Cognitive Function 3 and 12 Months After ICU Discharge—A Prospective Cohort Study:

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

OBJECTIVES

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

REVIEW METHODS USED

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

There is no study registration number.

Functional independence, frailty and perceived quality of life in patients who developed delirium during ICU stay: a prospective cohort study

BACKGROUND

Survivors of critical illness are frequently left with a long-lasting disability. We hypothesised that patients who developed delirium during ICU stay, compared with patients who did not, would have worse health-related quality of life following a critical illness.

METHODS

Prospective longitudinal observational and analytical study assessing functional independence, frailty and perceived quality of life measured with the Barthel Index, the Clinical Frailty Scale, and the SF-36, comparing patients who developed delirium during ICU stay and patients who did not. The questionnaires were used at different times during the follow-up (upon ICU admission, at ICU discharge, at hospital discharge and 2 years after hospital discharge).

RESULTS

In a cohort of 1462 patients, we matched 93 patients who developed delirium (delirium group) with 93 patients who did not develop delirium (no-delirium group). Of 156 completed questionnaires (84.7%), we observed that (a) in each of the two groups of patients, the scores related to functional independence (Barthel Index) and frailty (Clinical Frailty Scale) tended to improve over time (p < 0.001), being consistently less favourable in the delirium group compared to the no-delirium group (p < 0.001); (b) the patients who developed delirium also presented lower scores on the SF-36 scale, these differences being statistically significant, and therefore evidencing a worse quality of life, with impact on both the psychological and social spheres (p < 0.001).

CONCLUSIONS

Patients who developed delirium had significantly lower scores 2 years after hospital discharge on the three used questionnaires, displaying a clear negative impact on the physical, psychological, and social dimensions. The study's results reinforce the need to support and strengthen the care of ICU survivors.

Assessment of neuropsychiatric manifestations in a cohort of intensive care unit survivors: A proof of concept study

The aim of this study was to assess the feasibility and outcome of a neuropsychiatric evaluation protocol intended for adult intensive care unit survivors in a Danish regional hospital, in which a follow-up consultation was conducted 2 months after hospital discharge. Twenty-three participants were able to finalize the neuropsychiatric evaluation, and 20 (87%) among those were detected with neuropsychiatric manifestations, including cognitive impairment (n = 17; 74%) and fatigue (n = 17, 74%). This study finds a high prevalence of neuropsychiatric manifestations and fatigue, and evaluates a follow-up protocol for the ICU patient population.

Objective and subjective cognition in survivors of COVID-19 one year after ICU discharge: the role of demographic, clinical, and emotional factors

BACKGROUND

Intensive Care Unit (ICU) COVID-19 survivors may present long-term cognitive and emotional difficulties after hospital discharge. This study aims to characterize the neuropsychological dysfunction of COVID-19 survivors 12 months after ICU discharge, and to study whether the use of a measure of perceived cognitive deficit allows the detection of objective cognitive impairment. We also explore the relationship between demographic, clinical and emotional factors, and both objective and subjective cognitive deficits.

METHODS

Critically ill COVID-19 survivors from two medical ICUs underwent cognitive and emotional assessment one year after discharge. The perception of cognitive deficit and emotional state was screened through self-rated questionnaires (Perceived Deficits Questionnaire, Hospital Anxiety and Depression Scale and Davidson Trauma Scale), and a comprehensive neuropsychological evaluation was carried out. Demographic and clinical data from ICU admission were collected retrospectively.

RESULTS

Out of eighty participants included in the final analysis, 31.3% were women, 61.3% received mechanical ventilation and the median age of patients was 60.73 years. Objective cognitive impairment was observed in 30% of COVID-19 survivors. The worst performance was detected in executive functions, processing speed and recognition memory. Almost one in three patients manifested cognitive complaints, and 22.5%, 26.3% and 27.5% reported anxiety, depression and post-traumatic stress disorder (PTSD) symptoms, respectively. No significant differences were found in the perception of cognitive deficit between patients with and without objective cognitive impairment. Gender and PTSD symptomatology were significantly associated with perceived cognitive deficit, and cognitive reserve with objective cognitive impairment.

