizes and 95% confidence intervals were calculated. From 3,126 screened abstracts, 10 randomized controlled trials and five reviews were found. The mean Physiotherapy Evidence Database score was 5.4. Overall there was a significant positive effect favoring physical therapy for the critically ill to improve the quality of life (g = 0.40, 95% confidence interval 0.08, 0.71), physical function (g = 0.46, 95% confidence interval 0.13, 0.78), peripheral muscle strength (g = 0.27, 95% confidence interval 0.02, 0.52), and respiratory muscle strength (g = 0.51, 95% confidence interval 0.12, 0.89). Length of hospital (g = -0.34, 95% confidence interval -0.53, -0.15) and ICU stay (g = -0.34, 95% confidence interval -0.51, -0.18) significantly decreased and ventilator-free days increased (g = 0.38, 95% confidence interval 0.16, 0.59) following physical therapy in the ICU. There was no effect on mortality.

CONCLUSION

Physical therapy in the ICU appears to confer significant benefit in improving quality of life, physical function, peripheral and respiratory muscle strength, increasing ventilator-free days, and decreasing hospital and ICU stay. However, further controlled trials of better quality and larger sample sizes are required to verify the strength of these tentative associations.

Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children

OBJECTIVE

To assess short-term neuropsychological function and academic performance in school children following admission to intensive care and to explore the role of critical neurologic and systemic infection.

DESIGN

A prospective observational case-control study.

SETTING

Two PICUs.

SUBJECTS

A consecutive sample of 88 children aged 5-16 years (median age=10.00, interquartile range=6.00-13.00) who were admitted to intensive care between 2007 and 2010 with meningoencephalitis, septic illness, or other critical illnesses. They were assessed 3 to 6 months following discharge, and their performance was compared with that of 100 healthy controls. Patients were without prior neurologic or neurodevelopmental disorder.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data encompassing demographic and critical illness details were obtained, and children were assessed using tests of intellectual function, memory, and attention. Questionnaires addressing academic performance were returned by teachers. After adjusting for covariates, the children admitted to PICUs significantly underperformed on neuropsychological measures in comparison to healthy controls (p<0.02). Teachers deemed more children admitted to PICUs than controls as performing educationally worse and having problems with school work (ps=0.001), as well as performing below average on aspects of executive function and attention (ps<0.04). Analysis of the effect of illness type on outcome revealed that aspects of neuropsychological function, such as memory function, and teacher-rated academic performance were most reduced in children with meningoencephalitis and septic illness. In the PICU group, multivariable linear regression revealed that worse performance on a composite score of neuropsychologic impairment was more prevalent when children were younger, from a lower social class, and had experienced seizures during their admission (ps<0.02).

CONCLUSIONS

Admission to intensive care is followed by deficits in neuropsychologic performance and educational difficulties, with more severe difficulties noted following meningoencephalitis and septic illness. These results highlight the importance of future studies on cognition and educational outcome incorporating type of illness as a moderating factor.

Neuroimaging after critical illness: implications for neurorehabilitation outcome

Survivors of critical illness frequently have severe and long-lasting cognitive impairments and psychiatric disorders, which adversely affect functional outcomes including return to work, and quality of life. While data regarding cognitive outcomes has increased over the last 15 years, neuroimaging data in medical and surgical critical populations is extremely limited. The abrupt development of new significant cognitive impairments after critical illness along with abnormalities on neuroimaging suggest that critical illness results in new acquired brain injury, similar to that observed in other acquired brain injuries. Abnormalities on neuroimaging including cortical and subcortical lesions, brain atrophy, and white matter hyperintensities (WMH) which occur in widely distributed brain regions. Patients admitted to neurorehabilitation who received critical care related to their primary diagnosis may have sustained neurological injury from the nonspecific effects of their critical illness and as demonstrated in this review, generalized, non-specific neuroimaging findings may be observed and quantified. Given the high prevalence rate of cognitive impairments in this population, neuroimaging is important to help elucidate neuropathology of critical illness acquired brain injury and may be beneficial in guiding rehabilitation outcomes in this population.