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Ramnarain D, Pouwels S, Fernández-Gonzalo S, Navarra-Ventura G, Balanzá-Martínez V. Delirium-related psychiatric and neurocognitive impairment and the association with post-intensive care syndrome-A narrative review. Acta Psychiatr Scand 2023; 147:460-474. [PMID: 36744298 DOI: 10.1111/acps.13534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest. These new-onset or worsening conditions, together with physical alterations, are called post-intensive care syndrome (PICS). Our aim is to update on the latest screening and follow-up options for psychological and cognitive sequelae of PICS. METHOD This narrative review discusses the occurrence of delirium in ICU settings and the relatively new concept of PICS. Psychiatric and neurocognitive morbidities that may occur in survivors of critical illness following delirium are addressed. Future perspectives for practice and research are discussed. RESULTS There is no "gold standard" for diagnosing delirium in the ICU, but two extensively validated tools, the confusion assessment method for the ICU and the intensive care delirium screening checklist, are often used. PICS complaints are frequent in ICU survivors who have suffered delirium and have been recognized as an important public health and socio-economic problem worldwide. Depression, anxiety, post-traumatic stress disorder, and long-term cognitive impairment are recurrently exhibited. Screening tools for these deficits are discussed, as well as the suggestion of early assessment after discharge and at 3 and 12 months. CONCLUSIONS Delirium is a complex but common phenomenon in the ICU and a risk factor for PICS. Its diagnosis is challenging with potential long-term adverse outcomes, including psychiatric and cognitive difficulties. The implementation of screening and follow-up protocols for PICS sequelae is warranted to ensure early detection and appropriate management.
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Affiliation(s)
- Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Intensive Care Medicine, Saxenburgh Medical Center, Hardenberg, The Netherlands.,Departmentof Medical and Clinical Psychology, Center of Research on Psychological and Somatic disease (CoRPS), Tilburg University, Tilburg, The Netherlands
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of General, Abdominal and Minimally Invasive Surgery, Helios Klinikum, Krefeld, Germany
| | - Sol Fernández-Gonzalo
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Guillem Navarra-Ventura
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Vicent Balanzá-Martínez
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Teaching Unit of Psychiatry and Psychological Medicine, Department of Medicine, University of Valencia, Valencia, Spain
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2
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Williams Roberson S, Azeez NA, Taneja R, Pun BT, Pandharipande PP, Jackson JC, Ely EW. Quantitative EEG During Critical Illness Correlates with Patterns of Long-Term Cognitive Impairment. Clin EEG Neurosci 2022; 53:435-442. [PMID: 33289394 PMCID: PMC8561666 DOI: 10.1177/1550059420978009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Many intensive care unit (ICU) survivors suffer disabling long-term cognitive impairment (LTCI) after critical illness. We compared EEG characteristics during critical illness with patients' 1-year neuropsychological outcomes. METHODS We performed a post hoc analysis of patients in the BRAIN-ICU study who had undergone EEG for clinical purposes during admission (n = 10). All survivors underwent formal cognitive assessments at 12-month follow-up. We evaluated EEGs by conventional visual inspection and computed 10 quantitative features. We explored associations between EEG and patterns of LTCI using Wilcoxon rank-sum tests and Spearman's rank correlations. RESULTS Of 521 Vanderbilt patients enrolled in the parent study, 24 had EEG recordings during admission. Ten survivors had EEG tracings available and completed follow-up cognitive testing. All but one inpatient EEG showed generalized background slowing. All patients demonstrated cognitive impairment in at least one domain at follow-up. The most common deficits occurred in delayed memory (DM-median index 62) and visuospatial/constructional (VC-median index 69) domains. Relative alpha power correlated with VC score (ρ = 0.78, P = .008). Peak interhemispheric coherence correlated negatively with DM (ρ = -0.81, P = .018). CONCLUSIONS Quantitative EEG features during critical illness correlated with domain-specific cognitive performance in our small cohort of ICU survivors. Further study in larger prospective cohorts is required to determine whether these relationships hold. SIGNIFICANCE EEG may serve as a prognostic biomarker predicting patterns of long-term cognitive impairment.