CONCLUSIONS

One-third of COVID-19 survivors suffered objective cognitive impairment with a frontal-subcortical dysfunction 12 months after ICU discharge. Emotional disturbances and perceived cognitive deficits were common. Female gender and PTSD symptoms emerged as predictive factors for perceiving worse cognitive performance. Cognitive reserve emerged as a protective factor for objective cognitive functioning.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04422444; June 9, 2021.

Patient and public involvement in contemporary large intensive care trials: A meta-epidemiological study

BACKGROUND

Patient and public involvement in randomised clinical trials has received increased focus, including in intensive care trials, but the frequency, method and extent is unknown. This meta-epidemiological study investigated patient and public involvement in contemporary, large ICU trials.

METHODS

We systematically searched PubMed for large (≥225 randomised patients), contemporary trials (published between 1 January 2019 and 31 January 2022) assessing interventions in adult patients in ICU settings. Abstracts and full-text articles were assessed independently and in duplicate. Data were extracted using a pre-defined, pilot-tested data extraction form with details on trials, patient and public involvement including categories and numbers of individuals involved, methods of involvement, and trial stage(s) with involvement. Trials authors were contacted as necessary.

RESULTS

We included 100 trials, with 18 using patient and public involvement; these were larger and conducted in more centres than trials without patient and public involvement. Among trials with patient and public involvement, patients (in 14/18 trials), clinicians (13 trials), and family members (12 trials) were primarily involved, mainly in the development of research design (15 trials) and development of research focus (13 trials) stages and mostly by discussion (12 trials) and solo interviews (10 trials). A median of 65 individuals (range 1-6894) were involved.

CONCLUSIONS

We found patient and public involvement in a fifth of large, contemporary ICU trials. Primarily patients, families, and clinicians were included, particularly in the trial planning stages and mostly through interviews and discussions. Increased patient and public involvement in ICU trials is warranted.

Delirium-related psychiatric and neurocognitive impairment and the association with post-intensive care syndrome-A narrative review

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.

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

Long-term health-related quality of life, healthcare utilisation and back-to-work activities in intensive care unit survivors: Prospective confirmatory study from the Frisian aftercare cohort

Purpose

More substantial information on recovery after Intensive Care Unit (ICU) admission is urgently needed. In a previous retrospective study, the proportion of non-recovery patients was 44%. The aim of this prospective follow-up study was to evaluate changes in Health-Related Quality of Life (HRQoL) in the first year after ICU-admission.

Methods

Long-stay adult ICU-patients (≥ 48 hours) were included. HRQoL was evaluated with the Dutch translation of the RAND-36 item Health Survey (RAND-36) at baseline via proxy measurement, and at three, six, and twelve months after ICU admission. Subsequently, the relation between physical functioning, healthcare utilisation, and work activities was explored.

Results

A total of 81 patients were included in this study. Fifty-five percent of patients did not meet criteria for full recovery and were allocated to the Non Recovery (NR)-group (Physical Functioning domain-score: 35 [15–55]). Baseline physical HRQoL differed significantly between the Recovery (R) and NR-group. Patients in the NR-group received home care more often and had higher healthcare utilisation (44 versus 17% in the first three months post-ICU, p = 0.013). Only fourteen percent of NR-patients were able to participate in work activities. Moreover, NR-patients persistently showed impaired overall HRQoL throughout the year after critical illness.

Conclusions

Limited recovery in ICU survivors is reflected in overall impaired HRQoL, as well as in far-reaching consequences for patients’ healthcare needs and their ability to reintegrate into society. In our study, baseline HRQoL appeared to be an important predictor of long-term outcomes, but not Clinical Frailty Scale (CFS) score. And, (proxy-derived) HRQoL may help to identify patients at risk of long-term non-recovery.

Efficacy and safety of unrestricted visiting policy for critically ill patients: a meta-analysis

Aim

To compare the safety and effects of unrestricted visiting policies (UVPs) and restricted visiting policies (RVPs) in intensive care units (ICUs) with respect to outcomes related to delirium, infection, and mortality.

