Co-Occurrence of Post-Intensive Care Syndrome Problems Among 406 Survivors of Critical Illness*

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d4533866e260">Objective</h5> <p id="P2">To describe the frequency of co-occurring newly acquired cognitive impairment, disability in activities of daily living (ADLs), and depression among survivors of a critical illness and to evaluate predictors of being Post-Intensive Care Syndrome (PICS)-free (i.e., no PICS problems). </p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d4533866e265">Design</h5> <p id="P3">Prospective cohort study</p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d4533866e270">Setting</h5> <p id="P4">Medical and surgical ICUs from 5 U.S. centers</p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d4533866e275">Patients</h5> <p id="P5">Patients with respiratory failure or shock, excluding those with preexisting cognitive impairment or disability in ADLs. </p> </div><div class="section"> <a class="named-anchor" id="S5">  </a> <h5 class="section-title" id="d4533866e280">Interventions</h5> <p id="P6">None</p> </div><div class="section"> <a class="named-anchor" id="S6">  </a> <h5 class="section-title" id="d4533866e285">Measurements and Main Results</h5> <p id="P7">At 3 and 12 months after hospital discharge we assessed patients for cognitive impairment, disability, and depression. We categorized patients into eight groups reflecting combinations of cognitive, disability, and mental health problems. Using multivariable logistic regression, we modeled the association between age, education, frailty, durations of mechanical ventilation, delirium, and severe sepsis with the odds of being PICS-free. </p> <p id="P8">We analyzed 406 patients with a median age of 61 years and an APACHE II of 23. At 3 and 12 months, one or more PICS problems were present in 64% and 56%, respectively. Nevertheless, co-occurring PICS problems (i.e., in two or more domains) were present in 25% at 3 months and 21% at 12 months. PICS problems in all three domains were present in only 6% at 3 months and 4% at 12 months. More years of education was associated with greater odds of being PICS-free (P<0.001 at 3 and 12 months). More severe frailty was associated with lower odds of being PICS-free (P=0.005 at 3 months and P=0.048 at 12 months). </p> </div><div class="section"> <a class="named-anchor" id="S7">  </a> <h5 class="section-title" id="d4533866e292">Conclusions</h5> <p id="P9">In this multicenter cohort study, one or more PICS problems were present in the majority of survivors, but co-occurring problems were present in only 1 out of 4. Education was protective from PICS and frailty predictive of the development of PICS. Future studies are needed to understand better the heterogeneous subtypes of PICS and to identify modifiable risk factors. </p> </div>

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Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study.

S. Bagshaw, H. T. Stelfox, R. C. McDermid … (2014)

Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability to adverse outcomes. We determined the prevalence, correlates and outcomes associated with frailty among adults admitted to intensive care. We prospectively enrolled 421 critically ill adults aged 50 or more at 6 hospitals across the province of Alberta. The primary exposure was frailty, defined by a score greater than 4 on the Clinical Frailty Scale. The primary outcome measure was in-hospital mortality. Secondary outcome measures included adverse events, 1-year mortality and quality of life. The prevalence of frailty was 32.8% (95% confidence interval [CI] 28.3%-37.5%). Frail patients were older, were more likely to be female, and had more comorbidities and greater functional dependence than those who were not frail. In-hospital mortality was higher among frail patients than among non-frail patients (32% v. 16%; adjusted odds ratio [OR] 1.81, 95% CI 1.09-3.01) and remained higher at 1 year (48% v. 25%; adjusted hazard ratio 1.82, 95% CI 1.28-2.60). Major adverse events were more common among frail patients (39% v. 29%; OR 1.54, 95% CI 1.01-2.37). Compared with nonfrail survivors, frail survivors were more likely to become functionally dependent (71% v. 52%; OR 2.25, 95% CI 1.03-4.89), had significantly lower quality of life and were more often readmitted to hospital (56% v. 39%; OR 1.98, 95% CI 1.22-3.23) in the 12 months following enrolment. Frailty was common among critically ill adults aged 50 and older and identified a population at increased risk of adverse events, morbidity and mortality. Diagnosis of frailty could improve prognostication and identify a vulnerable population that might benefit from follow-up and intervention.

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Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up

Linda Denehy, Elizabeth H Skinner, Lara Edbrooke … (2013)

Introduction The purpose of this trial was to investigate the effectiveness of an exercise rehabilitation program commencing during ICU admission and continuing into the outpatient setting compared with usual care on physical function and health-related quality of life in ICU survivors. Methods We conducted a single-center, assessor-blinded, randomized controlled trial. One hundred and fifty participants were stratified and randomized to receive usual care or intervention if they were in the ICU for 5 days or more and had no permanent neurological insult. The intervention group received intensive exercises in the ICU and the ward and as outpatients. Participants were assessed at recruitment, ICU admission, hospital discharge and at 3-, 6- and 12-month follow-up. Physical function was evaluated using the Six-Minute Walk Test (6MWT) (primary outcome), the Timed Up and Go Test and the Physical Function in ICU Test. Patient-reported outcomes were measured using the Short Form 36 Health Survey, version 2 (SF-36v2) and Assessment of Quality of Life (AQoL) Instrument. Data were analyzed using mixed models. Results The a priori enrollment goal was not reached. There were no between-group differences in demographic and hospital data, including acuity and length of acute hospital stay (LOS) (Acute Physiology and Chronic Health Evaluation II score: 21 vs 19; hospital LOS: 20 vs 24 days). No significant differences were found for the primary outcome of 6MWT or any other outcomes at 12 months after ICU discharge. However, exploratory analyses showed the rate of change over time and mean between-group differences in 6MWT from first assessment were greater in the intervention group. Conclusions Further research examining the trajectory of improvement with rehabilitation is warranted in this population. Trial registration The trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606.

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The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial

B. Cuthbertson, Alison J. Rattray, M Campbell … (2009)

Objectives To test the hypothesis that nurse led follow-up programmes are effective and cost effective in improving quality of life after discharge from intensive care. Design A pragmatic, non-blinded, multicentre, randomised controlled trial. Setting Three UK hospitals (two teaching hospitals and one district general hospital). Participants 286 patients aged ≥18 years were recruited after discharge from intensive care between September 2006 and October 2007. Intervention Nurse led intensive care follow-up programmes versus standard care. Main outcome measure(s) Health related quality of life (measured with the SF-36 questionnaire) at 12 months after randomisation. A cost effectiveness analysis was also performed. Results 286 patients were recruited and 192 completed one year follow-up. At 12 months, there was no evidence of a difference in the SF-36 physical component score (mean 42.0 (SD 10.6) v 40.8 (SD 11.9), effect size 1.1 (95% CI −1.9 to 4.2), P=0.46) or the SF-36 mental component score (effect size 0.4 (−3.0 to 3.7), P=0.83). There were no statistically significant differences in secondary outcomes or subgroup analyses. Follow-up programmes were significantly more costly than standard care and are unlikely to be considered cost effective. Conclusions A nurse led intensive care follow-up programme showed no evidence of being effective or cost effective in improving patients’ quality of life in the year after discharge from intensive care. Further work should focus on the roles of early physical rehabilitation, delirium, cognitive dysfunction, and relatives in recovery from critical illness. Intensive care units should review their follow-up programmes in light of these results. Trial registration ISRCTN 24294750