Critical Illness, Delirium, and Cognitive Impairment: Current Issues and Future Directions - PowerPoint PPT Presentation

1 / 57
About This Presentation
Title:

Critical Illness, Delirium, and Cognitive Impairment: Current Issues and Future Directions

Description:

Assistant Professor. Critical Care & Health Services Research. VA CRCOE ... Early mobilization and physical therapy. Attention to optimizing sleep patterns ... – PowerPoint PPT presentation

Number of Views:314
Avg rating:3.0/5.0
Slides: 58
Provided by: HSA61
Category:

less

Transcript and Presenter's Notes

Title: Critical Illness, Delirium, and Cognitive Impairment: Current Issues and Future Directions


1
Critical Illness, Delirium, and Cognitive
Impairment Current Issues and Future Directions
  • James C. Jackson, PsyD
  • Assistant Professor
  • Critical Care Health Services Research
  • VA CRCOE
  • Vanderbilt University, Nashville, TN

2
Disclosure
James C. Jackson has no commercial or financial
relationships to disclose.
3
Anecdote Sepsis Patient 1 year follow-up letter
Dear Doctor, you remember my sister, who is a 64
year old CEO with many employees. After she
developed delirium, we couldnt seem to get her
mental clouding cleared for quite some time. She
has tried to go back to work, and driving, and
functioning although she can not seem to fully
bounce back.   I saw her for the first time about
a month ago, when she came out for my daughter's
Bat Mitzvah.  She seems to have lost her
"spark".  She was such a personality pre-illness,
so gregarious and really the life of the party. 
She is very flat now, and has memory problems. 
She doesn't remember anything about her illness
or her hospitalization. Some long term, but
mostly short term memory problems.  She looks
much older, and is walking very slowly, always
holding onto railings, etc.  She looks like a
very elderly woman now.  The illness really
changed her. ref Tremendous deterioration in
cognitive and functional capacity (Kiely
Marcantonio, J Gerontol 200661204-08)
4
OUTLINE OF THE TALK
  • Definitions of delirium and cognitive impairment
  • Problems associated with delirium
  • Monitoring delirium
  • ICU delirium management
  • New studies addressing delirium
  • Delirium, critical illness, and long-term
    cognitive impairment.

5
Definition of Delirium
6
Delirium
  • Delirium is (1) fluctuation/change in mental
    status (2) inattention either/or(3)
    disorganized thinking (4) altered level of
    consciousness

DSM IV and CAM-ICU
7
Delirium Subtypes
  • Hyperactive delirium -
  • agitation, restlessness, pulling catheters or
    tubes, hitting, biting, and emotional lability.
    (At risk for self-extubation and subsequent
    reintubation)
  • Hypoactive delirium
  • withdrawal, flat affect, apathy, lethargy and
    perhaps even unresponsiveness often unrecognized
    due to these quiet symptoms (At risk for
    aspiration, pulmonary embolism, decubitus ulcers,
    and other complications related to immobility)
  • Mixed - combination

8
Delirium versus Cognitive Impairment
  • Delirium
  • rapid onset
  • fluctuation
  • clouded consciousness
  • Inattention, disorganized thought
  • not chronic
  • Cognitive impairment
  • variable to insidious onset
  • not fluctuating
  • no clouding of consciousness
  • many domains impaired
  • persistent/chronic (?)

Gordon SM, Intensive Care Med 301997-2008,
2004 Jackson JC, Intensive Care Med 302009-2016,
2004
9
Is Delirium a Significant problem in ICU patients?
10
Invisible Organ Dysfunction
  • 60 to 70 unrecognized
  • Delirium is not routinely monitored in the ICU 1
  • Validated tools - DSC 2 or CAM-ICU 3-4
  • Hyperactive vs. Hypoactive delirium
  • ICU Psychosis traditionally an expected outcome
  • In non-ICU settings, delirium has been associated
    with prolonged stay, institutionalization, and
    death 5-7

