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Effects of ICU stay linger long after discharge

From the August ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Stacey Butterfield

The anecdotes could have come from a horror story: nurses kidnapping a patient, blood and flesh dripping from the walls.

In fact, the tales were from The Johns Hopkins Hospital in Baltimore, reported by patients who had been treated in the intensive care unit (ICU). The visions weren't real, but they still seemed so to the patients, even a month after discharge.

Attendees listen to panelists at the American Thor...

Attendees listen to panelists at the American Thoracic Society 2010 International Conference. Photo by Steve Schneider, courtesy of American Thoracic Society.



A significant proportion of ICU survivors develop post-traumatic stress disorder, symptoms of which can include grisly visions. “These PTSD symptoms are common and don't appear to improve over time,” said Dale Needham, MD, PhD, associate professor of medicine at Johns Hopkins.

His research has found that about 22% of ICU survivors suffer from PTSD symptoms during the first year after discharge. Other studies have estimated the prevalence from 5% to 60%.

The problem is big, but there are steps that physicians and other ICU staff can take to reduce the risk or burden of PTSD and other negative effects of ICU stays for their patients, according to Dr. Needham and other experts who spoke at the American Thoracic Society's annual meeting in May.

Identified risks

Some patients carry a higher risk of developing PTSD before they even enter the ICU. Risk factors include younger age (under 65), existing (pre-hospitalization) psychopathology and certain personality traits, such as anxiety, Dr. Needham said.

Once they're in the ICU, other factors come into play. Patients who stay longer and those who can't remember ICU admission are more likely to develop PTSD, reported Elie Azoulay, MD, PhD, of the Hôpital Saint-Louis in Paris. The latter factor ties into the broader finding that patients who are more sedated have higher PTSD rates.

“Our thoughts that deep sedation is going to protect our patients from these symptoms is likely quite wrong,” said Dr. Needham. In fact, use of benzodiazepines has been associated with greater risk of PTSD, as have physical restraints and agitation, he said.

Patient agitation may be easier to avoid if you deal effectively with delirium, another common issue in the ICU. Delirium has not been identified as a direct cause of PTSD after an ICU stay, but it does cause lasting psychological harm, according to Yoanna Skrobik, MD, of the Hôpital Maisonneuve-Rosemont in Montreal.

“Patients who remember being delirious are extremely distressed by the experience,” she said. Delirium has also been associated with increased risk of death, longer lengths of stay and a greater chance of being discharged to somewhere other than home.

Other speakers at the meeting suggested that ICUs implement programs to screen for delirium, but Dr. Skrobik warned that there's no point in screening unless you know what you're going to do with the information.

At the very least, staff should be trained to reassure patients who have signs of and concerns about delirium. “If you ask the patients if they're frightened, you can reassure them verbally,” she said.

Screeners should also keep in mind that there aren't clear cut-offs between patients who are delirious and those who aren't. About 35% of ICU patients are clearly delirious and about 30% are totally normal, but 35% fall in between, showing some evidence of delirium, Dr. Skrobik reported.

She proposed non-pharmacologic options for treating and preventing delirium in the ICU. “We throw drugs at people,” she said. “Sometimes a more holistic approach might be interesting to consider.”

Nurses could help patients keep diaries of their ICU stays, taking photos and writing down visitors. There's not much research to support this technique, but it seems like a good way to help people deal with flashbacks, Dr. Skrobik said.

Of course, the diary project—like most efforts to increase interaction with ICU patients—does make more work for the nurse. “Some nurses like very sedated patients,” said Dr. Skrobik.

The ICU environment puts a lot of stress on staff and family members as well as patients, noted Dr. Azoulay. He estimated that as many as 10% to 20% of ICU nurses present with symptoms of PTSD, while about a third of patients' family members develop the condition.

He also offered solutions. A major factor in nurses' risk is the frequency of conflict with colleagues, so reducing these conflicts and giving nurses more decision-making input can help. Families, on the other hand, benefit from policies that allow them 24/7 access to the ICU. “It is the only way to decrease the fantasy of what is in there,” said Dr. Azoulay.

Early mobilization

ICUs should also open themselves to occupational and physical therapists, the experts advised. Early mobilization shows promise for reducing the after-effects of ICU stays.

“These people are able to return home sooner,” said Cheryl Esbrook, OTR/L, an inpatient therapist and fieldwork coordinator at the University of Chicago. An ICU mobilization program may require a little more OT and/or PT staff (a good caseload is about 20 patients per therapist, she noted), but the cost may be recouped by less need for therapy or assistance after the patients leave the ICU and the hospital.

Mobility therapy may even help with one of the most problematic and irreparable consequences of an ICU stay: cognitive impairment. Ramona Hopkins, PhD, chair of psychology at Brigham Young University in Provo, Utah, presented case studies and research data showing how frequently ICU patients permanently lose cognitive abilities during their admission. Some studies have shown that almost 80% of ICU patients suffer substantial cognitive impairment, even among the non-elderly.

“This is not age-related decline. Factors associated with the critical illness or its treatment likely contribute to the observed cognitive decline,” Dr. Hopkins said. The cognitive problems could be a result of hypoxemia or cerebral perfusion changes, she noted. Other research has shown delirium and both fluctuating and high glucose levels to be associated with worse cognitive outcomes.

Unfortunately, there's not much research on what can be done to prevent cognitive impairment, she added, but hypotension and corticosteroid use may contribute to the problem, while mobility and decreased sedation and analgesia could help.

There's no research on whether cognitive rehabilitation provides benefit to these patients, but Dr. Hopkins thinks it's worth a try. “We under-refer to rehabilitation,” she said.

Referrals may also be in order for the estimated 28% of patients who suffer from depression in the year after an ICU stay. Risk factors include pre-hospital psychopathology and poor physical function before ICU admission, and poor or traumatic recall of the experience afterward. These risk factors all can be detected while patients are still in the hospital, according to Dr. Needham.

“Patients with early psychiatric symptoms, after the ICU, need to be raising a red flag for us regarding potential longer-term psychiatric problems,” he said.

Whether it's a flag signaling depression, PTSD, delirium or cognitive impairment, ICU physicians need to be watching their patients for these, and doing what they can to prevent or alleviate the problems. “It's time we get with the program and address the psychological components of our patients' care,” said Dr. Skrobik.

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