Methods

MEDLINE, Cochrane Library, Embase, Web of Science, CINAHL, CBMdisc, CNKI, Wanfang, and VIP database records generated from their inception to 22 January 2022 were searched. Randomized controlled trials and quasi-experimental studies were included. The main outcomes investigated were delirium, ICU-acquired infection, ICU mortality, and length of ICU stay. Two reviewers independently screened studies, extracted data, and assessed risks of bias. Random‑effects and fixed-effects meta‑analyses were conducted to obtain pooled estimates, due to heterogeneity. Meta-analyses were performed using RevMan 5.3 software. The results were analyzed using odds ratios (ORs), 95% confidence intervals (CIs), and standardized mean differences (SMDs).

Results

Eleven studies including a total of 3741 patients that compared UVPs and RVPs in ICUs were included in the analyses. Random effects modeling indicated that UVPs were associated with a reduced incidence of delirium (OR = 0.4, 95% CI 0.25–0.63, I² = 71%, p = 0.0005). Fixed-effects modeling indicated that UVPs did not increase the incidences of ICU-acquired infections, including ventilator-associated pneumonia (OR = 0.96, 95% CI 0.71–1.30, I² = 0%, p = 0.49), catheter-associated urinary tract infection (OR 0.97, 95% CI 0.52–1.80, I² = 0%, p = 0.55), and catheter-related blood stream infection (OR = 1.15, 95% CI 0.72–1.84, I² = 0%, p = 0.66), or ICU mortality (OR = 1.03, 95% CI 0.83–1.28, I² = 49%, p = 0.12). Forest plotting indicated that UVPs could reduce the lengths of ICU stays (SMD =  − 0.97, 95% CI − 1.61 to 0.32, p = 0.003).

Conclusion

The current meta-analysis indicates that adopting a UVP may significantly reduce the incidence of delirium in ICU patients, without increasing the risks of ICU-acquired infection or mortality. Further large-scale, multicenter studies are needed to confirm these indications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04129-3.

Long term cognitive and functional status in Danish ICU patients with COVID-19

Background

ICU admission due to COVID‐19 may result in cognitive and physical impairment. We investigated the long‐term cognitive and physical status of Danish ICU patients with COVID‐19.

Methods

We included all patients with COVID‐19 admitted to Danish ICUs between March 10 and May 19, 2020. Patients were the contacted prospectively at 6 and 12 months for follow‐up. Our primary outcomes were cognitive function and frailty at 6 and 12 months after ICU admission, estimated by the Mini Montreal Cognitive Assessment, and the Clinical Frailty Scale. Secondary outcomes were 6‐ and 12‐month mortality, health‐related quality of life (HRQoL) assessed by EQ‐5D‐5L, functional status (Barthel activities of daily living and Lawton–Brody instrumental activities of daily living), and fatigue (Fatigue Assessment Scale). The study had no information on pre‐ICU admission status for the participants.

Results

A total of 326 patients were included. The 6‐ and 12‐month mortality was 37% and 38%, respectively. Among the 204 six‐month survivors, 105 (51%) participated in the 6‐month follow‐up; among the 202 twelve‐month survivors, 95 (47%) participated in the 12‐month follow‐up. At 6 months, cognitive scores indicated impairment for 26% (95% confidence interval [CI], 11.4–12.4) and at 12 months for 17% (95% CI, 12.0–12.8) of participants. Frailty was indicated in 20% (95% CI, 3.4–3.9) at 6 months, and for 18% (95% CI, 3.3–3.8) at 12 months. Fatigue was reported by 52% at 6 months, and by 47% at 12 months. For HRQoL, moderate, severe, or extreme health problems were reported by 28% at 6 months, and by 25% at 12 months.

Conclusion

Long‐term cognitive, functional impairment was found in up to one in four of patients surviving intensive care for COVID‐19. Fatigue was present in nearly half the survivors at both 6 and 12 months. However, pre‐ICU admission status of the patients was unknown.

Health-related quality of life, anxiety and depression and physical recovery after critical illness - A prospective cohort study

BACKGROUND

Critical illness is often followed by mental and physical impairments. We aimed to assess the health-related quality of life (HRQoL), symptoms of anxiety and depression, and physical function in critically ill patients after discharge from the intensive care unit.

METHODS

For this prospective cohort study we included all available adult patients admitted to the ICU for >24 h during a 12-month period. Home visits took place at 3 and 12 months after discharge from the hospital and included Short-Form Health Survey (SF-36), Hospital Anxiety and Depression Scale, and Chelsea Critical Care Assessment Too (CPAx).

