The relationship between executive dysfunction, depression, and mental health-related quality of life in survivors of critical illness: Results from the BRAIN-ICU investigation

Long term cognitive dysfunction among critical care survivors: associated factors and quality of life-a multicenter cohort study

OBJECTIVES

To identify the prevalence and associated factors of cognitive dysfunction, 1 year after ICU discharge, among adult patients, and it´s relation with quality of life.

METHODS

Multicenter, prospective cohort study including ICUs of 10 tertiary hospitals in Brazil, between May 2014 and December 2018. The patients included were 452 adult ICU survivors (median age 60; 47.6% women) with an ICU stay greater than 72 h.

RESULTS

At 12 months after ICU discharge, a Montreal Cognitive Assessment (tMOCA) telephone score of less than 12 was defined as cognitive dysfunction. At 12 months, of the 452 ICU survivors who completed the cognitive evaluation 216 (47.8%) had cognitive dysfunction. In multivariable analyses, the factors associated with long-term (1-year) cognitive dysfunction were older age (Prevalence Ratio-PR = 1.44, P < 0.001), absence of higher education (PR = 2.81, P = 0.005), higher comorbidities on admission (PR = 1.089; P = 0.004) and delirium (PR = 1.13, P < 0.001). Health-related Quality of life (HRQoL), assessed by the mental and physical dimensions of the SF-12v2, was significantly better in patients without cognitive dysfunction (Mental SF-12v2 Mean difference = 2.54; CI 95%, - 4.80/- 0.28; p = 0.028 and Physical SF-12v2 Mean difference = - 2.85; CI 95%, - 5.20/- 0.50; P = 0.018).

CONCLUSIONS

Delirium was found to be the main modifiable predictor of long-term cognitive dysfunction in ICU survivors. Higher education consistently reduced the probability of having long-term cognitive dysfunction. Cognitive dysfunction significantly influenced patients' quality of life, leading us to emphasize the importance of cognitive reserve for long-term prognosis after ICU discharge.

Evaluating neurocognitive outcomes in out-of-hospital cardiac arrest survivors: A comparative study of performance-based and reported measures

AIMS

To (1) describe the prevalence of cognitive dysfunctions using performance-based and reported measures, and (2) explore the correlations between selected performance-based, patient-reported, and observer-reported neurocognitive outcome measures three months after hospital discharge in a population of out-of-hospital cardiac arrest (OHCA) survivors.

METHODS

Data from 193 OHCA survivors was derived from the Danish multicenter REVIVAL cohort study. At three months, four subtests of the performance-based Delis-Kaplan Executive Function System (D-KEFS) (Trail making, Color-word interference, Verbal fluency, and Figure design), the patient-reported Behavior Rating Inventory of Executive Function - Adult (BRIEF-A), and the observer-reported 16-item Short Form (SF) Informant Questionnaire on Cognitive Decline after Cardiac Arrest (SF-16 IQCODE-CA) were collected. Spearman's rank coefficient correlation analysis was performed to examine correlations between D-KEFS, BRIEF-A, and SF-16 IQCODE-CA.

RESULTS

Overall, 21% of survivors exhibited impairment in executive functioning using the D-KEFS subtest Color-word interference, while only 9% self-reported executive impairment (BRIEF-A) and 7% of relatives reported cognitive decline (SF-16 IQCODE-CA) in survivors at three months post-arrest. All correlations between D-KEFS, BRIEF-A and SF-16 IQCODE-CA were negligible to low.

CONCLUSION

The results of this REVIVAL substudy suggest that although the performance-based and reported measures did not correlate, dual neurocognitive screening tools containing both a self-reported and an informant-reported version may have the potential to detect executive discrepancies in the return to everyday life and guide targeted neurorehabilitation after OHCA.

Perioperative research into memory (PRiMe), part 2: Adult burns intensive care patients show altered structure and function of the default mode network

BACKGROUND

Long-term cognitive impairment (LTCI) is experienced by up to two thirds of patients discharged from burns intensive care units (BICUs), however little is known about its neurobiological basis. This study investigated if patients previously admitted to BICU showed structural and functional MRI changes of the Default Mode Network (DMN).

METHODS

Fifteen patients previously admitted to BICU with a significant burns injury, and 15 matched volunteers, underwent structural and functional MRI scans. Functional connectivity, fractional anisotropy and cortical thickness of the main DMN subdivisions (anterior DMN (aDMN), posterior DMN (pDMN) and right (rTPJ) and left (lTPJ) temporo-parietal junctions) were compared between patients and volunteers, with differences correlated against cognitive performance.

RESULTS

Functional connectivity between rTPJ and pDMN (t = 2.91, p = 0.011) and between rTPJ and lTPJ (t = 3.18, p = 0.008) was lower in patients compared to volunteers. Functional connectivity between rTPJ and pDMN correlated with cognitive performance (r2 =0.33, p < 0.001). Mean fractional anisotropy of rTPJ (t = 2.70, p = 0.008) and lTPJ (T = 2.39, p = 0.015) was lower in patients but there was no difference in cortical thickness.

CONCLUSIONS

Patients previously admitted to BICU show structural and functional disruption of the DMN. Since functional changes correlate with cognitive performance, this should direct further research into intensive-care-related cognitive impairment.

Cognitive Impairment, Physical Impairment, and Psychological Symptoms in Intensive Care Unit Survivors

BACKGROUND

Post-intensive care syndrome (PICS) affects 25% to 50% of adults who survive an intensive care unit (ICU) stay. Although the compounding of PICS impairments (cognitive, physical, and psychological) could intensify the syndrome, research on relationships among impairments is limited, particularly in patients with delirium.

OBJECTIVES

To examine associations among PICS impairments and examine delirium status and its relationship to PICS impairments at ICU discharge and 1 month later.

METHODS

A descriptive, correlational study of adults who survived an ICU stay. Participants completed measures for depression, anxiety, posttraumatic stress, physical function, functional status, and cognition at ICU discharge and 1 month later. Relationships among PICS impairments were examined with Spearman correlations; differences in impairments by delirium status were assessed with t tests.

RESULTS

Of 50 enrolled participants, 46 were screened for PICS impairment at ICU discharge and 35 were screened 1 month later. Cognitive impairment was the most common impairment at both time points. A positive correlation was found between cognition and functional status at ICU discharge (ρ = 0.50, P = .001) and 1 month later (ρ = 0.54, P = .001). Cognition and physical functioning were positively correlated 1 month after discharge (ρ = 0.46, P = .006). The group with delirium had significantly lower functional status scores than the group without delirium at ICU discharge (P = .04).

CONCLUSIONS

The findings suggest a moderate correlation between cognitive and physical impairments. This relationship should be explored further; ICU survivors with undiagnosed cognitive impairment may have delayed physical recovery and greater risk for injury.