1 Ely EW CCM 200432106-112 2 Bergeron, ICM
200127859-64 3 Ely EW JAMA 2001286,2703-2710 4
Ely EW CCM 200129,1370-79 5 Inouye, Am J Med
1999106565-573 6 Lawlor, Arch Intern Med
2000160786-794 7 McCusker, Arch Intern Med
2002162457-463
11
Core Points ICU Delirium
  • 60 to 80 of ventilated patients develop
    delirium
  • 20 to 50 of lower severity ICU patients develop
    delirium
  • TRANSLATION right now 30,000 to 40,000 ICU
    patients are delirious in U.S. alone
  • Hypoactive or mixed forms most common

Ely EW ICM 2001271892-900 Ely EW JAMA
2001286,2703-2710 Ely EW CCM 200129,1370-79 McNi
coll L, JAGS 200351591-98
Bergeron N, ICM 200127859-64 Thomason J, AJRCCM
2003167A968 Ely EW CCM 200432106-112 Peterson
et al, AJRCCM 2003167A968
12
Core Points ICU Delirium
  • 3 times higher risk of death by 6 months
  • 15k to 25k higher hospital costs
  • Estimated national 4 to 16 billion associated
    costs
  • 5 fewer ventilator free days (days alive and off
    vent), adjusted P0.03
  • 9 times higher incidence of cognitive impairment
    at hospital discharge, adj. P0.002
  • Using similar methodology (CAM-ICU, etc) a
    Taiwanese cohort found similar mortality data

Ely EW et al, JAMA 2004291-1753-1762 Milbrandt E
et al, Crit Care Med 200432955-962 Lin et al,
Crit Care Med 2004322254-59
13
Monitoring ICU Delirium
14
Delirium Monitoring in ICU - 1999
15
MeSH and Text for Delirium in ICU Since Year
2000
16
Delirium Monitoring in ICU - 2007
17
2002 SCCM - Clinical Practice Guidelines
Jacobi J, Fraser GL, Coursin DB, Riker R,
Fontaine D, Wittbrodt ET, et al. Clinical
practice guidelines for the sustained use of
sedatives and analgesics in the critically ill
adult. Crit Care Med 2002 30119-141.
18
Assessment of ICU Patients
Jacobi J et al. Clinical practice guidelines for
the sustained use of sedatives and analgesics in
the critically ill adult. Crit Care Med 2002
30119-141
19
The CAM-ICU takes 30 seconds on average for
either doctors or nurses to perform. Why?
Because most times delirium is diagnosed via just
a few steps!
20
Two Step Approach to Assessing Consciousness
  • Step 1 Level
  • Arousal/Sedation Assessment (RASS, SAS)
  • (If pt opens eyes to voice then proceed to Step
    2)
  • Step 2 Content
  • Delirium Assessment (CAM-ICU)

21
CAM-ICU
1. Acute onset of mental status changes or a
fluctuating course and 2. Inattention and
or
Delirium
Ely, E.W., et al. JAMA 286, 2703-2710, 2001.
Ely, E.W., et al. Crit Care Med 29, 1370-1379,
2001.
22
Can we achieve high compliance?
Truman B, Ely EW. Crit Care Nurse 2325-36,
2003 Pun BT, et al. Crit Care Med 33
(6)1199-1205, 2005
23
CAM-ICU Compliance
N1754
N1854
100
N1478
N2009
80
60
40
20
0
Jan-Mar
April-Jun
July-Sept
Oct-Dec
On 63 of shifts, the CAM-ICU was recorded by
nurses more often than the once/shift requirement
24
Will monitoring be done correctly?
Truman B, Ely EW. Crit Care Nurse 2325-36,
2003 Pun BT, et al. Crit Care Med 33
(6)1199-1205, 2005
25
CAM-ICU Agreement Between Nurse and Ref Standard
Rater
26
ICU Delirium and Management
27
Delirium prevention and management glass is
half full. Even with unanswered questions, there
are many things we can do for our patients!
28
Delirium Protocol Template
  • We have created an algorithm template that can be
    downloaded at www.icudelirium.org
  • Dynamic not static update and modify as new data
    become available
  • Nonpharmacological and pharmacological
    considerations will help patients maintain or
    recover normal brain function

29
Prevention of ICU Delirium
  • Consider developing protocolized approach (most
    data from non-ICU settings )
  • Treat underlying infection and CHF
  • Correct metabolic disturbances and hypoxemia
  • Frequent reorientation of patient by nurse and
    family
  • Goal-directed sedation/analgesia and/or daily
    wake-up
  • Stop the ventilator (SBT) each day to test
    readiness
  • Early mobilization and physical therapy
  • Attention to optimizing sleep patterns

