Long-term cognitive impairment in Critical Illness
Reviewed and revised 5 September 2015
OVERVIEW
Critical illness is associated with a spectrum of neurological failure (largely under-reported), including polyneuropathy, encephalopathy and long-term cognitive impairment after critical illness (LTCI-CI)
- LTCI-CI is common
- incidence and severity is poorly defined (4-62% in a systematic review by Wolters et al, 2013)
- neuropsychometric testing may detect subclinical cognitive impairment
- the mechanism of critical-illness associated cognitive dysfunction is poorly understood
- cognitive impairment tends to improve over time, without returning to baseline
- the socioeconomic costs of LTCI-CI are likely to be enormous
RISK FACTORS
Pre-exisiting
- Age
- Pre-existing dementia (affects ~ 1 in 3 ICU patients >65y)
- Educational level
- Depression and anxiety
ICU-associated
- Delirium (up to 9x the risk, but LTCI-CI also occurs in patients who did not experience delirium)
- hypoxia, hypoperfusion, and hyperglycemia
- MODS
- contributors to LTCI-CI include psychological disorders such as anxiety, depression and post-traumatic stress disorder
- Sedative and psychoactive medications
- Sleep disruption and deprivation
- bypass surgery
Family members are also at risk of PTSD, particularly if they experienced unfavourable outcomes or participated in end-of-life decision making
PREVENTION AND MANAGEMENT
The evidence-base for preventative and therapeutic measures is poor overall
Measures in ICU
- prevention and management of:
- delirium
- sleep interruption and sleep deprivation
- adequate analgesia (e.g. burns and trauma patients)
- allow ICU patients to develop factual information during their stay (e.g. daily interrupted sedation)
- patient diaries during the ICU stay (completed by the patient, family and/or staff)
- early mobilisation and physical rehabilitation
- psychological counseling and psychosocial support
Measures outside of ICU
- management of PTSD (cognitive behavioural therapy, SSRIs)
- physical rehabilitation
- psychological counseling and psychosocial support
- ICU follow up clinics
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
Journal articles
- Hopkins RO, Jackson JC. Long-term neurocognitive function after critical illness. Chest. 2006 Sep;130(3):869-78. PMID: 16963688.
- Karnatovskaia LV, Johnson MM, Benzo RP, Gajic O. The spectrum of psychocognitive morbidity in the critically ill: A review of the literature and call for improvement. J Crit Care. 2014 Oct 2. pii: S0883-9441(14)00407-9. PMID: 25449881
- Meyer NJ, Hall JB. Brain dysfunction in critically ill patients–the intensive care unit and beyond. Crit Care. 2006;10(4):223. PMC1751001.
- Wolters AE, Slooter AJ, van der Kooi AW, van Dijk D. Cognitive impairment after intensive care unit admission: a systematic review. Intensive Care Med. 2013 Mar;39(3):376-86. PMID: 23328935.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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