RESULTS

We visited 79 patients at 3 and 53 at 12 months. In patients with data from both visits the mental components SF-36 scores (median (IQR)) were 55 (43-63) at 3, and 58.5 (49.5-64) at 12 months; physical component SF-36 scores were 35 (28-45) at 3, and 36 (28-42) at 12 months. SF-36 subdomains of mental health, social functioning, and role emotional were close to normal. Vitality, bodily pain, general health, physical functioning, and role physical were severely affected. Incidences of anxiety and depression symptoms were 16%/8% at 3 and 13%/8% at 12 months) and physical function (CPAx) was 47 at both time points).

CONCLUSION

We found no change in HRQoL, anxiety, and depression, or physical function from 3 months to 1 year. Physical health-related quality of life was impaired at both time points. Subdomain scores for physical health-related quality of life were affected more than mental domains at both time points.

Risk factors associated with the development of delirium in general ICU patients. A prospective observational study

Objective

We aimed to analyze risk factors related to the development of delirium, aiming for early intervention in patients with greater risk.

Material and methods

Observational study, including prospectively collected patients treated in a single general ICU. These were classified into two groups, according to whether they developed delirium or not (screening performed using CAM-ICU tool). Demographics and clinical data were analyzed. Multivariate logistic regression analyses were performed to quantify existing associations.

Results

1462 patients were included. 93 developed delirium (incidence: 6.3%). These were older, scored higher on the Clinical Frailty Scale, on the risk scores on admission (SAPS-3 and SOFA), and had a greater number of organ failures (OF). We observed more incidence of delirium in patients who (a) presented more than two OF (20.4%; OR 4.9; CI95%: 2.9–8.2), and (b) were more than 74 years old albeit having <2 OF (8.6%; OR 2.1; CI95%: 1.3–3.5). Patients who developed delirium had longer ICU and hospital length-of-stays and a higher rate of readmission.

Conclusions

The highest risk observed for developing delirium clustered in patients who presented more than 2 OF and patients over 74 years old. The detection of patients at high risk for developing delirium could imply a change in management and improved quality of care.

Sleep-wake rhythms determined by actigraphy during in-hospital stay following discharge from an intensive care unit

BACKGROUND

Sleep and circadian disturbances play a major role in recovery after critical illness. Ample research has shown sleep to be disturbed during the stay at the intensive care unit (ICU); however, the trajectory of sleep after ICU discharge is sparsely described. The current study aimed to describe the development of the sleep-wake rhythm in subjects discharged from ICU to a hospital ward.

METHODS

Following discharge from the ICU to a general hospital ward, the participants were monitored with an ActiGraph for sleep assessment for 7 days or until hospital discharge or death. Data were analysed for day-to-day change with t-tests and for the whole period with repeated measures analysis.

RESULTS

For the 38 included patients, repeated measures analysis showed no significant improvement in total sleep time and wake time. However, for secondary outcomes, improvements for wake after sleep onset (P = .02) and reduction in the number of naps (P = .03) both in the day-to-day and overall trend analysis were observed.

CONCLUSION

The duration of sleep and wake time did not improve during ward stay. However, sleep became less fragmented and naps during the day declined. Due to the small sample size further, larger trials are needed.

Delirium and long term cognition in critically ill patients

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.

Physical and Cognitive Training to Enhance Intensive Care Unit Survivors' Cognition: A Mapping Review

PURPOSE

The aim of this study was to examine current literature regarding effects of physical or cognitive training and simultaneous (dual-task) physical and cognitive training on cognition in adults surviving an intensive care unit (ICU) stay.

DESIGN

Systematic mapping.

METHODS

A literature search was conducted to examine effects of physical and/or cognitive training on cognitive processes.

RESULTS

Few studies targeted adults surviving ICU. Independently, physical and cognitive interventions improved cognition in healthy older adults with and without cognitive impairment. Simultaneous interventions may improve executive function. Small sample size and heterogeneity of interventions limited the ability to make inferences.

CONCLUSION

Literature supports positive effects of single- and dual-task training on recovering cognition in adults. This training could benefit ICU survivors who need to regain cognitive function and prevent future decline.

RELEVANCE TO PRACTICE

With the growing number of ICU survivors experiencing cognitive deficits, it is essential to develop and test interventions that restore cognitive function in this understudied population.

