Research issues in the evaluation of cognitive impairment in intensive care unit survivors

ObjectiveTo characterise the clinical course of delirium for patients with COVID-19 in the intensive care unit, including postdischarge neuropsychological outcomes.DesignRetrospective chart review and prospective survey study.SettingIntensive care units, large academic tertiary-care centre (USA).ParticipantsPatients (n=148) with COVID-19 admitted to an intensive care unit at Michigan Medicine between 1 March 2020 and 31 May 2020 were eligible for inclusion.Primary and secondary outcome measuresDelirium was the primary outcome, assessed via validated chart review method. Secondary outcomes included measures related to delirium, such as delirium duration, antipsychotic use, length of hospital and intensive care unit stay, inflammatory markers and final disposition. Neuroimaging data were also collected. Finally, a telephone survey was conducted between 1 and 2 months after discharge to determine neuropsychological function via the following tests: Family Confusion Assessment Method, Short Blessed Test, Patient-Reported Outcomes Measurement Information System Cognitive Abilities 4a and Patient-Health Questionnaire-9.ResultsDelirium was identified in 108/148 (73%) patients, with median (IQR) duration lasting 10 (4–17) days. In the delirium cohort, 50% (54/108) of patients were African American and delirious patients were more likely to be female (76/108, 70%) (absolute standardised differences >0.30). Sedation regimens, inflammation, delirium prevention protocol deviations and hypoxic-ischaemic injury were likely contributing factors, and the most common disposition for delirious patients was a skilled care facility (41/108, 38%). Among patients who were delirious during hospitalisation, 4/17 (24%) later screened positive for delirium at home based on caretaker assessment, 5/22 (23%) demonstrated signs of questionable cognitive impairment or cognitive impairment consistent with dementia and 3/25 (12%) screened positive for depression within 2 months after discharge.ConclusionPatients with COVID-19 commonly experience a prolonged course of delirium in the intensive care unit, likely with multiple contributing factors. Furthermore, neuropsychological impairment may persist after discharge.

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Cognitive impairment in intensive care unit patients: A pilot mixed-methods feasibility study exploring incidence and experiences for recovering patients

Australian Critical Care ◽

10.1016/j.aucc.2018.01.003 ◽

2019 ◽

Vol 32 (2) ◽

pp. 131-138 ◽

Cited By ~ 1

Author(s):

Rosalind Elliott ◽

Elizabeth Yarad ◽

Sarah Webb ◽

Katherine Cheung ◽

Frances Bass ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cognitive Impairment ◽

Mixed Methods ◽

Feasibility Study

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Risk Factors for Cognitive Impairment in Intensive Care Unit Survivors

Journal of Korean Critical Care Nursing ◽

10.34250/jkccn.2020.13.3.75 ◽

2020 ◽

Vol 13 (3) ◽

pp. 75-85

Author(s):

Ji Yeon Kang ◽

Bo Kyung Yi

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Intensive Care ◽

Cognitive Impairment

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Long-Term Cognitive Impairment After Critical Illness

50 Studies Every Anesthesiologist Should Know ◽

10.1093/med/9780190237691.003.0017 ◽

2018 ◽

pp. 86-90

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cognitive Impairment ◽

Critical Illness ◽

Cognitive Outcomes ◽

Adult Patients ◽

Illness Experience ◽

Icu Patients ◽

Global Cognition

This case focuses on long-term cognitive impairment after critical illness by asking the question: What is the prevalence of long-term cognitive impairment after critical illness, and does the duration of delirium and use of sedative or analgesic medications affect cognitive outcomes? This study demonstrated that 74% of adult patients with critical illness experience delirium during their hospital course. Furthermore, patients in the intensive care unit (ICU) setting commonly experience global cognition and executive function deficits at 3 and 12 months following hospitalization. These findings highlight the importance of careful delirium surveillance in ICU patients.

