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by Robin Owings

Over 5 million U.S. Adults enter an Intensive Care Unit (ICU) each year.
Roughly half of these patients later experience Post-ICU Syndrome, defined as long-term cognitive and/or psychological disturbances after leaving the ICU (Robert Wood Johnson Foundation, 2010). Between 50-80% of ICU patients develop long-term cognitive impairment (Landro, 2011), while 30% develop clinical depression and 15-40% develop Post-Traumatic Stress Disorder (PTSD) (Vanderbilt University Medical Center [VUMC], 2011a).

In comparison, only 785,000 Americans have a first coronary attack each year (American Heart Association, 2012). Most Americans are familiar with the basic warning signs of a heart attack, yet very few know that Post-ICU Syndrome exists, what the warning signs are, and how to get help– even though more than three times as many people are affected. Similarly, many Americans are aware that PTSD may affect war veterans, yet few understand that an ICU patient may experience PTSD due to medical trauma.

Although much research has been conducted about delirium and patients’ experience within the ICU, little research explores the cognitive and psychological after effects of medical trauma once a patient leaves the ICU (Jackson et. al, 2004). Most of the research on these cognitive and psychological after-effects is preliminary, as little is known or understood about this complex topic in the medical community (VUMC, 2011b).

The ICU Environment
The main objective in an ICU is to keep critically-ill patients alive with the “best possible humane care” from medical staff through the use of advanced medical technology (American Thoracic Society, 2012). However, there are stressors in the ICU environment which may accentuate the inevitable stress of a life-threatening medical trauma. A patient is often immobilized, sedated or heavily drugged with narcotics, socially isolated, and attached to a breathing machine while they undergo invasive medical procedures (Wenham & Pittard, 2009). A patient may be sensitive to noises, lights and ambient temperatures, subject to irregular sleeping patterns, disoriented in time and space, uncomfortable or in pain, and unable to communicate well (Wenham & Pittard, 2009). Even simple tasks such as changing position in bed seem impossible; most ICU patients are completely dependent on others for basic needs. Many patients report feeling powerless, helpless, a loss of control over their bodies, a loss of self-esteem, anxiety, and confusion.

In addition, roughly two out of three patients develop delirium during their ICU stay (Robert Wood Johnson Foundation 2010). Delirium is an acute onset disorder, which is often marked by confusion, changes or fluctuations in mental status, a general misunderstanding of stimuli, disorganized thinking, hallucinations or other psychiatric symptoms (Wenham & Pittard, 2009). Some delirious patients are easy to diagnose because they are hyperactive; they may physically thrash out to caregivers, attempt to remove monitoring devices or struggle to get out of bed (Pun & Ely, 2007). Yet most delirious patients are difficult to diagnose. A person with hypoactive delirium may appear to be fine from the outside, yet internally is “quietly disconnected from reality, sometimes without staff or family members’ knowledge” (Moyer, 2011). They may experience terrible hallucinations and thoughts which they are unable to discern from reality: “If your thinking is confused, an IV becomes a knife” (Moyer, 2011). ICU patients may be negatively affected by prolonged delirium: “every day a patient is delirious brings a 20% increased risk of prolonged hospitalization & 10% increased risk of death” (Moyer, 2011). Delirium must be recognized and managed as early as possible in the ICU unit to improve patient outcome.

The medical community is doing what it can to 1. diagnose ICU delirium by using cognitive tests such as the ICU Confusion Assessment Method, 2. prevent it by, for example, judicious use of medications, and 3. treat it when necessary by using antipsychotics, and by getting patients off sedation as quickly as possible (VUMC, 2011c).

But what about after the patient leaves the ICU?
Up to a year after discharge, “as many as half of ICU patients are unable to return to work” (Landro, 2011). Increasing evidence suggests that “a significant portion of ICU patients go on to experience considerable psychological distress for months, even years, after their stay” (Skirrow et. al, 2001). This may manifest in the form of PTSD, depression, or anxiety.

If a loved one is affected:
While in the ICU, caregivers may be able to soothe some of the stresses of the ICU environment by helping patients understand what is going on, by providing earplugs to shut out unwanted noise or providing earbuds so that a patient may listen to pleasing music, by opening window blinds to let in sunlight and help establish daily rhythms, by providing familiarity through presence and visitations, or by finding other ways to reduce anxiety which are particular to the patient. If you recognize or suspect delirium in the ICU patient, let staff know and keep them informed of changes in the mental status of the patient, as you will likely understand the behavioral clues of a patient better than the medical staff and may recognize symptoms of delirium earlier.