Risk factors for long-term cognitive impairment in ICU survivors: A multicenter, prospective cohort study

PURPOSE

To describe the incidence of and risk factors for impaired cognitive function in intensive care unit (ICU) survivors. We hypothesized that age, severity of illness, and days in coma, delirium, mechanical ventilation in the ICU would be associated with impaired cognitive function.

METHODS

We included all adults, alive 6 months after acute admission to one of the 24 Danish ICUs participating in the AID-ICU cohort study. Trained professionals assessed cognitive function in patients' homes or in outpatient clinics using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) 6 months after ICU admission. Potential risk factors for cognitive impairment were analyzed with linear regression models.

RESULTS

In total, 237 ICU patients were alive 6 months after ICU admission and did not meet the exclusion criteria. A total of 106 patients completed the cognitive assessment. The median RBANS global cognitive score was 76 (interquartile range, 62-91), and 52% had a global cognitive score 1.5 SD below the normative mean and 36% displayed a global cognitive score 2 SD below the normative mean, similar to that of Alzheimer's disease. Higher age was associated with poorer RBANS global cognitive score (estimate -0.35 [95% confidence interval -0.63 to -0.07] per year).

CONCLUSIONS

In this multicenter study of adult ICU survivors, cognitive impairment was frequent and severe in those assessed at 6 months. Higher age was a risk factor for cognitive impairment, but events related to the ICU stay were not associated with poorer cognitive performance at 6 months.

Cognitive function and health-related quality of life 1 year after acute brain injury: An observational study

BACKGROUND

Cognitive impairment and reduced health-related quality of life (HRQoL) are well-established sequelae of critical illness. Studies on survivors of critical illness have found delirium to be a predictor of these conditions, but evidence regarding survivors of acute brain injury is sparse. We aimed to explore if delirium duration was associated with 1-year cognitive impairment and reduced HRQoL in patients with acute brain injury.

METHOD

Intensive care unit (ICU) delirium was assessed using the Intensive Care Delirium Screening Checklist. Cognitive status was assessed using the Repeatable Battery for Neuropsychological Status (RBANS) and HRQoL using the European Quality of Life 5-dimension questionnaire (EQ-5D). We used a multiple linear regression for testing the association of delirium duration with cognitive impairment and quality of life, respectively.

RESULTS

Forty-seven survivors of acute brain injury participated in follow-up and 35 completed RBANS. Delirium was present in 39 of 47 (83%) with a median duration of 4 days. Delirium duration did not predict cognitive impairment (95% CI -4.1 to 0.5) or lower HRQoL (95% CI -1.4 to 2.7). Moderate-to-severe cognitive impairment was present in 17 of 35 (49%) participants, and they had a mean EQ-5D health visual analogue scale of 70.9 vs 81.6 for the Danish age-matched norm.

CONCLUSIONS

Our sample did not demonstrate an association between delirium and 1-year cognitive impairment or reduced HRQoL. Still, a large proportion of the participants were cognitively impaired, and their quality of life was lower compared to norm. Larger studies are necessary to explore these associations further.

Factors Associated With Home Visits in a 5-Year Study of Acute Respiratory Distress Syndrome Survivors

BACKGROUND

Participant retention is vital for longitudinal studies. Home visits may increase retention, but little is known about the subset of patients they benefit.

OBJECTIVE

To evaluate patient-related variables associated with home visits.

METHODS

In a 5-year, longitudinal, multisite, prospective study of 195 survivors of acute respiratory distress syndrome, in-person assessments were conducted at a research clinic. Home visits were offered to participants who could not attend the clinic. Associations between having a home visit, prior follow-up visit status, and baseline and in-hospital patient variables were evaluated with multivariable, random-intercept logistic regression models. The association between home visits and patients' posthospital clinical status was evaluated with a subsequent regression model adjusted for these variables.

