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Cognitive impairment – the missing
piece of the puzzle?
Associate Professor Sue Berney
sue.berney@austin.org.au
Overview
• Mechanically ventilated patients approx 36% demonstrate cognitive impairment 6 months after discharge and 25%-54% at 12 months1,2
• Deficits in executive function; memory and mental processing abilities3
• Effects include attention problems, inability to plan and execute a task, inability to access short and working memory, slow mental processing, visio-spatial deficits4
• Increased odds of disability in in activities of daily living and worse motor sensory function at 12 months5
• Patients with co-morbidities particularly vulnerable6
1Pandharipande (2013) NEJM; 2Needham (2013) AJRCCM; 3Jackson (2015) Psych Clin N. America; 4Hopkins (2012) Sem Crit Care Med; 5Brummel (2013) CCM; 6Schillerstrom (2007) Psychomatics
In sepsis
• Cognitive impairment more likely in sepsis OR 3.34 (95% CI1.53-7.25) Iwashyna
2010 JAMA
• Mechanisms include:
– Cerebrovascular damage
– Metabolic disorders
– Brain inflammation Annane 2015 Lancet Respir Med
This representation of a clock was drawn at hospital discharge by an 81 year old man with sepsis who spent 14 days in ICU and 140 hours on mechanical ventilation. No previous cognitive impairment.
Occupation: Accountant.
Needham (2016) Lancet Resp Med
Causes of cognitive impairment in general ICU population
• Hypoxaemia1
• Hyperglycaemia2
• Delirium duration3
• Hypotension4
• ?Sedatives and Analgesics4
• Hospitalisation5
1Hopkins (1999) AJRCCM; 2Hopkins (2005) AJRCCM ; 3Girard (2006) AJRCCM; 4Hopkins (2004) J.Int NeoruPschol ; 5Ehlenbach (2010) JAMA
Delirium
• “Neurobehavioral condition that occurs widely in a variety of health care settings is associated with adverse outcomes and is the most common manifestation of acute brain dysfunction during critical illness”1
• Delirium occurs in approx 74%-80% of patients in ICU2,3,5,6
• Delirium results in hypoperfusion in in frontal, temporal and subcortical regions of the brain4
1Jackson (2015) Psych Clin N Am 2015; 2Pandharipande (2013) NEJM; 3Ely (2001) JAMA; 4Fong (2007) J. Gerontol A Bio;Sci Med Sci; 5Needham (2016) Lancet Resp Med; 6Needham (2013 )AJRCCM
Brain-ICU
• N=821 septic and respiratory failure
• Median age =59years
• 74% of patients developed delirium in ICU
• Delirium independent predictor of cognitive impairment
• Cognitive impairment occurred irrespective of age an co-morbidity
% Cognitive impairments
3 months 12 months
66% 54%
Prevention – “A long habit of not thinking a thing wrong,
gives it a superficial appearance of being right”
• Exercise is recognised as treatment for cognitive decline in older adults1
– Exercise in ICU reduced delirium from 57%-33%2
• Cognitive rehab - feasible3
• Improved sleep efficiency – QA project - daily delirium/coma free status (OR 1.64 [95%CI 1.04-2.58])4. Promising area for further research required establishing link between sleep interventions and delirium5
1Hopkins (2012) AJRCCM; 2Schweickert (2009) Lancet; 3Brummel (2014) ICM; 4Kamdur (2014) CCM; 5Flannery (2016) CCM
Wilcox (2013) CCM
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