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

LITFL

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.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.