RESULTS

Participants had a median age of 49 years and were 56% male and 58% White. The following had independent associations with home visits (adjusted odds ratio [95% CI]): age (per year: 1.03 [1.00-1.05]) and immediately preceding visit incomplete (2.46 [1.44-4.19]) or at home (8.24 [4.57-14.86]). After adjustment for prior-visit status and baseline and hospitalization variables, these posthospital patient outcome variables were associated with a subsequent home visit: instrumental activities of daily living (≥ 2 vs < 2 dependencies: 2.32 [1.29-4.17]), EQ-5D utility score (per 0.1-point decrease: 1.15 [1.02-1.30]), and 6-minute walk test (per 10-percentage-point decrease in percent-predicted distance: 1.50 [1.26-1.79]).

CONCLUSIONS

Home visits were important for retaining older and more physically impaired study participants, helping reduce selection bias caused by excluding them.

Post-intensive care syndrome: A concept analysis

OBJECTIVE

Post-intensive care syndrome is a term used to describe new or worsening multidimensional impairments in physical, psychological cognitive and social status arising from critical illness and persisting beyond hospital discharge. It is associated with high morbidity among patients discharged from intensive care units. However, due to its complexities, which encompass physical, psychological, cognitive and social impairments, the exact nature of this condition has not been fully conceptualized. The aim of this analysis therefore was to define the concept of post-intensive care syndrome. This conceptual clarity provides a general definition that is essential for practitioners and researchers to gain a comprehensive understanding of the syndrome and provide for accurate measurement of its incidence and prevalence.

DESIGN

The Walker and Avant approach to concept analysis guided this investigation.

DATA SOURCE

An electronic search of the literature using PubMed, CINHAL, PsycArticles, Academic search complete, Science Direct, MEDLINE and Health Source databases informed the analysis. The search included both quantitative and qualitative studies related to post-intensive care syndrome published in English between 2010 and 2020.

RESULTS

Of the 3948 articles identified, 24 ultimately met the inclusion criteria. Analysis identified the defining attributes of post-intensive care syndrome as: (1) new or worsening multidimensional impairments; (2) physical dysfunction; (3) psychological disorder; (4) cognitive impairment; (5) failed social reconstruction; and (6) persistent impaired multidimensional symptoms extending beyond intensive care and hospital discharge. Antecedents were divided into two categories: pre-existing and those related to the intensive care admission. Consequences were identified as both positive (for example the establishment of coping processes) and adverse (for example decreased quality of life and caregiver burden).

CONCLUSION

Post-intensive care syndrome affects more than half of patients discharged from intensive care units. This operational definition and conceptual understanding of this syndrome will help improve understanding and inform the design of preventative strategies to improve long-term consequences of the syndrome. Future research and standardized instrument development will serve to better understand the scope and characteristics of this syndrome and inform the development of possible preventative interventions.

Sleep Fragmentation and Cognitive Trajectories After Critical Illness

BACKGROUND

ICU survivors can experience both cognitive dysfunction and persistent sleep disturbances after hospitalization. Sleep disturbances have been linked with cognitive impairment in various patient populations, and the apolipoprotein E (APOE) genotype has been linked to sleep-related impairments in cognition.

RESEARCH QUESTION

Is there an association between sleep, long-term cognition, and APOE status in ICU survivors?

STUDY DESIGN AND METHODS

We enrolled 150 patients from five centers who had been mechanically ventilated for at least 3 days; 102 patients survived to ICU discharge. Actigraphy and cognitive testing were undertaken at 7 days, 6 months, and 12 months after ICU discharge, and sleep duration, quality, and timing were estimated by actigraphy. APOE single nucleotide polymorphisms were assessed for each patient.

RESULTS

Actigraphy-estimated sleep fragmentation, but not total sleep time or interdaily stability (estimate of circadian rhythmicity), was associated with worse cognitive impairment at 7 days of ICU discharge. No actigraphy-estimated variable of sleep estimation at 7 days post-ICU discharge predicted cognitive impairment or persistent sleep abnormalities at 6 and 12 months of follow-up in subsequently assessed survivors. Possessing the APOE ε4 allele was not significantly associated with sleep disturbances and its presence did not modify the risk of sleep-related cognitive impairment at follow-up.

INTERPRETATION

Sleep fragmentation estimated by actigraphy was associated with worse cognitive performance in hospital, but not at later time intervals. Further research is needed to better delineate the relationship between persistent sleep disturbances and cognition in larger numbers of ICU survivors.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02086877; URL: www.clinicaltrials.gov.