Efficacy of cognitive training on executive functions in healthy older adults: a systematic review with meta-analysis of randomized controlled trials

OBJECTIVE

Systematically review randomized controlled trials on the efficacy of cognitive training on executive functions in healthy older people.

MEASURES

The outcome measures were related to inhibitory control, working memory, and cognitive flexibility.

RESULTS

Thirty-one trials were included in the systematic review and thirteen trials in the meta-analysis. In the overall analysis, the cognitive training enhanced inhibitory control when measured by the Stroop task (p < .001, d = 1.64) and working memory when measured by the Corsi Block task (p = .002, d = .16). A marginal significance was found for working memory in the Digit Span task - Forward (p = .06, d = .92). However, cognitive training did not enhance inhibitory control when measured by the Go/No-Go task (p = .76, d = .59), working memory when measured by the Digit Span - Backward (p = .72, d = .95) and N-Back (p = .10, d = .26) tasks, and cognitive flexibility when measured by Trail Making - Part B (p = .08, d = .27) and Semantic Fluency (p = .49, d = .06) tasks.

CONCLUSION

Mixed evidence was found for inhibitory control and working memory; cognitive flexibility showed no evidence of improvement.

Effects of exercise on cognitive functioning in adults with serious mental illness: A meta analytic review

Cognitive performance is usually impaired in those with serious mental illness (SMI). Exercise may improve cognitive functioning, but studies examining the effects of exercise in SMI indicate heterogenous findings. To estimate the effects of exercise on cognitive outcomes in people with SMI. Randomized controlled trials evaluating the acute or chronic effects of exercise on cognitive functioning in SMI were searched from inception to December 26th, 2022 on major electronic databases. Random effect meta-analyses were conducted to assess the effects of exercise on over the cognitive domains and Standardized Mean Differences (SMD) and 95% confidence intervals (CIs) were used as the effect size measure. Funnel plots and Egger's test of effect size and the Trim and Fill procedure applied if evidence of publication bias was noted. Methodological quality was assessed using RoB 2. A total of 15 chronic (1 acute), 936 participants (46.7% women). Exercise showed large effects on reasoning and problem solving; small effects on executive functioning. Per diagnosis, exercise showed moderate positive effects on executive functioning and large effects on processing speed in people with depression; large effects on reasoning and problem solving in people with schizophrenia. The present study indicates a large beneficial effect of chronic physical exercise on reasoning and problem solving and small effects on executive functioning in people with SMI.

Use of focused computerized cognitive training (Neuroflex) to improve symptoms in women with persistent chemotherapy-related cognitive impairment

Purpose

Chemotherapy-related cognitive impairment (CRCI) is a distressing and increasingly recognized long-term sequela reported by breast cancer patients following cancer treatment. There is an urgent but unmet clinical need for treatments that improve CRCI. In this context, we proposed the use of a novel cognitive enhancement strategy called Neuroflex to target CRCI experienced by breast cancer survivors.

Methods

The primary aim of this pilot study was to evaluate the feasibility and acceptability of Neuroflex, a novel digital cognitive enhancement strategy, in breast and gynecologic cancer survivors with CRCI. Secondary analyses focused on whether improvements in performance on Neuroflex were associated with improvement in subjective cognitive complaints and objective cognitive performance measures.

Results

Participants (N = 21) completed an average of 7.42 hours of Neuroflex training per week, an average of 44.5 (±1.01) hours total, and had a 100% completion rate. Participants exhibited significant improvement in self-reported cognitive function as well as significant improvement on tasks of verbal learning and memory and auditory working memory. Participants also exhibited improvement in mood, as well as improvement on a disability assessment.

Conclusions

Results demonstrate feasibility and that breast cancer survivors are capable of completing a lengthy and challenging cognitive training program. Secondly, Neuroflex may confer specific cognitive benefits to both self-reported and objective performance. Results strongly support further investigation of Neuroflex in a larger controlled trial to establish efficacy for CRCI symptoms. Further studies may also result in optimization of this digital intervention for women with CRCI.

Researches on cognitive sequelae of burn injury: Current status and advances

Burn injury is a devastating disease with high incidence of disability and mortality. The cognitive dysfunctions, such as memory defect, are the main neurological sequelae influencing the life quality of burn-injured patients. The post-burn cognitive dysfunctions are related to the primary peripheral factors and the secondary cerebral inflammation, resulting in the destruction of blood-brain barrier (BBB), as is shown on Computed Tomography (CT) and magnetic resonance imaging examinations. As part of the neurovascular unit, BBB is vital to the nutrition and homeostasis of the central nervous system (CNS) and undergoes myriad alterations after burn injury, causing post-burn cognitive defects. The diagnosis and treatment of cognitive dysfunctions as burn injury sequelae are of great importance. In this review, we address the major manifestations and interventions of post-burn cognitive defects, as well as the mechanisms involved in memory defect, including neuroinflammation, destruction of BBB, and hormone imbalance.

Executive function predict the quality of life and negative emotion in older adults with diabetes: A longitudinal study

AIMS

To investigate the influence of executive function (EF) on current and future quality of life (QoL) and negative emotion (NE) in older adults with diabetes.

METHODS

A total of 128 older adults with diabetes were recruited. Independent variables (demographic information, health and medical conditions, cognitive function, life function) were collected in the first year. Dependent variables (QoL and NE) were collected for 3 years. Pearson's correlation coefficient analysis and stepwise multiple linear regression analysis were performed to identify the predictors of QoL and NE.

RESULTS

EF was the strongest predictor for overall QoL and NE in all 3 years, and accounted for 23.0-36.2% and 11.1-17.1% of the variance, respectively. The second strongest predictor for overall QoL in all 3 years was pain interference, which accounted for 3.2-5.8% of the variance. Pain interference was also the second strongest predictor for NE in the second year, accounting for 5.5% of the variance.

CONCLUSIONS

The present study revealed that EF is more predictive than pain for current and future QoL and NE in older adults with diabetes. We recommend that EF be included as an indicator for diabetes surveillance, and that prevention of EF decline be a part of diabetes management plans.

Association between the presence of delirium during intensive care unit admission and cognitive impairment or psychiatric problems: the Korean ICU National Data Study

Objective

Delirium in the intensive care unit (ICU) may be a preventable risk factor for cognitive impairment or psychiatric problems. We aimed to evaluate the association between the presence of delirium during hospitalization involving ICU care and post-discharge cognitive impairment or psychiatric problems.

Design

A retrospective cohort study.

Setting

A database of nationwide insurance claims data.

Patients

All adult patients aged 18 years or older who were admitted to an ICU between January 1, 2008, and May 31, 2015, and had no history of previous cognitive impairment or psychiatric problems were included in the study.

Interventions

None.