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Affiliation(s)
- Shawniqua Williams Roberson
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Naureen Abdul Azeez
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Randip Taneja
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C Jackson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
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3
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Morelli N, Parry SM, Steele A, Lusby M, Montgomery-Yates AA, Morris PE, Mayer KP. Patients Surviving Critical COVID-19 have Impairments in Dual-task Performance Related to Post-intensive Care Syndrome. J Intensive Care Med 2022; 37:890-898. [PMID: 35072548 PMCID: PMC9160440 DOI: 10.1177/08850666221075568] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective The purpose was to examine Dual Task (DT) performance in patients surviving
severe and critical COVID-19 compared to patients with chronic lung disease
(CLD). Secondarily, we aimed to determine the psychometric properties of the
Timed Up and Go (TUG) test in patients surviving COVID-19. Design Prospective, cross-sectional, observational study. Setting Academic medical center within United States. Patients Ninety-two patients including 36 survivors of critical COVID-19 that required
mechanical ventilation (critical-COVID), 20 patients recovering from
COVID-19 that required supplemental oxygen with hospitalization
(severe-COVID), and 36 patients with CLD serving as a control group. Measurements and Main Results Patients completed the TUG, DT-TUG, Short Physical Performance Battery
(SPPB), and Six Minute Walk Test (6MWT) 1-month after hospital discharge. A
subset of patients returned at 3-months and repeated testing to determine
the minimal detectable change (MDC). Critical-COVID group (16.8 ± 7.3)
performed the DT-TUG in significantly slower than CLD group (13.9 ± 4.8 s;
P = .024) and Severe-COVID group (13.1 ± 5.1 s;
P = .025). Within-subject difference between TUG and
DT-TUG was also significantly worse in critical-COVID group (−21%) compared
to CLD (−10%; P = .012), even despite CLD patients having a
higher comorbid burden (P < .003) and older age
(P < .001). TUG and DT-TUG demonstrated strong to
excellent construct validity to the chair rise test, gait speed, and 6MWT
for both COVID-19 groups (r = −0.84to 0.73, P < .05).
One- and 3-months after hospital discharge there was a floor effect of 14%
(n = 5/36) and 5.2% (n = 1/19), respectively for patients in the
critical-COVID group. Ceiling effects were noted in four (11%)
critical-COVID, six (30%) severe-COVID patients for the TUG and DT-TUG at
1-month. Conclusion The ability to maintain mobility performance in the presence of a cognitive
DT is grossly impaired in patients surviving critical COVID-19. DT
performance may subserve the understanding of impairments related to
Post-intensive care syndrome (PICS) for survivors of critical illness.
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Affiliation(s)
- Nathan Morelli
- Congdon School of Health Sciences, High Point University, High Point, NC, USA
| | - Selina M. Parry
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Angela Steele
- Pulmonary Rehabilitation Center, Therapeutic Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Megan Lusby
- Pulmonary Rehabilitation Center, Therapeutic Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Ashley A. Montgomery-Yates
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Kentucky, USA
- Kentucky Research Alliance for Lung Disease, University of Kentucky, Lexington, Kentucky, USA
| | - Peter E. Morris
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Kentucky, USA
- Kentucky Research Alliance for Lung Disease, University of Kentucky, Lexington, Kentucky, USA
| | - Kirby P. Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Kentucky, USA
- Kentucky Research Alliance for Lung Disease, University of Kentucky, Lexington, Kentucky, USA
- Center for Muscle Biology, University of Kentucky, Lexington, Kentucky, USA
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Abstract
Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.
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Affiliation(s)
- M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
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5
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Semler MW, Bernard GR, Aaron SD, Angus DC, Biros MH, Brower RG, Calfee CS, Colantuoni EA, Ferguson ND, Gong MN, Hopkins RO, Hough CL, Iwashyna TJ, Levy BD, Martin TR, Matthay MA, Mizgerd JP, Moss M, Needham DM, Self WH, Seymour CW, Stapleton RD, Thompson BT, Wunderink RG, Aggarwal NR, Reineck LA. Identifying Clinical Research Priorities in Adult Pulmonary and Critical Care. NHLBI Working Group Report. Am J Respir Crit Care Med 2020; 202:511-523. [PMID: 32150460 PMCID: PMC7427373 DOI: 10.1164/rccm.201908-1595ws] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 03/06/2020] [Indexed: 12/14/2022] Open
Abstract
Preventing, treating, and promoting recovery from critical illness due to pulmonary disease are foundational goals of the critical care community and the NHLBI. Decades of clinical research in acute respiratory distress syndrome, acute respiratory failure, pneumonia, and sepsis have yielded improvements in supportive care, which have translated into improved patient outcomes. Novel therapeutics have largely failed to translate from promising preclinical findings into improved patient outcomes in late-phase clinical trials. Recent advances in personalized medicine, "big data," causal inference using observational data, novel clinical trial designs, preclinical disease modeling, and understanding of recovery from acute illness promise to transform the methods of pulmonary and critical care clinical research. To assess the current state of, research priorities for, and future directions in adult pulmonary and critical care research, the NHLBI assembled a multidisciplinary working group of investigators. This working group identified recommendations for future research, including 1) focusing on understanding the clinical, physiological, and biological underpinnings of heterogeneity in syndromes, diseases, and treatment response with the goal of developing targeted, personalized interventions; 2) optimizing preclinical models by incorporating comorbidities, cointerventions, and organ support; 3) developing and applying novel clinical trial designs; and 4) advancing mechanistic understanding of injury and recovery to develop and test interventions targeted at achieving long-term improvements in the lives of patients and families. Specific areas of research are highlighted as especially promising for making advances in pneumonia, acute hypoxemic respiratory failure, and acute respiratory distress syndrome.