Inouye S, NEJM 1999340669-76 Marcantonio E,
JAGS 200149516-22 Milisen K, J Adv Pract Nurs
20055279-90
30
Treatment of ICU Delirium
  • Identify etiologies - usually multiple likely
    causes
  • Modify Risk Factors (e.g., reduce
    benzodiazepines)
  • No FDA approved therapies
  • Haloperidol (haldol) 2-5mg IV q 6h
  • Atypical antipsychotics are also used
  • Monitor side effects carefully QTc prolongation,
    torsades de pointes, extrapyramidal symptoms
  • Update approach as literature emerges from
    ongoing trials!

2002 Clinical Practice Guidelines Jacobi J, et
all. CPG for the sustained use of sedatives and
analgesics in the critically ill adult. Crit Care
Med 2002 30119-141.
31
Newer Generation of RCTs addressing Delirium
Management
32
The Awakening and Breathing Controlled (ABC) Trial
  • Vanderbilt University (Girard, Pun, Jackson,
    Shintani,
  • Thompson, Gordon, Light, Thomason, Dittus,
    Bernard, Ely)
  • (Coordinating center)
  • Saint Thomas of Nashville (Canonico and Dunn)
  • University of Chicago (Kress, Pohlman,
    Schweickert, Hall)
  • Univ. of Pennsylvania (Fuchs and Kinnery)
  • Penn Presbyterian (Taichman)

33
ABC Trial Main Outcomes
Median interquartile range except as noted
Girard T et al, Lancet 2008371126-34
34
Improved one-year survivalin ABC Trial
100
80
SATSBT (n167)
60
Patients Alive ()

40
SBT (n168)
20
Hazard ratio 0.68 (0.50-0.92), p.01
0

0
60
120
180
240
300
360
Days
Lancet 2008371126-34
35
Sepsis Subgroup Daily Interruption of
Sedation Reduced Septic Delirium
36
Delirium vs Long Term Cognitive Impairment
3.5

Mean Delirium Days (95 CI)
1.9

P0.0001
Normal
Cognitively Impaired
Neuropsychological Testing at 3 months
37
Delirium and Long Term Cognitive Impairment
  • Median with IQR and mean /- S.D.
  • Model includes delirium days, coma days, age
    and APACHE II scores.

38
The MENDS Trial
(Maximize Efficacy of targeted sedation and
reduce Neurological Dysfunction)
  • 1Pratik Pandharipande, MD, MSCI
  • 2E. Wesley Ely, MD, MPH
  • 1Department of Anesthesiology Critical Care
  • Vanderbilt University School of Medicine,
    Nashville, Tennessee
  • 2 Division of Pulmonary Critical Care
  • Vanderbilt University School of Medicine,
    Nashville, Tennessee
  • VA TN Valley GRECC, Nashville, Tennessee

39
MENDS Study
Pandharipande et al JAMA. 2007 Dec
12298(22)2644-53
40
Pandharipande et al, JAMA. 2007 Dec
12298(22)2644-53
41
Days
JAMA 20072982644-2653
42
Long-term cognitive impairment after ICU survival
43
After surviving ICU care, what long-term effects
will have occurred on cognitive abilities or
health-related quality of life? THINK
acquired and possibly preventable problems
44
Long-term cognitive impairment after ICU survival
  • 12 cohorts (600 pts) and the largest with
    neuropsychological testing was 100 patients
  • Summary gt 3 out of 4 ICU survivors leave the ICU
    with long-term cognitive impairment that equates
    to mild/moderate dementia (sometimes severe)
  • Deficits tend to be diffuse and occur in domains
    including memory, attention/concentration,
    language, And Executive Functioning

Rothenhausler, Gen Hosp Psych 20012390-96 Hopkin
s, AJRCCM 199916050-56 Jackson, Crit Care Med
2003311226-34 Hopkins, JINS 2004
101005-1017 Hopkins, AJRCCM 2005 171340-347
Marquis, AJRCCM 2000161A383 (Curtis) Al Saidi,
AJRCCM 2003167A737 (Herridge) Sukantarat,
Anaesthesia 200560847-853 Suchyta, AJRCCM 2004
169A18 Christie, AJRCCM 2004 169A781
45
  • Societal implications of an enlarging population
    of ICU survivors with cognitive impairment are
    tremendous and (extrapolating from others)
    probably already measure in the tens of billions