Measurements and main results

Of 306,011 patients who met the inclusion criteria, the proportion of those who experienced delirium during hospitalization was 55.0% (n = 168,190). The patients with delirium during hospitalization had significantly increased odds for cognitive impairment (adjusted hazard ratio [HR] 1.17; 95% confidence interval [CI] 1.05–1.29) and psychiatric problems (adjusted HR 1.78; 95% CI 1.67–1.90) after discharge compared with patients without delirium. In patients who had delirium, the incidence of cognitive impairment was 210.8 per 1000 person-years. In 19,496 patients who were diagnosed with cognitive impairment, depression (n = 3233, 16.5%), sleep disorder (n = 1791, 9.2%), and anxiety (n = 1683, 8.6%) were commonly co-diagnosed. The most common psychiatric problem was sleep disorder (148.7 per 1000 person-years), followed by depression (133.3 per 1000 person-years).

Conclusions

Among patients received ICU care, those who experienced delirium during hospitalization had an increased risk of developing cognitive impairment or psychiatric problems post-discharge. Many patients showed multiple cognitive impairment and psychiatric problems during the follow-up period. Efforts to decrease these problems should be made to increase the quality of life of these ICU survivors.

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.

Características del síndrome post cuidado intensivo: revisión de alcance

Objetivo: identificar la evidencia disponible de las características del síndrome post unidad de cuidado intensivo en el paciente que egresa de la unidad de cuidado intensivo. Método: revisión de alcance con la metodología del Joanna Briggs Institut, en cinco bases de datos con la estrategia de búsqueda ([PostIntensive AND Care AND Syndrome] [Nursing AND Care AND PICS]). Se incluyeron estudios primarios publicados entre los años 2010 y 2020, disponibles en texto completo. Resultados: después del análisis de los 48 estudios primarios se extrajeron seis categorías temáticas así: aspecto cognitivo en el síndrome post UCI, osteomusculares, psicoemocionales, estrategias de prevención con modelos de sobrevivientes de UCI, síndrome post unidad cuidado intensivo en la familia y herramientas de evaluación. Conclusiones: mejorar la calidad de atención de los pacientes que presentan este síndrome, prevenir la aparición y aumentar la calidad de vida prestada a los sobrevivientes de UCI y sus familias. La evidencia reporta que entre los cuidadores se pueden desencadenar distintos trastornos que disminuyen su calidad de vida. La enfermería juega un papel crucial en la prevención de la aparición del síndrome mediante estrategias en la UCI e interdisciplinares; los planes de egreso y seguimiento a los pacientes pueden lograr que estos se rehabiliten más rápido y eviten discapacidades o secuelas a largo plazo.

Frequency and profile of objective cognitive deficits in hospitalized patients recovering from COVID-19

Early reports and case series suggest cognitive deficits occurs in some patients with COVID-19. We evaluated the frequency, severity, and profile of cognitive dysfunction in patients recovering from prolonged COVID-19 hospitalization who required acute inpatient rehabilitation prior to discharge. We analyzed cross-sectional scores from the Brief Memory and Executive Test (BMET) in a cohort of N = 57 COVID-19 patients undergoing inpatient rehabilitation, calculating the frequency of impairment based on neuropsychologist diagnosis and by age-normed BMET subtests. In total, 43 patients (75%) were male, 35 (61%) were non-white, and mean age was 64.5 (SD = 13.9) years. In total, 48 (84%) were previously living at home independently. Two patients had documented preexisting cognitive dysfunction; none had known dementia. Patients were evaluated at a mean of 43.2 (SD = 19.2) days after initial admission. In total, 50 patients (88%) had documented hypoxemic respiratory failure and 44 (77%) required intubation.  Forty-six patients (81%) had cognitive impairment, ranging from mild to severe. Deficits were common in working memory (26/47 [55%] of patients), set-shifting (21/44 [47%]), divided attention (18/39 [46%]), and processing speed (14/35 [40%]). Executive dysfunction was not significantly associated with intubation length or the time from extubation to assessment, psychiatric diagnosis, or preexisting cardiovascular/metabolic disease. Attention and executive functions are frequently impaired in COVID-19 patients who require acute rehabilitation prior to discharge. Though interpretation is limited by lack of a comparator group, these results provide an early benchmark for identifying and characterizing cognitive difficulties after COVID-19. Given the frequency and pattern of impairment, easy-to-disseminate interventions that target attention and executive dysfunctions may be beneficial to this population.

Self-Rated Executive Function and Health-Related Quality of Life in Young Adults With Persistent Post-Concussion Symptoms: A Cross-Sectional Study

OBJECTIVE

To assess self-reported executive dysfunction in young adult patients with persistent post-concussion symptoms (PCS) 2-6 months post-injury, and the association with self-reported Health-Related Quality of Life (HRQoL).

METHOD

This cross-sectional study carried out in a hospital setting was a secondary analysis of data from a separate randomized trial testing the effect of a novel intervention, "Get going After concussIoN " (GAIN), for persistent PCS. Patients (18-30 years) were recruited from a clinical cohort of patients with a hospital diagnosis of concussion or referred by primary care physicians. Main measures were The Behaviour Rating Inventory of Executive Function-Adult Version providing two index scores, that is, the Metacognitive Index (MI) and the Behavioural Regulation Index (BRI), and the Quality of Life after Brain Injury-Overall Scale.

RESULTS

Compared with normative data, patients had elevated scores (i.e., worse functioning) on both the MI and the BRI. In linear regression analysis, the MI score, but not the BRI score, was negatively associated with self-reported HRQoL (MI: slope = -.27, 95% confidence interval, CI [-.53, -.02], p = .03; BRI: slope = -.19, 95% CI [-.49, .13], p = .24), suggesting a positive association of subjective executive dysfunction and lower HRQoL. However, the association was attenuated after adjustment for self-reported psychological distress (MI: slope = -.09, 95% CI [-.34, .17], p = .51).

CONCLUSION

Self-reported executive dysfunction is common in young adult patients with persistent PCS, but not strongly associated with decreased HRQoL after adjusting for concurrent psychological distress.

Socioeconomic Factors and Intensive Care Unit-Related Cognitive Impairment

OBJECTIVE

We aimed to identify socioeconomic and clinical risk factors for post-intensive care unit (ICU)-related long-term cognitive impairment (LTCI).

SUMMARY BACKGROUND DATA

After delirium during ICU stay, LTCI has been increasingly recognized, but without attention to socioeconomic factors.

METHODS

We enrolled a prospective, multicenter cohort of ICU survivors with shock or respiratory failure from surgical and medical ICUs across 5 civilian and Veteran Affairs (VA) hospitals from 2010 to 2016. Our primary outcome was LTCI at 3- and 12 months post-hospital discharge defined by the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS) global score. Covariates adjusted using multivariable linear regression included age, sex, race, AHRQ socioeconomic index, Charlson comorbidity, Framingham stroke risk, Sequential Organ Failure Assessment, duration of coma, delirium, hypoxemia, sepsis, education level, hospital type, insurance status, discharge disposition, and ICU drug exposures.