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Affiliation(s)
| | | | - Shawn D. Aaron
- Division of Respirology, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Michelle H. Biros
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Roy G. Brower
- Division of Pulmonary and Critical Care Medicine and
| | - Carolyn S. Calfee
- Department of Medicine and
- Department of Anesthesia, University of California, San Francisco, San Francisco, California
| | | | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Department of Physiology, and
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Gong
- Department of Epidemiology
- Department of Population Health, and
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Ramona O. Hopkins
- Department of Psychology, Brigham Young University, Provo, Utah
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
| | - Catherine L. Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Theodore J. Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Bruce D. Levy
- Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas R. Martin
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Michael A. Matthay
- Department of Medicine and
- Department of Anesthesia, University of California, San Francisco, San Francisco, California
| | - Joseph P. Mizgerd
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Marc Moss
- Division of Pulmonary Sciences & Critical Care, University of Colorado, Denver, Colorado
| | | | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher W. Seymour
- Department of Critical Care Medicine and
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Renee D. Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont, Burlington, Vermont
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Harvard University, Boston, Massachusetts
| | - Richard G. Wunderink
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
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6
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Lane-Fall MB, Kuza CM, Fakhry S, Kaplan LJ. The Lifetime Effects of Injury: Postintensive Care Syndrome and Posttraumatic Stress Disorder. Anesthesiol Clin 2018; 37:135-150. [PMID: 30711227 DOI: 10.1016/j.anclin.2018.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Postintensive care syndrome (PICS) is a heterogeneous syndrome marked by physical, cognitive, and mental health impairments experienced by critical care survivors. It is a syndrome that bears significant human and health care costs. Additional research is needed to identify risk factors and diagnostic, preventative, and treatment strategies for PICS. Trauma intensive care unit patients are particularly vulnerable to posttraumatic stress disorder, which shares some of the adverse long-term consequences of PICS and also requires additional research into effective preventative and management strategies.
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Affiliation(s)
- Meghan B Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA.
| | - Catherine M Kuza
- Department of Anesthesiology and Critical Care, Keck School of Medicine of the University of Southern California, Los Angeles County Health System, 1450 San Pablo Street, Suite 3600, Los Angeles, CA 90033, USA
| | - Samir Fakhry
- Department of Surgery, Synergy Surgicalists, Inc, Reston Hospital Center, 1850 Town Center Parkway Suite 309, Reston, VA 20190, USA
| | - Lewis J Kaplan
- Surgical Services, Department of Surgery, Division of Trauma, Surgical Critical Care and Emergency Surgery, Hospital of the University of Pennsylvania, Veteran's Administration Medical Center, Corporal Michael J Crescenz VA Medical Center, Perelman School of Medicine, University of Pennsylvania, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
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7
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Nitchingham A, Kumar V, Shenkin S, Ferguson KJ, Caplan GA. A systematic review of neuroimaging in delirium: predictors, correlates and consequences. Int J Geriatr Psychiatry 2018; 33:1458-1478. [PMID: 28574155 DOI: 10.1002/gps.4724] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/23/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Neuroimaging advances our understanding of delirium pathophysiology and its consequences. A previous systematic review identified 12 studies (total participants N = 764, delirium cases N = 194; years 1989-2007) and found associations with white matter hyperintensities (WMH) and cerebral atrophy. Our objectives were to perform an updated systematic review of neuroimaging studies in delirium published since January 2006 and summarise the available literature on predictors, correlates or outcomes. METHODS Studies were identified by keyword and MeSH-based electronic searches of EMBASE, MEDLINE and PsycINFO combining terms for neuroimaging, brain structure and delirium. We included neuroimaging studies of delirium in adults using validated delirium assessment methods. RESULTS Thirty-two studies (total N = 3187, delirium N = 1086) met the inclusion criteria. Imaging included magnetic resonance imaging (MRI; N = 9), computed tomography (N = 4), diffusion tensor imaging (N = 3), transcranial Doppler (N = 5), near infrared spectroscopy (N = 5), functional-MRI (N = 2), single photon emission computed tomography (N = 1), proton MRI spectroscopy (N = 1), arterial spin-labelling MRI (N = 1) and 2-13 fluoro-2-deoxyglucose positron emission tomography (N = 1). Despite heterogeneity in study design, delirium was associated with WMH, lower brain volume, atrophy, dysconnectivity, impaired cerebral autoregulation, reduced blood flow and cerebral oxygenation and glucose hypometabolism. There was evidence of long-term brain changes following intensive care unit delirium. CONCLUSIONS Neuroimaging is now used more widely in delirium research due to advances in technology. However, imaging delirious patients presents challenges leading to methodological limitations and restricted generalisability. The findings that atrophy and WMH burden predict delirium replicates findings from the original review, while advanced techniques have identified other substrates and mechanisms that warrant further investigation.
