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What should I address at follow-up of patients who survive critical illness?

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Patients who survive critical illness such as shock or respiratory failure warranting admission to an intensive care unit (ICU) often develop a constellation of chronic symptoms including cognitive decline, psychiatric disturbances, and physical weakness. These changes can prevent patients from returning to their former level of function and often necessitate significant support for patients and their caregivers.1

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Figure 1. Prevalence of long-term cognitive, emotional, functional, and socioeconomic sequelae of critical illness.

Figure 1. Prevalence of long-term cognitive, emotional, functional, and socioeconomic sequelae of critical illness.

But unlike the deconditioning that results from noncritical care hospitalization, these symptoms can persist for 1 year or longer and have been termed postintensive care syndrome (PICS) (Figure 1).2–6

With growing awareness of the unique needs of ICU survivors, multidisciplinary PICS clinics have emerged. However, access to these clinics is limited, and most patients discharged from the ICU eventually follow up with their primary care provider. Primary care physicians who recognize PICS, understand its prognosis and its burden on caregivers, and are aware of tools that have shown promise in its management will be well prepared to address the needs of these patients.

COGNITIVE DECLINE

Several studies have shown that survivors of critical illness suffer from long-term impairment of multiple domains of cognition, including executive function. In one study, 40% of ICU survivors had global cognition scores at 1 year after discharge that were worse than those seen in moderate traumatic brain injury, and over 25% had scores similar to those seen in Alzheimer dementia.2 Age had poor correlation with the incidence of long-term cognitive impairment. Cognitive impairment may not be recognized in younger patients without a high index of suspicion and directed cognitive screening. Well-known cognitive impairment screening tests such as the Montreal Cognitive Assessment may help in the evaluation of PICS.

No treatment has been shown to improve long-term cognitive impairment from any cause. The most important intervention is to recognize it and to consider how impaired executive function may interfere with other aspects of treatment, such as participation in physical therapy and adherence to medication regimens.

Evidence is also emerging that patients are often inappropriately discharged on psychoactive medications (including atypical antipsychotic drugs and sedatives) that were started in the inpatient setting.7 These medications increase the risk of accidents, arrhythmia, and infection, as well as add to the overall cost of postdischarge care, and they do not improve the prolonged confusion and cognitive impairment associated with PICS.8 Psychoactive medications should be discontinued once delirium-associated behavior has resolved, as recommended in the American Geriatrics Society guideline on postoperative delirium.9 Further, patients and caregivers should be counseled so that they have reasonable expectations regarding the timing of cognitive recovery, which may be prolonged and incomplete.

PHYSICAL WEAKNESS

Prolonged physical weakness may affect up to one-third of patients who survive critical illness, and it may persist for years, severely compromising quality of life.10 In addition to deconditioning due to bedrest and illness, ICU patients often develop critical illness myopathy and critical illness polyneuropathy.

Although the mechanisms and risk factors for injury to muscles and peripheral nerves are not completely understood, the severity has been well described and ranges from proximal muscle weakness to complete quadriparesis, with inability to wean from mechanical ventilation. There is also an association with the severity of sepsis and the use of glucocorticoids and paralytics.10

Physical weakness can be readily apparent on routine history and physical examination. Differentiating critical illness myopathy from critical illness polyneuropathy requires invasive testing, including electromyography, but the results may not change management in the outpatient setting, making it unnecessary for most patients.

Physical weakness places a heavy burden on patients and their family and caregivers. As a result, most ICU patients suffer loss of employment and require supportive services on discharge, including home health aides and even institutionalization.

Physical therapy and occupational therapy are effective in reducing weakness and improving physical functioning; starting physical therapy in the outpatient setting may be as effective as early intervention in the ICU.11 Given the high prevalence of respiratory and cardiovascular disease in patients after ICU discharge, referral for pulmonary or cardiovascular rehabilitation is recommended. Because of the possible link between glucocorticoids and critical illness myopathy, these drugs should be decreased or discontinued as soon as possible.

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Critical care medicine: An ongoing journey

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