RESULTS

Of 1040 patients, 71% experienced delirium, and 47% and 41% of survivors had RBANS scores >1 standard deviation below normal at 3- and 12 months, respectively. Adjusted analysis indicated that delirium, non-White race, lower education, and civilian hospitals (as opposed to VA), were associated with at least a half standard deviation lower RBANS scores at 3- and 12 months (P ≤ 0.03). Sex, AHRQ socioeconomic index, insurance status, and discharge disposition were not associated with RBANS scores.

CONCLUSIONS

Socioeconomic and clinical risk factors, such as race, education, hospital type, and delirium duration, were linked to worse PICS ICU-related, LTCI. Further efforts may focus on improved identification of higher-risk groups to promote survivorship through emerging improvements in cognitive rehabilitation.

The effect of postintensive care syndrome on the quality of life of intensive care unit survivors: A secondary analysis

BACKGROUND

Despite increasing interest in postintensive care syndrome and the quality of life of intensive care unit survivors, the empirical literature on the relationship between these two variables is limited.

OBJECTIVES

This study aimed to examine whether postintensive care syndrome predicts the quality of life of intensive care unit survivors.

METHODS

We analysed secondary data, which were collected as part of a larger cross-sectional study. The participants were recruited from six health institutions in Korea. The data of 496 survivors who had been admitted to an intensive care unit for at least 48 h during the past year were analysed. They responded to measures of postintensive care syndrome and quality of life.

RESULTS

The participants' mean physical and mental component summary scores (quality of life) were 40.08 ± 8.99 and 40.24 ± 11.19, respectively. Physical impairment (β = -0.48, p < 0.001), unemployment (β = -0.19, p < 0.001), low income (β = -0.11, p = 0.004), older age (β = -0.08, p = 0.039), and cognitive impairment (β = -0.11, p = 0.045) predicted lower physical component summary scores. Mental (β = -0.49, p < 0.001) and cognitive impairment (β = -0.14, p = 0.005) and low income (β = -0.09, p = 0.014) predicted mental component summary scores.

CONCLUSIONS

The participants reported poor physical and mental health-related quality of life. Postintensive care syndrome, unemployment, low income, and older age were the main predictors of poor quality of life. In addition, postintensive care syndrome was a stronger risk factor for poor quality of life than demographic characteristics and intensive care unit treatment factors.

Delirium

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.

Approaches to Addressing Post-Intensive Care Syndrome among Intensive Care Unit Survivors. A Narrative Review

Critical illness can be lethal and devastating to survivors. Improvements in acute care have increased the number of intensive care unit (ICU) survivors. These survivors confront a range of new or worsened health states that collectively are commonly denominated post-intensive care syndrome (PICS). These problems include physical, cognitive, psychological, and existential aspects, among others. Burgeoning interest in improving long-term outcomes for ICU survivors has driven an array of potential interventions to improve outcomes associated with PICS. To date, the most promising interventions appear to relate to very early physical rehabilitation. Late interventions within aftercare and recovery clinics have yielded mixed results, although experience in heart failure programs suggests the possibility that very early case management interventions may help improve intermediate-term outcomes, including mortality and hospital readmission. Predictive models have tended to underperform, complicating study design and clinical referral. The complexity of the health states associated with PICS suggests that careful and rigorous evaluation of multidisciplinary, multimodality interventions-tied to the specific conditions of interest-will be required to address these important problems.

Long-term cognitive impairment after ICU treatment: a prospective longitudinal cohort study (Cog-I-CU)

In this prospective cohort study we aimed to investigate the trajectory of the cognitive performance of patients after discharge from an intensive care unit (ICU). Special consideration was given to patients with suspected premorbid cognitive impairment who might be at risk for the development of dementia. Clinical characteristics were collected until discharge. The premorbid cognitive state was estimated by a structured interview with a close relative. Cognitive outcome was assessed using the Consortium to Establish a Registry of Alzheimer’s Disease (CERAD) Plus battery and the Stroop Color and Word Test at the time of discharge from ICU and 9 months later. The results of the study group were compared to an established healthy control group and to normative data. A total number of 108 patients were finally included. At the time of discharge, patients underperformed the healthy control group. In linear regression models, delirium during the ICU stay and the factor premorbid cognitive impairment were associated with poorer cognitive outcome (p = 0.047 and p = 0.001). After 9 months, in 6% of patients without evidence of premorbid cognitive impairment long-lasting deficits were found. In patients with suspected premorbid cognitive impairment, performance in tests of executive function failed to improve.

Association of self-reported executive function and mood with executive function task performance across adult populations

Executive function (EF) impacts behavior associated with health outcomes. EF can be measured using self-report and/or performance measures, but the correlations between these types of measures are mixed in the extant literature. This study examined self-report and performance-based measures of EF using data from 6 studies, including community and clinical populations (410 participants, ages 19-80, 71% female). Partial correlations revealed significant relationships between performance on the Trail making, Delay Discounting, and Stop Signal tasks with self-reported EF (p < .006 after controlling for age). Mood scores were significantly related to all self-reported domains of EF (p < .0001), and mood and EF scores were correlated over time. When also controlling for mood, correlations between delay discounting and stop signal tasks with self-reported EF remained significant (p < .006). Finally, examining EF scores in participants with and without clinically elevated mood scores showed a wider distribution of self-reported EF scores among those with clinically elevated mood symptoms than among those without. We conclude that self-reported EF is associated with tasks measuring delay discounting and response inhibition in our large, heterogenous population and that assessing EF may be particularly important for those with high levels of mood symptoms.

Randomized Clinical Trial of an ICU Recovery Pilot Program for Survivors of Critical Illness

OBJECTIVES

To examine the effect of an interdisciplinary ICU recovery program on process measures and clinical outcomes.

DESIGN

A prospective, single-center, randomized pilot trial.

SETTING

Academic, tertiary-care medical center.

PATIENTS

Adult patients admitted to the medical ICU for at least 48 hours with a predicted risk of 30-day same-hospital readmission of at least 15%.

INTERVENTIONS

Patients randomized to the ICU recovery program group were offered a structured 10-intervention program, including an inpatient visit by a nurse practitioner, an informational pamphlet, a 24 hours a day, 7 days a week phone number for the recovery team, and an outpatient ICU recovery clinic visit with a critical care physician, nurse practitioner, pharmacist, psychologist, and case manager. For patients randomized to the usual care group, all aspects of care were determined by treating clinicians.

MEASUREMENTS AND MAIN RESULTS

Among the primary analysis of enrolled patients who survived to hospital discharge, patients randomized to the ICU recovery program (n = 111) and usual care (n = 121) were similar at baseline. Patients in the ICU recovery program group received a median of two interventions compared with one intervention in the usual care group (p < 0.001). A total of 16 patients (14.4%) in the ICU recovery program group and 26 patients (21.5%) in the usual care group were readmitted to the study hospital within 30 days of discharge (p = 0.16). For these patients, the median time to readmission was 21.5 days (interquartile range, 11.5-26.2 d) in the ICU recovery program group and 7 days (interquartile range, 4-21.2 d) in the usual care group (p = 0.03). Four patients (3.6%) in the ICU recovery program and 14 patients (11.6%) in the usual care group were readmitted within 7 days of hospital discharge (p = 0.02). The composite outcome of death or readmission within 30 days of hospital discharge occurred in 20 patients (18%) in the ICU recovery program group and 36 patients (29.8%) in usual care group (p = 0.04).

