Memories for ICU and Post Traumatic Stress Disorder

Dr Christina Jones

Nurse Consultant Critical Care Follow-up

School of Clinical Science, University of Liverpool,

and Intensive Care, Whiston Hospital, UK

Intensive Care Research Group

Follow-up programme at Whiston Hospital since 1990– outpatient clinic– questionnaire follow-up– ward visits– support group (1992-1997)– Rehabilitation intervention study (1997-1999) – Validation of tool for post traumatic stress disorder (2001-

2002)– European study examining the incidence of PTSD (2003 -

2005)– Cognitive deficits following critical illness (2003 - 2005)

Psychological problems within ICU

No basis for a unique “ICU-syndrome” or “ICU-

psychosis”

ICU environment “Stressors” weak and ambiguous– Noisy & painful – v – sensory deprived?– Hostile & frightening - v - safety and comfort?

Sleep deprivation & disturbed circadian rhythm– May be a result of delirium but not the cause

» Review of 80 studies in post-opDyer CB et al Arch Intern Med 1995; 155:461-465– Common & related to illness severity– Not been shown to induce psychosis

Delirium is a medical condition

Is an acutely changed or fluctuating mental state characterised by:

– Inattention, inability to focus– Disorganised thinking– Delusions and hallucinations– Altered levels of consciousness– Agitation or Passivity

Is sufficient explanation of “ICU syndrome” in the sick ICU population

Impact of delirium in ICU 48 medical ICU patients

»Excluded neurological/psychiatric disease

– 24/48 ventilated 81% (39/48) developed delirium

– 60% within ICU Onset 2.6 days lasted 3.4 days (means) Associated with increased LOS ICU Predictor of long hospital stay (p=0.006)

Ely EW et al (Nashville, USA) Int Care Med. 2001; 27:1892-1900

Delirium in ICU patients 19% developed delirium (> 24hr stay) Most within 36 – 72 hrs of admission Risk factors for ICU patients

– Pre-ICU»Smoking»Hypertension

– In ICU»Abnormal biochemistry»Opiate use in ICU»High doses of benzodiazepines

Dubois, Bergeron, Dumont, Dial, Skrobik. Delirium in an intensive care unit. Intensive Care Medicine 2001;27:1297-1304.

Delirium no great surprise due to cerebral pathology!

Drug related delirium states– Medication & Recreational– Toxic and withdrawal

Encephalopathy and cerebral injury– Occurs in sepsis, more common than appreciatedZauner C et al. Crit Care Med 2002; 30: 1136-1139Sharshar T et al. Crit Care Med 2002; 30: 2371-2375Sharshar T et al (France) Lancet 2003; 362:1799-805

Cognitive impairment– Anecdotally apparent for many years on ICU and after

» Now being formally characterised

– Frequent deficits in problem solving and executive functioning (making decisions)

» Half of these patients still show deficits 3-6 months later

Assessing Cognitive function in ICU

T Slater et al Intensive Care Medicine 2004; 30 (1): S199 (ESCIM 770)

0

20

40

60

80

100

ICU Ward 3 months 6 months

Pt 1 Pt 2 Pt 3 Pt 4 Pt 5 Pt 6

Pt 7 Pt 8

“Stockings of Cambridge” testPercentage of age & sex matched norms

Importance of memory for ICU

Memory of Illness-is it important?

Many ICU patients suffer amnesia– Memory disturbances are a threat to recovery– No true experience, gap in autobiography– Distorted perspective on illness & recovery – Conflicts with experience of relatives

Many ICU patients suffer delusions– For those with no recall of reality but memory of

paranoid delusions lead to high risk of PTSD Implications for how we sedate patients in ICU

Recall memory of ICU at 2 months

No memory of ICU52%

Dreams Delusions

23%

ICU procedures

23%

Full recall2%

159 patients in clinicEmergency admissionsWith ICU stay > 4 days

Paranoid delusions of being killed by staff

Data from clinical experience running a general ICU follow-up service in UKJones C et al Br J Intensive Care 1994; 2:46-53

The ICU patient experience: a review of 26 studies 1967-1997 from USA

No recall in 20% to 40%– Rest had both positive and negative experiences– Highly dependent on case mix

» Many post-operative studies Discomforts

– Sleep, talking, restrictions, pain, fear, anxiety Comforts

– Safety, security, emotional support Delirium in 20% - 40%

– Nightmares, distorted perceptions, Persecutory delusions

Stein-Parbury J et al. Am J Critical Care. 2000; 9: 20-27

Memory study Emergency admissions with ICU stay > 48 hours Previous psychological history recorded Initial assessment on the ward at 2 weeks post ICU discharge

– Interviewed using the ICU Memory Tool » proven factual events» feelings, such as panic and pain» delusional memories, such as paranoid delusions, hallucinations and

nightmaresC. Jones et al. Clinical Intensive Care 2000;11(5):251-255.

– Hospital Anxiety and Depression Scale (HAD) Assessment Post traumatic stress disorder symptoms at 8

weeks– Impact of Events Scale (IES)

Post Traumatic Stress Disorder (PTSD)

DSM IV – RAmerican Psychiatric Association 2000

17 symptoms divided into 3 symptom categories:– 1. Re-experiencing

» (e.g. nightmares, flashbacks; physiological reactions)

– 2. Avoidance » (e.g. not talk/think about event, memory loss)

– 3. Arousal » (e.g. sleep disturbance, irritability)

Symptoms must be present > 1 month Must cause significant impairment in functioning Once symptoms > 3 months chronic PTSD

PTSD related symptoms & ICU memories

Delusions butNo recall of ICU

Delusions butcan recall ICU

No delusions

30 ICU patients recall tested at 2 weeks & IES at 8 weeks post ICU

Jones C, Griffiths RD, Humphris G, Skirrow PM. Critical Care Medicine 2001; 29:573-580

Impact ofEventsScale

at 8 weeks

P=0.001

wor

se

IES > 19

Conclusions

Even relatively unpleasant memories of ICU may give some protection from anxiety and PTSD-related symptoms post ICU.