Chelluri L, Crit Care Med 20043261-69 Im K,
Chest 2004125597-606 Chodosh J, JAGS
521456-62 Rockwood K, Stroke2002331605-09 Lang
a K, JGIM 200116770-78
46
Case Study of Cognitive Decline in an ARDS
Survivor
47
Background Information
  • Patient (Jane Doe)
  • 49 y/o woman
  • Honors - B.S. in mathematics
  • Employed corporate executive
  • No significant psychiatric history
  • Good Health
  • No Hx prior cognitive problems
  • Community acquired pneumonia on antibiotics
  • 48 hours later in septic shock/ARDS on ventilator

48
Data on link between delirium and long-term CI
growing no proven link to sedation. This person
retained a functional life, and though lost her
profession, has stabilized.
49
A comparison of IQ Scores before and after ICU
hospitalization
50
The REY-O Copy Test
In ambulatory patient with no motor deficits or
stroke
Immediately
30 min later
51
(No Transcript)
52
The BRAIN ICU Project - Overview -
53
Our Research Engine Over 30 Specialist Team
Members
  • Wes Ely, MD, MPH
    Critical Care and Aging Research
  • Robert Dittus, MD, MPH
    Division Chief GIM, GRECC Director
  • Gordon Bernard, MD
    Asst. Vice Chancellor for Research
  • Lorraine Ware, MD
    Biomarkers in Critical Care
  • Pratik Pandharipande, MD, MSCI
    Anesthesiology Critical Care
  • Paula Watson, MD
    Sleep Medicine, Critical Care
  • Tim Girard, MD, MSCI Aging
    Critical Care
  • Russ Miller, MD, MPH Rich Tyson, MD
    Pulm/Critical Care Fellows
  • Bryan Cotton, MD Bill Obremskey MD
    Trauma and Orthopedic Surgery
  • Herbert Meltzer, MD Stephan Heckars, MD
    Psychiatry
  • Sharon Gordon, PhD Jim Jackson, PsyD
    Geriatric Neuropsychology
  • Venice Anderson, MS Psychological
    Testing Expertise
  • Howard Kirshner, MD
    Behavioral Neurology
  • Mike Stein, PhD Usha Nair PhD
    Clinical
    Pharmacology
  • Ayumi Shintani PhD, MPH, Frank Harrell, PhD

    Biostatisticians
  • Ted Speroff, PhD Psychometrics, Safety
  • Jennifer Thompson, BS, MA
    Database, Biostatistics
  • Renee Stiles, PhD Steve Deppen, MS

    Resource Use / Cost
  • Brenda Pun, RN, MSN, ACNP
    Project and Nurse
    Coordinator

54
Why do Something?
  • Hundreds of thousands are being kept alive daily
    in ICUs
  • 67 billion spent annually in U.S. during ICU
    care
  • Critical care is the fastest growing segment of
    healthcare
  • There is untold cost to survivors and society in
    lost productivity, impaired relationships,
    healthcare cost, caregiver burden, psychological
    burden,
  • Only 1/3 of patients discharged from a medical or
    surgical ICU stay receive any form of
    rehabilitation
  • There has been one RCT evaluating a
    rehabilitation package post ICU stay, but
    overall, post-ICU care is unstructured, unstudied
    and unproven

55
Post-ICU Syndrome
  • Triad characterized by
  • Long term cognitive impairments
  • Critical illness neuromyopathy
  • Frailty
  • Resulting in great difficulty returning to
    previous level of function and quality of life.

56
Conclusions
  • Delirium is pervasive in the ICU and associated
    with poor outcomes.
  • Delirious is largely under-recognized but can be
    effectively monitored and rapidly identified.
  • Strategies to manage and prevent delirium are
    emerging.
  • Long term cognitive impairment is a serious
    problem for over 2/3rd of ICU survivors and may
    be influenced by delirium and other factors.

57
www.ICUdelirium.org
Educational Delirium Website
Write a Comment
User Comments (0)
About PowerShow.com