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Post-Intensive Care Syndrome (PICS): Is survival a new beginning, a different existence or the beginning of the end?

James C. Jackson PsyD Assistant Professor Assistant Director, ICU Recovery Center Vanderbilt University School of Medicine Nashville, TN

KEY REFERENCES – Laying the foundation for “Continuity of Care”

Hopkins R O Am J Respir Crit Care Med 1999; 160:50- 56

Schweickert W D Lancet 2009; 373:1874- 1882

Iwashyna T J JAMA 2010; 304:1787- 1794

Herridge M S N Engl J Med 2011; 364:1293- 1304

Jackson J C Crit Care Med 2012; 40:1088- 1097

Bienvenu O J Am J Respir Crit Care Med 2012; 185:517- 524

Pandharipande P P N Engl J Med 2013; 369:1306- 1316

Jackson J C Lancet Respir Med 2014; 2: 369- 379

From an ICU Survivor

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Post-Intensive Care Syndrome (PICS)

• The term PICS was agreed on as the recommended term at a 2010 SCCM Task Force Meeting.

• Describes new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization.

Needham DM, et al. Crit Care Med. 2012;40:502–509.

Cognitive

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Cognitively

Impaired

• Executive Function • Memory • Attention

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The Picture of Cognitive Impairment Following ICU Care

Pandharipande, et al. NEJM 2013;269:1306-1316

Delirium and Executive Function

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The REY-O Copy

Test

30 min later…

Immediately

Abnormal Clock Drawing

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Barr J, et al. Crit Care Med. 2013;41:263–306.

Mental Health

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Poor

Mental

Health

• Anxiety • Depression • PTSS • PTSD

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Psychological Morbidity

Daydow et al., Psychosom Med. 2008 May;70(4):512-9

Psychological Morbidity - PTSD

• >25 studies

• Median point prevalence “clinically significant” PTSD symptoms was 22% (n = 1,104)

• Newer studies suggest rates of PTSD may be lower than previously believed.

Davydow et al., Gen Hosp Psychiatry 2008 Sep-Oct;30(5):421-34 Jackson et al., Lancet Respiratory Medicine 2014 May; 2(5):369-379

“I would make detours while travelling to avoid the sight of a hospital. I could not watch hospital documentaries or dramas and hid all my medical textbooks and journals. I enjoyed sport but began to avoid exercise, as I was terrified of the sensation of breathlessness. Even certain inanimate objects filled me with fear. I still cannot bear a shower curtain to be drawn as it reminds me of closed hospital curtains and hidden death.”

Dr. Sarah Wake, BMJ 2013;346

Symptoms of PTSD

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Examples of Persistent Delusional Memories

Memory: Delusions

• Real Memory vs. Delusional Memory

• At 2 wks post Discharge • 73% had delusional memories

• 27% had no factual recall

• Those who had no factual recall but had delusional memories were more likely to have PTSD-related symptoms

Jones et al Crit Care Med 2001; 29: 573-580

Psychological Morbidity - Depression

• >20 studies

• Depressive symptoms occur in ~30 of ICU survivors • Somatic expressions of depression are more common than cognitive

expressions.

• Suicidal ideation is rare.

Davydow et al., Gen Hosp Psychiatry 2008 Sep-Oct;30(5):421-34 Jackson et al., Lancet Respiratory Medicine 2014 May; 2(5):369-379

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Co-Occurrence of Symptoms

• Among ICU survivors, mental health symptoms rarely exist in a vacuum.

• 59% of individuals with any mental health condition (anxiety, depression, PTSD) have symptoms in 2 or more domains.

Bienvenu et al, Crit Care Medicine 2015; 43 (3); 6432-53.

Is Depression driving Cognitive Impairment? or Is Cognitive Impairment driving Depression?

Lamberty & Bieliauskas, Arch of Clinical Neuropsychology 1993 8: 149-170

Psychological Morbidity Spouses

Davydow et al., Crit Care Med. 2012 August; 40(8): 2335–2341.

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Physical

Latronico Lancet Neurol 2011; 10: 931

Physical/Functional

Impaired

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• Pulmonary • Neuromuscular

Physical Debility

• 60%–80% of patients are functionally impaired

• ICU-acquired weakness (diffuse, symmetric, generalized muscle weakness)

□ Critical illness polyneuropathy

□ Critical illness myopathy

□ Prolonged neuromuscular blockade

□ Disuse atrophy

• Lung capacity/volume impairment

• Impaired activities of daily living (ADLs)

Scruth EA. Clin Nurse Spec. 2014;28(1):9-11. Latronico N, et al. Lancet Neurol. 2011;10(10):931-941.

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Employment Status

Of 12 month survivors, 47% employed at bsln:

• Of these previously employed survivors:

48% not working at 12 months

• 77% of these attribute unemployment due to health-related reasons

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Needham et al., BMJ, 2013; 346; f1532

Early Mobility in the ICU

• Early exercise = progressive mobility

• Study design: paired SAT/SBT protocol with PT/OT from earliest days of mechanical ventilation

Schweickert WD, et al. Lancet. 2009;373:1874-1882.