CONCLUSIONS

This randomized pilot trial found that a multidisciplinary ICU recovery program could deliver more interventions for post ICU recovery than usual care. The finding of longer time-to-readmission with an ICU recovery program should be examined in future trials.

Postseptic Cognitive Impairment and Expression of APOE in Peripheral Blood: The Cognition After SepsiS (CASS) Observational Pilot Study

BACKGROUND

Cognitive impairment after sepsis is an important clinical problem. Determinants of postseptic cognitive impairment are not well understood. We thus undertook a systems biology approach to exploring a possible role for apolipoprotein E (APOE) in postseptic cognitive impairment.

DESIGN

Prospective, observational cohort.

SETTING

Intermountain Medical Center, a tertiary referral center in Utah.

PATIENTS/PARTICIPANTS

Patients with sepsis admitted to study intensive care units.

INTERVENTIONS

None.

METHODS

We obtained peripheral blood for deep sequencing of RNA and followed up survivors at 6 months with a battery of cognitive instruments. We defined cognitive impairment based on the 6-month Hayling test of executive function. In our primary analysis, we employed weighted network analysis. Secondarily, we compared variation in gene expression between patients with normal versus impaired cognition.

MEASUREMENTS AND MAIN RESULTS

We enrolled 40 patients, of whom 34 were follow-up eligible and 31 (91%) completed follow-up; 1 patient's RNA sample was degraded-the final analytic cohort was 30 patients. Mean Hayling test score was 5.8 (standard deviation 1.1), which represented 20% with impaired executive function. The network module containing APOE was dominated by low-expression genes, with no association on primary analysis (P = .8). Secondary analyses suggested several potential lines of future investigation, including oxidative stress.

CONCLUSIONS

In this prospective pilot cohort, executive dysfunction affected 1 in 5 survivors of sepsis. The APOE gene was sparsely transcribed in peripheral leukocytes and not associated with cognitive impairment. Future lines of research are suggested.

Challenges in conducting long-term outcomes studies in critical care

PURPOSE OF REVIEW

Evaluating longer term mortality, morbidity, and quality of life in survivors of critical illness is a research priority. This review details the challenges of long-term follow-up studies of critically ill patients and highlights recently proposed methodological solutions.

RECENT FINDINGS

Barriers to long-term follow-up studies of critical care survivors include high rates of study attrition because of death or loss to follow-up, data missingness from experienced morbidity, and lack of standardized outcome as well as reporting of key covariates. A number of recent methods have been proposed to reduce study patients attrition, including minimum data set selection and visits to transitional care or home settings, yet these have significant downsides as well. Conducting long-term follow-up even in the absence of such models carries a high expense, as personnel are very costly, and patients/families require reimbursement for their time and inconvenience.

SUMMARY

There is a reason why many research groups do not conduct long-term outcomes in critical care: it is very difficult. Challenges of long-term follow-up require careful consideration by study investigators to ensure our collective success in data integration and a better understanding of underlying mechanisms of mortality and morbidity seen in critical care survivorship.

Comprehensive care of ICU survivors: Development and implementation of an ICU recovery center

PURPOSE

To describe the design and initial implementation of an Intensive Care Unit Recovery Center (ICU-RC) in the United States.

MATERIALS AND METHODS

A prospective, observational feasibility study was undertaken at an academic hospital between July 2012 and December 2015. Clinical criteria were used to develop the ICU-RC, identify patients at high risk for post intensive care syndrome (PICS), and offer them post-ICU care.

RESULTS

218/307 referred patients (71%) survived to hospital discharge; 62 (28% of survivors) were seen in clinic. Median time from discharge to ICU-RC visit was 29days. At initial evaluation, 64% of patients had clinically meaningful cognitive impairment. Anxiety and depression were present in 37% and 27% of patients, respectively. One in three patients was unable to ambulate independently; median 6min walk distance was 56% predicted. Of 47 previously working patients, 7 (15%) had returned to work. Case management and referral services were provided 142 times. The median number of interventions per patient was 4.

CONCLUSIONS

An ICU-RC identified a high prevalence of cognitive impairment, anxiety, depression, physical debility, lifestyle changes, and medication-related problems warranting intervention. Whether an ICU-RC can improve ICU recovery in the US should be investigated in a systematic way.

In a Model of Neuroinflammation Designed to Mimic Delirium, Quetiapine Reduces Cortisol Secretion and Preserves Reversal Learning in the Attentional Set Shifting Task

Quetiapine, an atypical antipsychotic medication has lacked pre-clinical validation for its purported benefits in the treatment of delirium. This laboratory investigation examined the effects of quetiapine on the attentional set shifting task (ASST), a measure of cognitive flexibility and executive functioning, in a rodent model of lipopolysaccharide (LPS) mediated neuroinflammation. 19 Sprague Dawley female rats were randomly selected to receive intraperitoneal placebo (N = 5), LPS and placebo (N = 7) or LPS and quetiapine (n = 7) and performed the ASST. We measured trials to criterion, errors, non-locomotion episodes and latency to criterion, serum cortisol and tumor necrosis factor alpha (TNF-α) levels. TNF-α levels were not different between groups at 24 h. Cortisol levels in the LPS + Quetiapine group were reduced compared to LPS + Placebo (P < 0.001) and did not differ from the placebo group (P = 0.15). Analysis between LPS + Quetiapine and LPS + Placebo treated rats demonstrated improvement in the compound discrimination reversal (CD Rev1) (P = 0.016) and the intra-dimensional reversal (ID Rev2) (P = 0.007) discriminations on trials to criterion. LPS + Quetiapine treated rats had fewer errors than LPS + Placebo treated animals in the compound discrimination (CD) (P = 0.007), CD Rev1 (P = 0.005), ID Rev2 (P < 0.001) discriminations. There was no difference in non-locomotion frequency or latency to criterion between the three groups in all discriminations (P > 0.0167). We demonstrated preserved reversal learning, no effect on attentional set shifting and normalized cortisol levels in quetiapine-treated rats in this neuroinflammatory model of delirium. This suggests that quetiapine's beneficial effects in delirium may be related to the preservation of reversal learning and potential downstream effects related to reduction in cortisol production. Graphical Abstract.

Relationship of symptoms associated with ICU-survivorship: An integrative literature review

BACKGROUND

The number of adults who survive a critical illness involving admission to an intensive care unit is increasing. These survivors have an increased risk of developing impairments in cognition, physical function and psychological health.

