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E. Wesley Ely, MD, MPH Professor of Medicine Vanderbilt University, Nashville, TN VA TN Valley Health Care System GRECC Delirium and Long-Term Cognitive Impairment in ICU Survivors

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Page 1: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

E. Wesley Ely, MD, MPH Professor of Medicine

Vanderbilt University, Nashville, TN VA TN Valley Health Care System GRECC

Delirium and Long-Term Cognitive Impairment in ICU Survivors

Page 2: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Disclosures: - NIH and VA U.S. Federal Funding

- Abbott, Hospira, Orion

- Author of PAD Guidelines of SCCM 2013

- Chair of SCCM Delirium section for PAD

- Co-Chair of SCCM ICU Liberation project to aid

world-wide implementation

Page 3: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,
Page 4: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Ely EW, JAMA 2004;291:1753-62

Page 5: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Shehabi Y, et al. CCM 2010; 38:2311–2318

Delirium Duration & Mortality R

elat

ive

Haz

ard

of

Dea

th

0 1 2 3 4 5 6 0

1

2

3

4

p<.001

Days of Delirium

0 vs 1 HR 1.7 1.27-2.29 <0.001

0 vs 2 HR 2.69 1.58-4.57 <0.001

0 vs 3 HR 3.73 1.92-7.23 <0.001

Page 6: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Mild Cognitive Impairment

Moderate/Severe Cog

Impairment

20

15

10

5

0

% survivors

cognitively

impaired

-3 years -1 year +1 year + 3 years

25

p<0.001

After Sepsis Before Sepsis

Iwashyna T, JAMA 2010;304:1787-1794

Cognitive Impairment: Sepsis

Page 7: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Delirium and Cognitive Decline

Fong T, et al. Neurology 2001;72:1570-75

Page 8: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,
Page 9: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

NEJM 2012;367:30-9

Page 10: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

0

10

20

30

40

50

60

0 5 10 15 20 Days of ICU Delirium

Cognitiv

e F

unction a

t 1 y

ear

(pre

dic

ted m

ean T

-score

) p=.005

Delirium and Long-Term Cognitive Outcomes

Girard T et al CCM 2010; 38:1513–1520

Page 11: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,
Page 12: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

BRAIN-ICU Hypothesis

• We hypothesized that duration of delirium is a predictor of LTCI in patients at 3 and 12 months after ICU discharge.

• Primary purpose was to identify potentially modifiable risk factors of long-term cognitive impairment such as development of delirium and exposure to sedative medications.

Page 13: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Time

Delirium Duration

Drug Exposure

Long Term Cognitive

Impairment (LTCI) Battery

Health-Related Quality

of Life (HRQL) Battery

Patient enrollment 12-month follow-up

INDEPENDENT VARIABLES DEPENDENT VARIABLES

Time

Delirium Duration

Drug Exposure

Long Term Cognitive

Impairment (LTCI) Battery

Health-Related Quality

of Life (HRQL) Battery

Patient enrollment 12-month follow-up

INDEPENDENT VARIABLES DEPENDENT VARIABLES

Page 14: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,
Page 15: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Methods

Page 16: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Prospective Cohort Study

Enrollment Exposures

(ICU) Outcomes

(3- & 12-mo)

Included

Adults

Medical/surgical ICU

Respiratory failure

Shock

Excluded

Recent ICU time

Dementia

Cardiac surgery

Substance abuse

Psychiatric disorder

Primary: Delirium subtypes

CAM-ICU

RASS

Covariates

Age

Education (years)

Baseline cognition

Comordid illness

Severity of illness

Coma

Sedatives

Repeatable Battery

Assessment of

Neuropsychological

Status (RBANS)

Trailmaking Test, Part B

MMSE

Page 17: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Characteristic Hospital Cohort (N=821)

Follow-Up Cohort (N=467)

Age, years 61 [51-71] 59 [49-69]

Education, years 12 [12-14] 12 [12-14]

Cognitive impairment, % 6% 6%

APACHE II 25 [19-31] 24 [19-30]

Admission diagnoses, %

Severe sepsis 30 30

Acute respiratory failure 16 15

Cardiac 17 17

Other 37 38

Mechanically ventilated

Patients, % 74 75

Duration, days 3 [1-8] 2 [1-6]

Hospital length of stay, days 10 [6-17] 10 [6-18]

Baseline and Clinical Characteristics

Page 18: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

BRAIN-ICU Outcomes

Long-term cognitive impairment

Page 19: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

The Picture of Dementia Following ICU Care

Page 20: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Global Cognitive Scores by Age

Page 21: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Global Cognitive Scores by Age and Comorbidity

Page 22: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Delirium and Executive Function

Page 23: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

• Bonn Germany, 2 center 6-24 month follow-up of 25 septic and 19 non-septic ICU survivors

• Sepsis survivors showed cognitive deficits in verbal learning and memory

• Significant reductions of hippocampal volume vs. controls

• More low frequency EEG activity indicating brain dysfunction

Semmler A, J Neurol Neurosurg Psych 2013;84:62-70

Page 24: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,
Page 25: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

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

Delirium

Page 26: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

Barr J et al, CCM 2013;41:263-306

Page 27: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

E C

B A

ABCDEs: Building blocks of managing Pain, Agitation & Delirium

Page 28: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

“ 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

“

Page 29: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

The ICU Delirium and Cognitive Impairment Study

Group at the Loveless Café, Nashville TN

Page 30: Delirium and Long-Term Cognitive Impairment in ICU … · Delirium and Long-Term Cognitive Impairment in ICU Survivors . Disclosures: ... Other 37 38 Mechanically ventilated Patients,