Wake Up, Breathe, and Move

Early Mobility Study Results

Return to independent functional status at d/c

• 59% in intervention group

• 35% in control group (p=.02)

Schweickert WD, et al. Lancet. 2009;373:1874-1882.

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Early Mobility and Safety

• 1110 patients (w/ 5267 PT sessions)

• <1% sessions had an abnormality or safety event

• Arrhythmias

• Hypotension

• Hypertension

• Of these….

• 0.1% required minimal additional treatment or cost

• no increase in LOS

• Routine PT interventions were safe!

Sricharoenchai T, et al/ Journal of Critical Care 29 (2014) 395-400

What can be done after the hospital?

Education

Little appreciation for critical illness as a traumatic stressor

(even among sophisticated patients)

Provide education to help adjust expectations

Brochures on what to expect after discharge

Websites with patient/family-centered info

Signs of depression, anxiety, and PTSD

Consider creating educational materials for discharge packets

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THRIVE Campaign

ICU Recovery Center at Vanderbilt

Interdisciplinary Compositions

Vanderbilt ICU Recovery Center

• Started in mid-2012

• Patients are ICU survivors seen within 2 weeks of discharge

• Multidisciplinary in nature (physicians, psychologists, pharmacists, nurse practitioners)

• Incorporates cognitive, psychological, and functional evaluations AND in some cases, ongoing therapy

• Main goal is to assist patients with critical transitions and make informed decisions about their future healthcare

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A Short Assessment Battery (Example)

Cognition Montreal Cognitive Assessment (MOCA) Trails A and B

Depression Beck Depression Inventory II (BDI-II) Hospital Anxiety and Depression Scale (HADS)

A Short Assessment Battery (Example)

PTSD Post Traumatic Stress Checklist (PCL)

Daily Functioning Functional Activities Questionnaire World Health Organization Disability Assessment

Scale (WHODAS)

Lezak et al, Neuropsychological Assessment 2012

Rehabiliation

• VA Office of Rural Health (ORH) supported program – RETURN-II.

• Funded in 2013 and will hopefully be funded until 2015 (for a total of 3 years)

• Cognitive rehabiliation for survivors of acute/critical illness.

• Goal Management Training (GMT) to target attention and executive dysfunction.

Levine, Stuss, Winocur JINS 2007

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Cognitive Rehabilitation

Levine et al, JINS 2000 6:299-312

Cognitive & Physical Rehabilitation: RETURN

3 Month Follow-Up Enrollment

Tower Test Achievement Score

0

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18 Intervention

Control

Jackson et al. CCM 2012

Computerized Cognitive Training

• CCT is a promising modality that harnesses neuroplasticity.

• Can be “scaled” in a way that traditional rehabiliation programs cannot.

• Can be done in safety of a patient’s own home, potentially leading to greater compliance and greater engagement.

• Does not require a “professional” to manage.

• Early pilot efforts are ongoing at Vanderbilt and elsewhere.

Nahum et al Schizophr Res Cogn. 2014 Mar 1;1(1):e11-e1 Zelinski, et al 2011 J. Am. Geriatr. Soc. 59, 258–265. doi: Merzenich, M. M. 2013 Soft-Wired: How the New Science of Brain Plasticity Can Change Your Life. San Francisco: Parnassus Publishing

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Is a Patient Capable of Managing a Complex Medication Regimen?

Fitness to Drive?

Obesity

• Many patients lose substantial amounts of weight during a critical illness hospitalization

• Data from the Vanderbilt ICU Recovery Center suggest that patients sometimes lose up to 100 pounds

• Patients often “joke” about the “ICU Diet” and express anxiety over regaining weight. • In the absence of education and interventions, the

“status quo” will re-emerge.

• “I

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Smoking Cessation

• Many patients are “cigarette free” for the longest period of time since they started smoking.

• In a majority of cases, nicotine withdrawal symptoms have peaked.

• In a significant percentage of cases, there is no residual nicotine in the bodies of ICU survivors.

• Nevertheless, without intervention, patients will return to previous addictive patterns.

Post-traumatic Growth

• Definition: Psychological • In a majority of cases, nicotine withdrawal

symptoms have peaked. • In a significant percentage of cases, there is no

residual nicotine in the bodies of ICU survivors. • Nevertheless, without intervention, patients will

return to previous addictive patterns.

Time

ICU Discharge

Recovery

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Transtheoretical Model of Change

Prochaska JO et al. ( 1994 ) Health Psychology 13, 39 – 46

Recent Survivors of Critical Illness

“ I survived and that is the main thing.

And I am so grateful to God that I

survived and am now off all oxygen

and consider myself all well except

that I can’t remember to take my

medications...

-SB

“

Online Resources Families and Patients www.ardsusa.org www.ICUdelirium.org www.sepsisalliance.org www.myicucare.org/Adult-Support/Pages/Post-intensive-Care-

Syndrome.aspx http://icusteps.org

Healthcare Professionals www.nice.org.uk/CG83 http://www.icu-diary.org