Factual memories may allow patients to recognise that nightmares etc are not real.

Post ICU PTSD 27% incidence of PTSD following ARDS

– Retrospective (10yr) of patient experiences after ARDSSchelling et al Crit Care Med 1998; 26: 651-659

– Patients recall of adverse experiences » Terrifying nightmares (64%), Anxiety (42%), Pain (40%),

Respiratory Distress (38%), None in 21%

– Suggested less symptoms in steroid treated groups ?ICU: Schelling et al Crit Care Med 1999; 27:2678-2683Cardiac Surg: Schelling et al Biol Psychiatry 2004; 55:627-633

5 -14% incidence after general ICU– Relationship to duration of ventilation

Cuthbertson BH et al Int Care Med 2004, 30: 450-455 Drug usage in ICU

– PTSD correlated with days of sedation and paralysisNelson, Weinert, Bury, Marinelli Crit Care Med 2000;28(11):3626-3630

RACHEL project (2002-2004) Aims of study

– To determine the ratio of patients suffering from post traumatic stress disorder (PTSD).

– To record a detailed description of patients’ stay in ICU »delirium, sedation depth, opiate and sedation doses,

withdrawal symptoms»Memories for ICU

– To investigate the relationship between:-»the psychological outcome of patients after ICU, the

ICU environment and patient care practice, e.g. sedation or physical restraint

– To examine the psychological outcome where patient receives an ICU diary

Questionnaires used CAM-ICU (in ICU)

Ely et al. Crit Care Med. 2001;29:1370-1379

– Delirium test ICU Memory Tool (2 weeks)

– Memory for hospital admission– Memory for ICU

» factual events » Feelings» delusional events (nightmares, hallucinations, paranoid

delusions)

PTSS-14 (2 and 3 months)– Short PTSD symptom screening tool

Posttraumatic Diagnostic Scale PDS (3 months)      Foa et al Psych Assess 1997;9:445-451.

– PTSD interview tool

RecruitmentCentre Recruite

d3

monthsPTSD

Whiston 52 50 5 (9.6%)

Norrkoping 31 31 1 (3%)

Bergen 34 27 2 (5.8%)

Gotenburg 43 42 2 (4.8%)

Ferrara 81 81 12 (14.8%)

Memory of Illness

Centre Recall hospital

admission

Recall some

factual ICU memories

Delusional memories

Whiston 21 (44%) 39 (81%) 28 (54%)

Norrkoping 20 (64%) 26 (84%) 24 (77%)

Bergen 12 (42%) 18 (65%) 15 (44%)

Gotenburg 28 (65%) 29 (67%) 23 (53%)

Ferrara 73 (90%) 77 (95%) 37 (46%)

Factors associated with PTSD

In ICU Physical restraint (23% of restrained patients)

– Combined with no sedation Deep sedation/large sedative doses Recall of delusional memoriesPatient factors Recall of delusional memories for ICU

– More common where history of previous psychological problems

» Depression, anxiety, panic attacks, phobias

– Deep sedation/large sedative doses

Structural equation Modelling

E16

PTSDICUPTSD E14

DelusionsDelusions

E12

PHYSREST

MEANHRRE

Restraint

E18

E20

DAYSLORA

DAYSMORPH

Sedation

E3

E5

D1

PREVPSYCPsych health

PTSD

Delusions

Restraint

Sedation

Psych health

Chi-square 7.88 df = 11 p = 0.72

Comparative fit = 1.00

Root mean square error of approximation = 0.001

0.368

0.172

0.464

Daily sedative withdrawal Not a new RCT

– Follow up of earlier study after > 1 year

– Only 30% of survivors studied

– ? Selection bias Waking group

– Less Ventilation– Less ICU stay– Fewer stress

symptoms– No PTSD

0

5

10

15

20

25

30

Vent d ICU d Hosp d IES PTSD

Control Waking

Kress JP et al (Chicago) Am J Respir Crit Care Med 2003; 168: 1457-1461

ICU relatives at risk of PTSD

Relatives highly anxious in ICU– ICU nurses important source of confiding support.

Jones C & Griffiths RD Brit. J. Int. Care 1995 Feb:44-47

Symptoms of Post-traumatic stress disorder in relatives– Risk predicted by high anxiety at 2 weeks & 2 months

p=0.007 & p=0.05

Close correlation between High PTSD-related symptoms in the patient & relative

Jones C et al Inten Care Med 2004, 30: 456-460

Long-term significance of psychological problems

• Alcohol abuse for symptom numbing• Not returning to work or socialising

– Social isolation– Stressful for other family members

»May only leave the house if with someone»Marriage breakdown

• Chronic physical problems– Chronic pain– Psychosomatic illnesses

ISBN 0-7279-1794-3 www.bmjbooks.com € 26, £ 15.95 Multi author text from an

ICS Focus meeting– Episodic memory– Risk of PTSD– Delirium, the patient’s

perspective– Delirium & Confusion– Psychological stress– Paediatric issues– Cognitive impairment– Photo-diary– Staff stress