Once a patient leaves the ICU, your role as a friend, parent, sibling, or relative is important. Be aware of changes in the ICU survivor as they return to a daily routine, including changes in thought patterns (such as mood swings, feeling “jumpy” or on edge, feeling unhappy, or easily agitated), or behavior (such as a lack of energy, being less talkative, socially isolating the self, or beginning to use drugs or alcohol). Also, be aware of these changes in yourself, as caregivers may also experience cognitive problems after a loved one’s medical trauma (Skirrow et. al, 2001). Talk to your doctor if you or the patient experience signs of PTSD, depression or anxiety; the sooner the after-effects of a trauma are recognized, the sooner one can get help. The medical community is becoming increasingly aware of the long-term effects of an ICU visit, but may not ask about changes in cognitive status on a check-up, and a patient may not have the words to describe or verbalize their post-ICU experience. That’s where you, a future family member or friend of an ICU patient, come into play. Be aware of the symptoms, and help spread the word about the potential cognitive after-effects of medical trauma and the ICU experience.

If you are affected:
There are many issues which need to be addressed during recovery from a critical illness beyond just the physical recovery process (VUMC, 2011a). You may experience forgetfulness, frustration, uncomfortable or frightening flashbacks from the ICU, or have difficulty concentrating or managing tasks like shopping or balancing a checkbook (VUMC, 2011a). These issues are all common during critical illness recovery. It is important to talk with your doctor and your family about these issues, as therapy or other forms of rehabilitation may help you through the healing process. You are not alone, and there are many resources on the web for ICU Survivors. A great place to start is ICU Steps ( http://icusteps.org/) and the Vanderbilt ICU Delirium website (http://www.mc.vanderbilt.edu/icudelirium/).

REFERENCES

American Heart Association. (2012). AHA Statistical Update: Heart and Stroke Statistics, 2012. In Circulation. Retrieved June 5, 2012, from http://circ.ahajournals.org/content/125/1/e2

American Thoracic Society. (2012). What is the Purpose of an Intensive Care Unit? In Critical Care. Retrieved June 5, 2012, from http://www.thoracic.org/

Landro, L. (2011, February 15). Changing Intensive Care to Improve Life Afterward. The Wall Street Journal. Retrieved June 5th, 2012, from http://online.wsj.com/

Jackson, J.C., Gordon, S.M., Hart, R.P., Hopkins, R.O., Ely, E.W. (2004). The association between delirium and cognitive decline; a review of the empirical literature. In Neuropsychology Review. Retrieved June 5, 2012, from http://www.ncbi.nlm.nih.gov/pubmed/

Moyer, J. (2011, April 11). Hospitals fight a form of delirium that often strikes ICU patients. The Washington Post. Retrieved June 5, 2012, at http://www.washingtonpost.com/national/health/

Pun, B.T., and Ely E.W, (2007). The importance of managing and diagnosing ICU delirium. In Chest. 132(2). Retrieved June 5, 2012, at http://www.ncbi.nlm.nih.gov/pubmed/

Robert Wood Johnson Foundation. (2010). Interdisciplinary University of Nebraska Team Receives $300,000 Grant to
Skirrow, P., Jones, C., Griffiths, R.D., and Kaney, S. (2001). Intensive Care– Easing the Trauma. Psychologist. 14(12). Retrieved June 5th, 2012, from http://www.thepsychologist.org.uk/archive/

Study and Disseminate Program to Manage Delirium in Critically Ill Adults. In Robert Wood Johnson Foundation News Release. Retrieved June 5, 2012, from http://www.unmc.edu/nursing/RWJ_Foundation_News_Release_2010Nov16.htm

Vanderbilt University Medical Center. (2011a). Cognitive Impairment Following ICU Hospitalization. In Outcomes and Reports of ICU Patients. Retrieved June 5, 2012, from http://www.mc.vanderbilt.edu/icudelirium/outcomes.html

Vanderbilt University Medical Center. (2011b). Are there any long-term problems that delirium can cause?. In Patient and Family Information. Retrieved June 5, 2012, from http://www.mc.vanderbilt.edu/icudelirium/patients.html

Vanderbilt University Medical Center. (2011c). Assessment resources for ICU Delirium. In Delirium. Retrieved June 5, 2012, from http://www.mc.vanderbilt.edu/icudelirium/assessment.html

Wenham, T., and Pittard, A. (2009). Intensive Care Unit Environment. Continuing Education in Anaesthesia, Critical Care & Pain, 9(6), 178-183.

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