ICU Delirium and Cognitive Impairment Study Group: selected local members

Pratik Pandharipande Jim Jackson Jin Han Ed Vasilevskis Chris Hughes Alessandro Morandi Paula Watson Lorraine Ware Gordon Bernard Bob Dittus Ted Speroff Wes Ely

Leanne Boehm Joyce Okahashi Cayce Strength Brenda Pun Lauren Hardy Amy Lipsey Ryan Black Jessica McCurley Michael Santoro Carrie Jones Morgan Crawford Mayur Patel

Tim Girard John Gore Baxter Rogers Stephan Heckers Cathy Fuchs Heidi Smith Ty Berutti Brad Strohler Elizabeth Card Jennifer Thompson Ayumi Shintani Stephanie Hamilton


Medicine Hat Regional Hospital ICU Delirium Collaborative

ICU Pain, Agitation, and Delirium Care · PDF file ICU Pain, Agitation, and Delirium Care Bundle Assess pain ≥4x/shift & prn Preferred pain assessment tools: • Patient able to

Delirium in icu

Delirium in the ICU

ICU Pain, Agitation, and Delirium Care Bundle

The Post - ICU Patient - HealthManagement.org...Delirium Delirium is a common acute brain dysfunc - tion that affects critically ill patients. Even though delirium was first described

Delirium Monitoring in the Pediatric ICU · Delirium Monitoring in the Pediatric ICU Mary Hamilton Chestnut MSN, APN, Heidi AB Smith MD, MSCI Delirium is a disturbance of BOTH cognition

Rapidly progressive cognitive impairment without delirium

Delirium care in ICU - IJN College Care in ICU final.pdfClick to edit Master title style INSTITUT JANTUNG NEGARA National Heart Institute Why does delirium matter? • Affects up to

ICU Delirium Prevention and Treatment: Medication ... Safety and...ICU Delirium Prevention and Treatment: Medication-Associated Implications John W. Devlin, PharmD, FCCP, ... Wang

PAIN, AGITATION and DELIRIUM in ICU · PAIN, AGITATION and DELIRIUM in ICU Dr. Bram Rochwerg Assistant Professor Department of Medicine & Department of Health Research Methods, Evidence

Theory Application Paper: Preventing ICU Delirium

Preventing ICU Subsyndromal Delirium Conversion …...Preventing ICU Subsyndromal Delirium Conversion to Delirium With Low-Dose IV Haloperidol:A Double-Blind, Placebo-Controlled Pilot

Pharmacological Treatment of Delirium - Critical Care … · Pharmacological Treatment of Delirium ... ETIOLOGY MNEMONIC ... – Rx until ICU discharge or coma and delirium-free x

ADULT ICU DELIRIUM UPDATE...Before/after (notification) 652 Duration of ICU and Delirium and mortality No Diff Reade Crit Care Resusc 2011 Before/after (CAM use) 288 RN documentation

Acquired Delirium Occupational Therapy Impacting ICU · Delirium ICU syndrome chosis cute brain failure hysteria Metabolic derangement Acute confusional state. Who is more at risk

1 the Importance of Diagnosing and Managing ICU Delirium

Reducing Delirium in the ICU - Maryland Patient Safety … DIAGRAM (PROCESS MAP) Process Name: Reducing Delirium in the ICU ICU Care Team, Patient, family Patient/Family RN, Pharmacy,

Iatrogenic Delirium Overview - MHA Delirium... · Iatrogenic Delirium Overview Julie Apold Sr. Director , Patient Safety ... Assessment Tools NEECHAM CAM-ICU CAM Delirium Rating Scale

Royal Columbian Hospital ICU Delirium Quality Improvement Initiative

Delirium in ICU -By Dr.Tinku Joseph

Delirium in the ICU - Pitt · Subsyndromal delirium • Pts that fall short of the diagnos_c threshold for delirium (ICDSC ≥ 4) • ICU paents without delirium compared to those

Delirium in the ICU · CCPOT (see handout) CCPOT Posi_ve (score >2) Treat pain Reassess CCPOT. Did score decrease? S_ll not directable 3. Delirium Assessment CAM-ICU (see handout)

RESTRAINT USE in the ICU › presentations › 2012 › restraint_use_in… · PHYSICAL RESTRAINT USE IN THE ICU. Delirium. Delirium. Smoking Objective: to reduce need for sedatives

Coma-Delirium in ICU/CCM Board review

ABCDE Protocol ICU Delirium and Cognitive Impairment Study Group [email protected]

Sleep & Delirium in the ICU: What is the Relationship? · Sleep & Delirium in the ICU: What is the Relationship? Karen J. Bosma, MD, FRCPC Associate Professor, Department of Medicine,

Patients Gone Wild: Agitation and Delirium in the ICU

CAM-ICU Basics ICU Delirium and Cognitive Impairment Study Group [email protected]

Using the Evidence: Developing an ICU Delirium Protocol

Delirium Prevention and Treatment: Current Evidence Gaps · • Cohort studies suggest patient’s taking a statin at the time of ICU admission have reduced ICU delirium Page VJ et

Delirium · 2020-04-22 · Care Unit (CAM-ICU), and the Intensive Care Delirium Screening Checklist (ICDSC). CAM-ICU and ICDSC are checklists that healthcare staff can use to identify

ICU Delirium and sedation: understanding their role in long-term … · 2019-09-27 · ICU Delirium and sedation: understanding their role in long-term patient outcomes Yoanna Skrobik

Delirium in ICU: Nomenclature and Diagnosis

Delirium in the Intensive Care Unit (ICU): a guide for …Delirium a guide for patients and families How can you help prevent and manage delirium? in the Intensive Care Unit (ICU)