OBJECTIVE

This integrative literature review examined the literature for studies exploring the relationships among two or more of the variables of interest, i.e. cognitive, physical, and psychological symptoms (depressive, anxiety, or posttraumatic stress) in intensive care unit survivors post-hospital discharge.

METHODS

A literature search was conducted using PubMed, CINHAL and PsycINFO databases.

FINDINGS

While all 13 studies included in the review explored some aspect of a relationship among the variables of interest, none explored associations among all three variables. Five studies explored physical function and psychological symptoms, four studies explored cognitive impairment and psychological symptoms and five studies explored the association among different psychological symptoms. Inconsistencies were found in the study designs, follow-up time frames, patient populations and measures used.

CONCLUSIONS

Further research using well-designed methodologies and standardized instruments is warranted. Gaining a better understanding of the relationships among these impairments has the potential to contribute to the development of screening guidelines, preventative strategies, and treatments.

Changes in health-related quality of life after discharge from an intensive care unit: a systematic review

Quality of life after critical illness is becoming increasingly important as survival improves. Various measures have been used to study the quality of life of patients discharged from intensive care. We systematically reviewed validated measures of quality of life and their results. We searched PubMed, CENTRAL, CINAHL, Web of Science and Open Grey for studies of quality of life, measured after discharge from intensive care. We categorised studied populations as: general; restricted to level-3 care or critical care beyond 5 days; and septic patients. We included quality of life measured at any time after hospital discharge. We identified 48 studies. Thirty-one studies used the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and 19 used the EuroQol-5D (EQ-5D); eight used both and nine used alternative validated measures. Follow-up rates ranged from 26-100%. Quality of life after critical care was worse than for age- and sex-matched populations. Quality of life improved for one year after hospital discharge. The aspects of life that improved most were physical function, physical role, vitality and social function. However, these domains were also the least likely to recover to population norms as they were more profoundly affected by critical illness.

Early Post-Intensive Care Syndrome among Older Adult Sepsis Survivors Receiving Home Care

BACKGROUND/OBJECTIVES

New or worsened disabilities in functional, cognitive, or mental health following an intensive care unit (ICU) stay are referred to as post-intensive care syndrome (PICS). PICS has not been described in older adults receiving home care. Our aim was to examine the relationship between length of ICU stay and PICS among older adults receiving home care. We expected that patients in the ICU for 3 days or longer would demonstrate significantly more disability in all three domains on follow-up than those not in the ICU. A secondary aim was to identify patient characteristics increasing the odds of disability.

DESIGN

Retrospective cohort study.

SETTING

Hospitalization for sepsis in the United States.

PARTICIPANTS

A total of 21 520 Medicare patients receiving home care and reassessed a median of 1 day (interquartile range 1-2 d) after hospital discharge.

MEASUREMENTS

PICS was defined as a decline or worsening in one or more of 16 indicators tested before and after hospitalization using OASIS (Home Health Outcome and Assessment Information Set) and Medicare claims data.

RESULTS

The sample was predominantly female and white. All had sepsis, and most (81.8%) had severe sepsis. In adjusted models, an ICU stay of 3 days or longer, compared with no ICU stay, increased the odds of physical disability. Overall, the declines were modest and found in specific activities of daily living (16% for feeding and lower body dressing to 26% for oral medicine management). No changes were identified in cognition or mental health. Significant determinants of new or worsened physical disabilities were sepsis severity, older age, depression, frailty, and dementia.

CONCLUSION

Older adults receiving home care who develop sepsis and are in an ICU for 3 days or longer are likely to develop new or worsened physical disabilities. Whether these disabilities remain after the early postdischarge phase requires further study. J Am Geriatr Soc 67:520-526, 2019.

Deficits in Self-Reported Initiation Are AssociatedWith Subsequent Disability in ICU Survivors

OBJECTIVE

To determine whether deficits in a key aspect of executive functioning, namely, initiation, were associated with current and future functional disabilities in intensive care unit survivors.

METHODS

A nested substudy within a 2-center prospective observational cohort. We used 3 tests of initiation at 3 and 12 months: the Ruff Total Unique Design, Controlled Oral Word Association, and Behavior Rating Inventory of Executive Function initiation. Disability in instrumental activities of daily living (IADL) was measured with the Functional Activities Questionnaire. We used a proportional odds logistic regression model to evaluate the association between initiation and disability. Covariates in the model included age, education, baseline Functional Activities Questionnaire, pre-existing cognitive impairment, comorbidities, admission severity of illness, episodes of hypoxia, and days of severe sepsis.

RESULTS

In 195 patients, after adjusting for covariates, only the Behavior Rating Inventory of Executive Function initiation was associated with disability at any time point. Comparing the 25th vs the 75th percentile scores (95% confidence interval) of the Behavior Rating Inventory of Executive Function initiation at 3 months, patients with worse initiation scores had 5.062 times the odds (95% confidence interval: 2.539, 10.092) of disability according to the Functional Activities Questionnaire at 3 months, with similar odds at 12 months (odds ratio: 3.476, 95% confidence interval: 1.943, 6.216). Worse Behavior Rating Inventory of Executive Function initiation scores at 3 months were associated with future disability at 12 months odds ratio (95% confidence interval) 5.079 (2.579, 10.000).

CONCLUSIONS

Executive function deficits acquired after a critical illness in the domain of initiation are common in intensive care unit survivors, and when they are identified via self-report tools, they are associated with current and future disability in instrumental activities of daily living.

Predictors of Major Depressive Disorder following Intensive Care of Chronically Critically Ill Patients

OBJECTIVE

Major depressive disorder (MDD) is a common condition following treatment in the Intensive Care Unit (ICU). Long-term data on MDD in chronically critically ill (CCI) patients are scarce. Hence, the primary aim of the present study was to investigate the frequency and predictors of MDD after intensive care of CCI patients.

MATERIALS AND METHODS

In a prospective cohort study, patients with long-term mechanical ventilation requirements (n=131) were assessed with respect to a diagnosis of MDD, using the Structured Clinical Interview for DSM-IV, three and six months after the transfer from acute ICU to post-acute ICU. Sociodemographic, psychological, and clinical risk factors with p values ≤ 0.1 were identified in a univariate logistic regression analysis and entered in a multivariable logistic regression model. A mediator analysis was run using the bootstrapping method, testing the mediating effect of perceived helplessness during the ICU stay, between the recalled traumatic experience from the ICU and a post-ICU MDD.

RESULTS

17.6% (n=23) of the patients showed a full- or subsyndromal MDD. Perceived helplessness, recalled experiences of a traumatic event from the ICU, symptoms of acute stress disorder, and the diagnosis of posttraumatic stress disorder (PTSD) after ICU could be identified as significant predictors of MDD. In a mediator analysis, perceived helplessness could be proved as a mediator.

