Cognitive Outcomes after Critical Illness LUNG DAY 2010
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1 Cognitive Outcomes after Critical Illness LUNG DAY 2010 C. Terri Hough, MD MSc Assistant Professor of Medicine Pulmonary and Critical Care Medicine Harborview Medical Center
2 Acknowledgements Bill Ehlenbach Liz Parsons Mona Hopkins Wes Ely Jim Jackson Tim Girard Jason Christie
3 Cognitive function is an important component of health-related quality of life (HRQOL) Cognitive Emotional Physical
4 Potential relationships: the brain and critical illness Hopkins RO. Chest 2006
5 Patient and surrogate statements about cognitive impairment after critical illness At first, it felt like my brain was dead. My thinking improved about a month after leaving the hospital, but I still can t concentrate. And my memory still isn t what it used to be. ARDS survivors, 6 months later It was like I was married to someone else he did not remember anything I told him. We went to making lists for everything. I finally told him not to turn on the stove, the washing machine, anything! I was worried he d burn down the house. Wife of ARDS survivor, 6 months later Cox CE. Crit Care Med 2009
6 Imaging reveals acute and chronic changes ICU 3.5 years later Jackson JC. South Med Journal 2009
7 Outline Review 5 important studies of cognitive impairment after critical illness Incidence Duration Severity Potentially reversible risk factors Relationship with pre-morbid cognitive function
8 Landmark study of ARDS survivors Design: longitudinal cohort study Patients: ICU survivors of ARDS (P:F<150) Outcome measures: cognitive testing Four hours of QOL and neuropsychological tests Performed before hospital discharge and 12 months Hopkins RO. AJRCCM 1999
9 High severity and duration of illness in subjects Mean age (SD): 45 years (17) Hopkins RO. AJRCCM 1999
10 All subjects cognitively impaired at discharge, improved (but not normal) by 12 months [Mean=100, SD=15] [Mean=31-44] [Total=36] [Mean 1= ] [Mean 2= 8-14] [Mean delay= 10-12] Hopkins RO. AJRCCM 1999
11 Cognitive impairment remains at 12 months Cognitive function Test Number (%) abnormal after 1 year Attention, concentration and memory Wechsler Memory Scale, Revised Rey Auditory Visual Learning Test Rey-Osterrieth Complex Figure Test 43/55 (78%) General cognitive function Wechsler Adult Intelligence Scale, Revised 17/55 (30%) Mental processing speed Trail making tests, part A and B Digital Symbol Test 26/55 (48%) Hopkins RO. AJRCCM 1999
12 Second ARDS cohort also demonstrates persistent memory impairment past 1 year Wechsler Adult Intelligence Scale and Wechsler Memory Scale, Revised Mean improvement in general cognitive function to 1 year Memory remains markedly abnormal No significant change from 1 to 2 years Potential risk factors Hypotension Hypoxemia (Intelligence quotient tests: Full scale, verbal and performance) Hopkins RO. AJRCCM 2005
13 Prevalence of cognitive impairment varies with population, timing and type of testing Hopkins RO. Curr Op Crit Care 2006
14 Attention, memory, executive function and mental processing speed are commonly affected Hopkins RO. Curr Op Crit Care 2006
15 Impaired subjects have a high degree of dysfunction Normalized to mean (SD)= 50 (10) Jackson JC. Crit Care Med 2003
16 Memory, attention and concentration can be severely affected Rey-Osterrieth Complex Figure Test Jackson JC. Crit Care Med 2003
17 Prolonged cognitive impairment is associated with disability Cross-sectional study of ARDS survivors 46 patients assessed in person Median 6 years after ICU [range 1-12 years] Performed Estimations of premorbid IQ Short cognitive test (SKT) HRQOL test (SF-36) Interview regarding employment status Results 11/46 with significant cognitive impairment 19/46 were disabled, including all 11 subjects with cognitive impairment (p<0.001) Rothenhausler HB. Gen Hosp Psychiatry 2001
18 Prolonged cognitive impairment is associated with decreased HRQOL Rothenhausler HB. Gen Hosp Psychiatry 2001
19 Delirium and cognitive impairment are both common in survivors of critical illness Subject characteristics Age 61 [47-71] Pre-morbid cognitive impairment 9% (7/77) ALI/ARDS 51% (39/77) APACHE II 29 [23-34] Delirium prevelance 84% (65/77) Days of delirium 2 [1-5] Outcome No cognitive impairment Mild cog. impairment Severe cog. impairment 3 months N=76 12 months N=52 21% (16/76) 29% (15/52) 17% (13/76) 35% (18/52) 62% (47/76) 36% (19/52) Girard TD. Crit Care Med (in press)
20 Duration of delirium is an independent predictor of cognitive impairment after critical illness Days of delirium associated with presence and severity of cognitive impairment 3 and 12 months later Independent of age, education, pre-morbid cognitive function (proxy) severity of illness, sepsis and sedative exposure Girard TD. Crit Care Med (in press)
21 Interpretation difficult without baseline data Studies may over-estimate baseline function Cognitive decline may lead to hospitalization Studies may under-estimate baseline function Case of declining IQ from 99 th to 61 st percentile post-ards Verbal IQ PIQ FSIQ Pre-ICU Post-ICU 1 Post ICU 2 Jackson JC. South Med Journal 2009
22 First study of cognitive function after critical illness with baseline data Partnered with Adult Changes in Thought study Longitudinal cohort of healthy older adults at GHC Linked to hospitalization data Used ICD-9 coding to determine critical illness Shock, hypotension, respiratory failure, CPR Primary outcomes Incident dementia, change in cognitive function Used Cognitive Abilities Screening Instrument (CASI) Ehlenbach WJ. JAMA 2010
23 Relationships between the brain and critical illness Ehlenbach WJ. JAMA 2010
24 Critical illness is associated with declining cognitive function Ehlenbach WJ. JAMA 2010
25 Hospitalization is associated with incidence dementia (and critical illness may be, too) Ehlenbach WJ. JAMA 2010
26 Conclusions Post-ICU cognitive impairment is Common Associated with disability and impaired HRQOL Associated with duration of delirium Not explained by pre-morbid cognitive status Strategies for reducing duration of delirium may improve cognitive outcomes Huge research gaps Effect of ICU interventions on cognitive outcomes Importance of screening and early intervention
27 Thank you!
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