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Affiliation(s)
- Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Varun Kumar
- Department of Psychiatry, Blacktown Hospital, Sydney, Australia
| | - Susan Shenkin
- Department of Geriatric Medicine, The University of Edinburgh, Edinburgh, UK
| | - Karen J Ferguson
- Department of Geriatric Medicine, The University of Edinburgh, Edinburgh, UK
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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8
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Jackson JC, Warrington HJ, Kessler R, Kiehl AL, Ely WE. Florbetapir-PET β-amyloid imaging and associated neuropsychological trajectories in survivors of critical illness: A case series. J Crit Care 2017; 44:331-336. [PMID: 29274595 DOI: 10.1016/j.jcrc.2017.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 10/02/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Cognitive impairment resembling Alzheimer's disease is common in survivors of critical illness. We hypothesized that Intensive Care Unit (ICU) survivors with cognitive impairment would have significant amyloid and designed a pilot study to explore this relationship. MATERIALS AND METHODS A pilot, case series of a convenience sample of 14 adult medical and surgical ICU survivors, in a clinical neuroradiology clinic. Patients underwent cognitive testing at 3months, 1year, 4years, and 6years after hospital discharge with the Repeatable Battery for the Assessment of Neuropsychological Status. They received a single PET scan using amyloid PET imaging (florbetapir F18) 2 to 4years after their ICU stay. RESULTS Amyloid (defined as a Standard Uptake Value ratio or SUVr >1.10) was present in 2 of 14 (14%) individuals, both of whom demonstrated significant cognitive impairment yet no consistent decline over time. Of the 6 impaired patients (RBANS<78), 4 (66.7%) were amyloid negative. CONCLUSIONS It is feasible to assess ICU survivors with amyloid imaging. In this small sample, most patients with cognitive impairment were negative on amyloid PET imaging, which raises the possibility that ICU survivors may experience a unique form of dementia not driven by an amyloid related mechanism.
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Affiliation(s)
- James C Jackson
- Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, United States; Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, United States; VA Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States.
| | - Hillary J Warrington
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, United States
| | - Robert Kessler
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Amy L Kiehl
- Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Wesley E Ely
- Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, United States; VA Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
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9
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Haggstrom L, Welschinger R, Caplan GA. Functional neuroimaging offers insights into delirium pathophysiology: A systematic review. Australas J Ageing 2017; 36:186-192. [DOI: 10.1111/ajag.12417] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Lucy Haggstrom
- University of New South Wales; Sydney New South Wales Australia
| | - Robert Welschinger
- Department of Geriatric Medicine; Prince of Wales Hospital; Sydney New South Wales Australia
| | - Gideon A Caplan
- Department of Geriatric Medicine; Prince of Wales Hospital; Sydney New South Wales Australia
- Prince of Wales Clinical School; University of New South Wales; Sydney New South Wales Australia
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10
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Abstract
Delirium is common in critically ill patients and associated with increased length of stay in the intensive care unit (ICU) and long-term cognitive impairment. The pathophysiology of delirium has been explained by neuroinflammation, an aberrant stress response, neurotransmitter imbalances, and neuronal network alterations. Delirium develops mostly in vulnerable patients (e.g., elderly and cognitively impaired) in the throes of a critical illness. Delirium is by definition due to an underlying condition and can be identified at ICU admission using prediction models. Treatment of delirium can be improved with frequent monitoring, as early detection and subsequent treatment of the underlying condition can improve outcome. Cautious use or avoidance of benzodiazepines may reduce the likelihood of developing delirium. Nonpharmacologic strategies with early mobilization, reducing causes for sleep deprivation, and reorientation measures may be effective in the prevention of delirium. Antipsychotics are effective in treating hallucinations and agitation, but do not reduce the duration of delirium. Combined pain, agitation, and delirium protocols seem to improve the outcome of critically ill patients and may reduce delirium incidence.
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Affiliation(s)
- A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - R R Van De Leur
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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