CONCLUSIONS

Every fifth CCI patient suffers from MDD up to six months after being discharged from ICU. Particularly, perceived helplessness during the ICU stay seems to mainly affect the long-term evolvement of MDD. CCI patients with symptoms of acute stress disorder/PTSD should also be screened for MDD.

Health-related quality of life in intensive care survivors: Associations with social support, comorbidity, and pain interference

BACKGROUND

Experiences during a stay in the intensive care unit (ICU), including pain, delirium, physical deterioration, and the critical illness itself, may all influence survivors' health-related quality of life (HRQOL). However, few studies have examined the influence of social support, comorbidity, and pain interference on ICU survivors' HRQOL.

OBJECTIVES

To investigate possible associations between social support, number of comorbidities, and pain interference on HRQOL in ICU survivors.

METHODS

ICU survivors responded to a survey 3 months (n = 118) and 1 year (n = 89) after ICU discharge. HRQOL was measured using the Short Form Health Survey-12 (v1), social support using the revised Social Provision Scale, pain interference using the Brief Pain Inventory-Short Form, and comorbidities using the Self-Administered Comorbidity Questionnaire.

RESULTS

Physical and mental HRQOL were reduced at both 3 months and 1 year in ICU survivors compared with the general population. This reduction was more pronounced at 3 months for physical HRQOL, while a small reduction in mental HRQOL was not clinically relevant. Social support was statistical significantly positively associated with mental HRQOL at 3 months, while number of comorbidities was statistical significantly associated with a reduction in physical HRQOL at 3 months and 1 year and mental HRQOL at 1 year. Lastly pain interference was significantly associated with a reduction in physical HRQOL at 3 months and 1 year.

CONCLUSIONS

ICU survivors primarily report reduced physical HRQOL. Social support was positively associated with mental HRQOL, while number of comorbidities, and pain interference were all significantly associated with a reduction in HRQOL. Pain interference was associated with the largest reduction in HRQOL.

Perioperative Research into Memory (PRiMe): Cognitive impairment following a severe burn injury and critical care admission, part 1

INTRODUCTION

An investigation into long-term cognitive impairment and Quality of Life (QoL) after severe burns.

METHODS

A proof of principle, cohort design, prospective, observational clinical study. Patients with severe burns (>15% TBSA) admitted to Burns ICU for invasive ventilation were recruited for psychocognitive assessment with a convenience sample of age and sex-matched controls. Participants completed psychological and QoL questionnaires, the Cogstate^® electronic battery, Hopkins Verbal Learning, Verbal Fluency and Trail making tasks.

RESULTS

15 patients (11M, 4F; 41±14 years; TBSA 38.4%±18.5) and comparators (11M, 4F; 40±13 years) were recruited. Burns patients reported worse QoL (Neuro-QoL Short Form v2, patient 30.1±8.2, control 38.7±3.2, p=0.0004) and cognitive function (patient composite z-score 0.01, IQR -0.11 to 0.33, control 0.13, IQR 0.47-0.73, p=0.02). Compared to estimated premorbid FSIQ, patients dropped an equivalent of 8 IQ points (p=0.002). Cognitive function negatively correlated with burn severity (rBaux score, p=0.04). QoL strongly correlated with depressive symptoms (Rho=-0.67, p=0.009) but not cognitive function.

CONCLUSIONS

Severe burns injuries are associated with a significant, global, cognitive deficit. Patients also report worse QoL, depression and post-traumatic stress. Perceived QoL from cognitive impairment was more closely associated with depression than cognitive impairment.

Return to work after severe traumatic brain injury: a national study with a one-year follow-up of neurocognitive and behavioural outcomes

The objectives were to investigate the frequency of return-to-work (RTW) one year after severe traumatic brain injury (sTBI: Glasgow Coma Scale, GCS 3-8) and to identify which demographic and injury-related characteristics and neurocognitive factors are associated with RTW. This study is part of a prospective national study on sTBI conducted in all four Norwegian Trauma Referral Centres, including patients aged >15 years over a period of three years (n = 378). For the purpose of this study, only pre-employed individuals of working age (16 to 67 years) were investigated for RTW (n = 143), and of these, 104 participants underwent neuropsychological testing. Measures of acute injury severity, neuropsychological composite scores (Memory, Processing Speed, Executive Functions) at the one-year follow-up, and the Behaviour Rating Inventory of Executive Functions (patient- and relative reports) were explored as predictors of RTW. The frequency of RTW was 54.5%. Multivariate logistic regression analyses identified younger age, shorter length of stay in intensive care, better Processing Speed scores, and lower levels of metacognitive difficulties as rated by relatives as significant predictors of RTW. Findings support the importance of neuropsychological measures in predicting long-term RTW and highlight the need to address neurocognitive and behavioural difficulties to improve RTW after sTBI.

Does pulmonary rehabilitation alleviate depression in older patients with chronic obstructive pulmonary disease

Objectives:

To identify if pulmonary rehabilitation can achieve a clinically significant alleviation in the level of depression among chronic obstructive pulmonary disease (COPD) patients older than 70 years.

Methods:

We conducted a retrospective secondary analysis of the patients’ electronic records from a major pulmonary rehabilitation center in Cleveland, OH, United States between 2010 and 2014. Profiles of 105 participants who had completed more than 6 pulmonary rehabilitation sessions and were older than 70 years at the time of enrollment in the program were included. The Beck Depression Inventory scores at the baseline and the end of the pulmonary rehabilitation sessions were compared.

Results:

There was a statistically and clinically significant reduction in mean scores of depression from the baseline to the end of pulmonary rehabilitation: mean± SD: 104±5.6; p=0.00. The mean±SD depression score at the end was 9±4.3 compared with the baseline 17±7.8. Seventy-seven (73%) participants showed clinically significant improvement in depression; however, 20 participants (27%) had no clinically significant improvement, and 8 (8%) had worse depression at the end of pulmonary rehabilitation. Participants with higher depression scores at the baseline were 1.3 times more likely to achieve clinically significant alleviation in depression at the end of rehabilitation (odds ratio = 1.3, p=0.00).

Conclusion:

Pulmonary rehabilitation induced clinically significant alleviation in depression among participants with COPD aged over 70 years.

Prevalence, Location, and Characteristics of Chronic Pain in Intensive Care Survivors

BACKGROUND

A growing number of studies have addressed the long-term consequences of intensive care unit (ICU) treatment, but few have studied the prevalence of chronic pain and pain characteristics longitudinally.

AIMS

The goal of the work described here was to investigate the prevalence and characteristics of chronic pain in ICU survivors 3 months and 1 year after ICU discharge and to identify risk factors for chronic pain 1 year after ICU discharge.

DESIGN

The design used was an explorative and longitudinal study.

SETTING/PATIENTS

The patients in this work had stayed >48 hours in two mixed ICUs in Oslo University Hospital, a tertiary referral hospital.

METHODS

Patients completed a survey questionnaire 3 months and 1 year after ICU discharge. Pain was assessed using the Brief Pain Inventory-Short Form.

