Date Presented 04/06/19
Study aim was to evaluate the frequency and severity of depressive and anxiety symptoms and cognitive impairment at ICU dismissal and three months after hospital dismissal. Delirium, days of invasive ventilator use, and ICU length of stay were associated with worse psychocognitive scores. Data indicates cognitive impairment and anxiety and depression symptoms can be present at ICU dismissal, but not significantly different across ICU settings, suggesting an OT role in intervention and assessment.
Primary Author and Speaker: Jennifer Bergstrom
Additional Authors and Speakers: Leah Struss
BACKGROUND: Patients in medical and surgical intensive care units (ICUs) are at high risk for long-term cognitive impairment (Pandharipande et al., 2013). Studies have shown that critical illness and ICU hospitalization can lead to Post Intensive Care Syndrome (PICS), which is a group of symptoms including cognitive dysfunction, depression, anxiety and post-traumatic stress, and physical debility (Jackson et al., 2007). Limited data exists on which ICUs may have the most significant need or prevalence of PICs symptoms. The purpose of this research was to quantify the frequency and severity of depressive symptoms, anxiety symptoms and cognitive impairment at dismissal from the ICU and three months after hospital dismissal, across multiple ICUs.
DESIGN: Institutional Review Board approval was obtained. 299 patients were enrolled in the study across 6 different ICUs in a single institution. Inclusion criteria included: 18 years of age or older and completion of ICU stay greater than 48 hours. Exclusion criteria included: admitted for a suicide attempt, known prior cognitive impairment, prior diagnosis of post-traumatic stress disorder, life expectancy of less than 3 months, non-English speaking, and active delirium.
METHODS: Patients were approached for consent within 96 hours of ICU discharge. Demographic information and ICU characteristic information was collected. Following ICU dismissal, patients completed the Montreal Cognitive Assessment-Blind (MoCA-blind); Impact of Events Scale-Revised (IES-R); Hospital Anxiety and Depression Scale (HADS). Three months following dismissal from the hospital, patients were contacted by telephone to complete the assessments again. Patients were also asked to rate barriers faced and supports used in their recovery. Descriptive data was analyzed as means, medians and interquartile ranges. Variables were compared by analysis of variance. Statistical significance was p-value of <0.05.
RESULTS: 170 males and 129 females were included in the study with average patient age of 61.7. Majority (95%)of patients were Caucasian. Average length of ICU stay was 4.2 days. Average length of invasive ventilator use was 2.13 days. Across all ICUs, 19.1% of patients were positive for delirium in the ICU. Baseline psychocognitive scores were similar across ICU settings, MoCA-BLIND mean was 16.7(standard deviation=3.09), HADS-D mean was 6.3(4.1), and HADS-A mean was 7.2 (4.1). Days of invasive ventilator use and delirium were associated with increased odds of HADS-A ≥8 (p=0.035, p=0.008). Prior history of depression and longer ICU length of stay was associated with increased HADS-D score (p=0.001, p0.043). 174 subjects completed follow up at 3 months after hospitalization. Of the 125 non-responders, 25 were known to be deceased. MoCA blind mean was 18.5(2.98), HADS-D mean was 4.92(3.8), HADS-A mean was 4.82(4). Barriers included fatigue (4.12), mobility (3.49) and memory problems (2.94). Strategies that helped recovery included support from family (8.42), relaxation (6.82) and medical visits (6.79).
CONCLUSION: Data suggests cognitive impairment, as well as anxiety and depression symptoms, can be present following an ICU stay, and not significantly different across ICU settings. Delirium, days of invasive ventilator use and ICU length of stay were associated with worse psychocognitive outcomes. This research is valuable from a clinical perspective as it provides insight in to the prevalence and severity of cognitive impairment and anxiety and depression symptoms following an ICU stay. It also suggests that delirium in the ICU may affect long term outcomes. Results point to a role for OT in the prevention of PICs by providing delirium assessment and prevention interventions in the ICU
References
Bemis-Dougherty, A. R., & Smith, J. M. (2013). What follows survival of critical illness? Physical therapists' management of patients with post-intensive care syndrome. Phys Ther, 93(2), 179-185. doi:10.2522/ptj.20110429
Jackson, J. C., Hart, R. P., Gordon, S. M., Hopkins, R. O., Girard, T. D., & Ely, E. W. (2007). Post-traumatic stress disorder and post-traumatic stress symptoms following critical illness in medical intensive care unit patients: assessing the magnitude of the problem. Crit Care, 11(1), R27. doi:10.1186/cc5707
Pandharipande, P. P., Girard, T. D., Jackson, J. C., Morandi, A., Thompson, J. L., Pun, B. T., . . . Ely, E. W. (2013). Long-Term Cognitive Impairment after Critical Illness. New England Journal of Medicine, 369(14), 1306-1316. doi:10.1056/NEJMoa1301372