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Delirium and Post-Discharge Neuropsychological Outcomes in Critically Ill Patients with COVID-19: an Institutional Case Series

10.1101/2020.11.03.20225466 ◽

2020 ◽

Author(s):

Jacqueline Ragheb ◽

Amy McKinney ◽

Mackenzie Zierau ◽

Joseph Brooks ◽

Maria Hill-Caruthers ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cognitive Impairment ◽

Critically Ill ◽

Critically Ill Patients ◽

Case Series ◽

Care Facility ◽

Study Cohort ◽

Contributing Factors ◽

Post Discharge

AbstractDelirium is a serious and common complication among critically ill patients with COVID-19. The objective of this study was to characterize the clinical course of delirium for COVID-19 patients in the intensive care unit, including post-discharge cognitive outcomes. A retrospective chart review was conducted for patients diagnosed with COVID-19 (n=148) admitted to an intensive care unit at Michigan Medicine between 3/1/2020 and 5/31/2020. Delirium was identified in 107/148 (72%) patients in the study cohort, with median (interquartile range) duration lasting 10 (4 – 17) days. Sedative regimens, inflammation, deviation from delirium prevention protocols, and hypoxic-ischemic injury were likely contributing factors, and the most common disposition for delirious patients was a skilled care facility (41/148, 38%). Among patients who were delirious during hospitalization, 4/17 (24%) later tested positive for delirium at home based on caretaker assessment, 5/22 (23%) demonstrated signs of questionable cognitive impairment or cognitive impairment consistent with dementia, and 3/25 (12%) screened positive for depression within two months after discharge. Overall, patients with COVID-19 commonly experience a prolonged course of delirium in the intensive care unit, likely with multiple contributing factors. Furthermore, neuropsychological impairment may persist after discharge.

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Detection and Management of Pre-existing Cognitive Impairment and Associated Behavioral Symptoms in the Intensive Care Unit

Critical Care Clinics ◽

10.1016/j.ccc.2008.05.006 ◽

2008 ◽

Vol 24 (4) ◽

pp. 723-736 ◽

Cited By ~ 14

Author(s):

Hochang B. Lee ◽

Candyce J. DeLoatch ◽

SeongJin Cho ◽

Paul Rosenberg ◽

Simon C. Mears ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cognitive Impairment ◽

Behavioral Symptoms

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Commentary on “Socioeconomic Factors and Intensive Care Unit-Related Cognitive Impairment”

Annals of Surgery ◽

10.1097/sla.0000000000004375 ◽

2020 ◽

Vol 272 (4) ◽

pp. 603-603

Author(s):

Nicole S. Gibran

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cognitive Impairment ◽

Socioeconomic Factors

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Daytime-to-Nighttime Sleep Ratios and Cognitive Impairment in Older Intensive Care Unit Survivors

American Journal of Critical Care ◽

10.4037/ajcc2021221 ◽

2021 ◽

Vol 30 (2) ◽

pp. e40-e47

Author(s):

Maya N. Elías ◽

Cindy L. Munro ◽

Zhan Liang

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cognitive Impairment ◽

Sleep Duration ◽

Intensive Care Unit Discharge ◽

Dimensional Change ◽

Card Sort ◽

Daytime Sleep ◽

The Mean ◽

Nighttime Sleep

Background Sleep duration and proportion of daytime versus nighttime sleep may affect cognitive function in older patients in the transition out of the intensive care unit. Objective To explore the relationship between the daytime-to-nighttime sleep ratio and cognitive impairment in older intensive care unit survivors. Methods The study enrolled 30 older adults within 24 to 48 hours after intensive care unit discharge. All participants were functionally independent before admission and underwent mechanical ventilation in the intensive care unit. Actigraphy was used to estimate daytime (6 AM to 9:59 PM) and nighttime (10 PM to 5:59 AM) total sleep duration. Daytime-to-nighttime sleep ratios were calculated by dividing the proportion of daytime sleep by the proportion of nighttime sleep. The National Institutes of Health Toolbox Cognition Battery Dimensional Change Card Sort Test (DCCST) was used to assess cognition. Associations between sleep and cognition were explored using multivariate regression after adjusting for covariates. Results The mean (SD) daytime sleep duration was 7.55 (4.30) hours (range, 0.16-14.21 hours), and the mean (SD) nighttime sleep duration was 4.99 (1.95) hours (range, 0.36-7.21 hours). The mean (SD) daytime-to-nighttime sleep ratio was 0.71 (0.30) (range, 0.03-1.10). Greater daytime sleep duration (β = −0.351, P = .008) and higher daytime-to-nighttime sleep ratios (β = −0.373, P = .008) were negatively associated with DCCST scores. Conclusions The daytime-to-nighttime sleep ratio was abnormally high in the study population, revealing an altered sleep/wake cycle. Higher daytime-to-nighttime sleep ratios were associated with worse cognition, suggesting that proportionally greater daytime sleep may predict cognitive impairment.

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