RESULTS

At 3 months after discharge, 58 of 118 ICU survivors (49.2%) reported pain, and at 1 year after discharge, 34 of 89 survivors (38.2%) reported pain. The most common sites of pain at 3 months were the shoulder and abdomen; the shoulder remained the second most common site at 1 year. There was an increase in the interference of pain with daily life at 1 year. Possible risk factors for chronic pain at 1 year were increased severity of illness, organ failure, ventilator time >12 days, and ICU length of stay >15 days. The most common sites of pain were not linked to the admission diagnosis.

CONCLUSIONS

These findings may enable health care providers to improve care and rehabilitation for this patient group.

Long-term recovery following critical illness in an Australian cohort

BACKGROUND

Almost all data on 5-year outcomes for critical care survivors come from North America and Europe. The aim of this study was to investigate long-term mortality, physical function, psychological outcomes and health-related quality of life in a mixed intensive care unit cohort in Australia.

METHODS

This longitudinal study evaluated 4- to 5-year outcomes. Physical function (six-minute walk test) and health-related quality of life (Short Form 36 Version 2) were compared to 1-year outcomes and population norms. New psychological data (Center for Epidemiological Studies-Depression, Impact of Events Scale) was collected at follow-up.

RESULTS

Of the 150 participants, 66 (44%) patients were deceased by follow-up. Fifty-six survivors were included with a mean (SD) age of 64 (14.2). Survivors' mean (SD) six-minute walk distance increased between 1 and 4 to 5 years (465.8 m (148.9) vs. 507.5 m (118.2)) (mean difference = - 24.5 m, CI - 58.3, 9.2, p = 0.15). Depressive symptoms were low: median (IQR) score of 7.0 (1.0-15.0). The mean level of post-traumatic stress symptoms was low-median (IQR) score of 1.0 (0-11.0)-with only 9 (16%) above the threshold for potentially disordered symptoms. Short-Form 36 Physical and Mental Component Scores did not change between 1 and 4 to 5 years (46.4 (7.9) vs. 46.7 (8.1) and 48.8 (13) vs. 48.8 (11.1)) and were within a standard deviation of normal.

CONCLUSIONS

Outcomes of critical illness are not uniform across nations. Mortality was increased in this cohort; however, survivors achieved a high level of recovery for physical function and health-related quality of life with low psychological morbidity at follow-up.

TRIAL REGISTRATION

The trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606.

Aging and Post-Intensive Care Syndrome: A Critical Need for Geriatric Psychiatry

Because of the aging of the intensive care unit (ICU) population and an improvement in survival rates after ICU hospitalization, an increasing number of older adults are suffering from long-term impairments because of critical illness, known as post-intensive care syndrome (PICS). This article focuses on PICS-related cognitive, psychological, and physical impairments and the impact of ICU hospitalization on families and caregivers. The authors also describe innovative models of care for PICS and what roles geriatric psychiatrists could play in the future of this rapidly growing population.

Intensive care survivor-reported symptoms: a longitudinal study of survivors' symptoms

BACKGROUND

There is growing interest in potential long-term outcomes following intensive care, but few researchers have studied the prevalence of multiple symptoms or the association between pain and other symptoms.

AIMS

To investigate the prevalence of anxiety, depression, fatigue, sleep disturbance and post-traumatic stress symptoms (PTSS) among intensive care survivors 3 months and 1 year after being discharged from an intensive care unit (ICU) and to determine whether pain is associated with higher prevalence of these symptoms 3 months and 1 year after ICU stay.

STUDY DESIGN

Exploratory, longitudinal cohort of intensive care survivors from two mixed ICUs in a tertiary referral hospital in Norway.

METHODS

Intensive care survivors completed surveys at 3 months (n = 118) and 1 year (n = 89) after ICU discharge. Clinical Trials: NCT02279212.

RESULTS

Prevalence rates of intensive care survivors' symptoms were pain 58 (49·2%), anxiety/depression 24/118 (20·8%), fatigue 18/118(15·3%), PTSS 15 (12·8%) and sleep disturbance 58/118 (49·2%) at 3 months after ICU discharge (n = 118). Prevalence rates at 1 year (n = 89) changed only slightly to pain 34 (38·2%), anxiety/depression 17 (20·0%), fatigue 12 (13·8%), PTSS 13 (15·1%) and sleep disturbance 40/89 (46·5%). Associations were strong between pain and presence of sleep disturbance, anxiety/depression, PTSS and fatigue.

CONCLUSIONS

Intensive care survivors have multiple symptoms and the prevalence rates of these symptoms remained almost unchanged from 3 months to 1 year after ICU discharge. The presence of pain was associated with high odds for the presence of sleep disturbance, anxiety/depression, PTSS and fatigue, compared to a no-pain group. ICU survivors may benefit from targeted interventions designed to alleviate the symptom burden.

RELEVANCE TO CLINICAL PRACTICE

Knowledge about ICU survivor's prevalence and risk for having multiple symptoms may help health care professionals to give better care, if needed, to the ICU survivors.

A study protocol for an observational cohort investigating COGnitive outcomes and WELLness in survivors of critical illness: the COGWELL study

INTRODUCTION

Up to 9 out of 10 intensive care unit (ICU) survivors will suffer some degree of cognitive impairment at hospital discharge and approximately half will have decrements that persist for years. The mechanisms for this newly acquired brain injury are poorly understood. The purpose of this study is to describe the prevalence of sleep abnormalities and their association with cognitive impairment, examine a well-known genetic risk factor for dementia (Apolipoprotein E ε4) that may allow for genetic risk stratification of ICU survivors at greatest risk of cognitive impairment and determine if electroencephalography (EEG) is an independent predictor of long-term cognitive impairment and possibly a candidate intermediate end point for future clinical trials.

METHODS AND ANALYSIS

This is a multisite, prospective, observational cohort study. The setting for this trial will be medical and surgical ICUs of five large tertiary care referral centres. The participants will be adult patients admitted to a study ICU and invasively ventilated for ≥3 days . Participants will undergo follow-up within 7 days of ICU discharge, 6 months and 1 year. At each time point, patients will have an EEG, blood work (biomarkers; gene studies), sleep study (actigraphy), complete a number of questionnaires as well as undergo neuropsychological testing. The primary outcome of this study will be long-term cognitive function at 12 months follow-up as measured by the Repeatable Battery for the Assessment of Neuropsychological Status and Trails Making Test B.

ETHICS AND DISSEMINATION

The study has received the following approvals: University Health Network Research Ethics Committee (13-6425-BE), Sunnybrook Health Centre Research Ethics Committee (365-2013), Mount Sinai Research Ethics Committee (14-0194-E) and St. Michael's Hospital Research Ethics Committee (14-295). Results will be made available to critical care survivors, their caregivers, the funders, the critical care societies and other researchers.

TRIAL REGISTRATION NUMBER

NCT02086877; Pre-results.