Gender Differences Regarding the Impact of Change in Cognitive Function on the Functional Status of Intensive Care Unit Survivors: A Prospective Cohort Study

PURPOSE

This study aimed to identify gender differences with regard to the impact of change in cognitive function on functional status 3 months after receiving critical care.

DESIGN AND METHODS

This prospective cohort study investigated 152 intensive care unit (ICU) patients. Their functional status and cognitive function were assessed using the validated Korean version of the Modified Barthel Index and Mini-Mental State Examination, respectively. Hierarchical regression was used to evaluate the impact of change in cognitive function on functional status in ICU survivors by gender.

FINDINGS

The proportion of women suffering from consistent cognitive impairment was significantly higher than that of men. Women had a rate of improvement to normal cognitive function within 3 months after discharge that was higher than that of men. Functional status 3 months after discharge was significantly lower for patients whose cognitive impairment was consistent than that for those whose cognitive function was normal. The impact of change in cognitive function on men (R² change = .28) was greater than that on women (R² change = .13).

CONCLUSIONS

Persistent cognitive impairment after critical illness had a negative effect on functional status in ICU survivors. Importantly, the negative impact of consistent cognitive impairment was greater in men than in women.

CLINICAL RELEVANCE

Early careful assessment of functional and cognitive status after critical illness is warranted. Strategies addressing the gender-specific characteristics related to cognitive improvement should also be developed.

Healthcare providers' knowledge and handling of impairments after intensive unit treatment: A questionnaire survey

BACKGROUND

Numerous patients experience long-term impairments after discharge from the intensive care unit (ICU), including physical, psychological and cognitive deficiencies. This study aims to investigate the knowledge and handling of post-intensive care impairments among Danish doctors and nurses in the medical and surgical wards.

METHODS

An electronic questionnaire survey was distributed to consultants and development nurses, head nurses and assistant head nurses at departments of abdominal surgery and internal medicine of hospitals with an ICU in the Region Zealand of Denmark.

RESULTS

We invited 350 employees to participate, 48% responded. Most participants, 82.8% nurses and 86.6% doctors, reported their knowledge of in-hospital needs of the ICU patients to be average or higher. Sixty per cent of doctors reported having average or higher knowledge of the patients' post-discharge needs. More than half the doctors (60.2%) reported that they "Rarely" or "Never" addressed possible ICU-related impairments in the discharge summary. During hospital admission, 22.9% replied "No screening performed" for physical impairment, while the rates for psychological and cognitive impairments were 70.7% and 57.3%, respectively. Most respondents believed that doctors (92.8%) and nurses (92.1%) in the ward and ICU doctors (89.4%) play an important role in detecting ICU-related impairments; 63.8% felt that general practitioners play a key role.

CONCLUSION

Doctors and nurses generally reported having average or higher knowledge of ICU patients' in-hospital needs, but few screened systematically for ICU-related impairments. Most respondents believed that detecting these problems is a shared responsibility between professionals in the primary and, especially, the secondary healthcare sector.

Physical function and actigraphy in intensive care survivors-A prospective 3-month follow-up cohort study

BACKGROUND

Impaired physical function after intensive care unit (ICU) stay is common. We aimed to study the association between activity levels in the ward after discharge from ICU and physical function at 3-month follow-up.

METHODS

Prospective cohort study of adult patients admitted to the ICU for more than 24 hours. Patients wore an accelerometer for up to 7 days at the ward. At discharge from ICU and at 3-month follow-up, patients were tested with the Chelsea Critical Care Physical Assessment Tool (CPAx).

RESULTS

We screened 66 consecutive, eligible patients; 41 completed actigraphy and 19 patients were visited at 3 months. The median CPAx increased from 31 (IQR 23-41) at discharge from ICU to 47 (IQR 44-49) at follow-up (P < 0.0001). Mean daily activity for the first week was correlated with CPAx at ICU discharge (R²  = 0.14, P = 0.017; all 41 patients). For the 19 visited patients, we found no significant correlation for activity levels with CPAx at ICU discharge (R²  = 0.12, P = 0.14) nor at visit (R²  = 0.2, P = 0.058).

CONCLUSION

We found improved physical function for most patients 3 months after ICU treatment. Activity levels for 1 week after ICU discharge at the ward were not associated with better physical function at 3-month follow-up.