2005_memory_ptsd.ppt
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Memories for ICU and Post Traumatic Stress Disorder
Dr Christina Jones
Nurse Consultant Critical Care Follow-up
School of Clinical Science, University of Liverpool,
and Intensive Care, Whiston Hospital, UK
Intensive Care Research Group
Follow-up programme at Whiston Hospital since 1990– outpatient clinic– questionnaire follow-up– ward visits– support group (1992-1997)– Rehabilitation intervention study (1997-1999) – Validation of tool for post traumatic stress disorder (2001-
2002)– European study examining the incidence of PTSD (2003 -
2005)– Cognitive deficits following critical illness (2003 - 2005)
Psychological problems within ICU
No basis for a unique “ICU-syndrome” or “ICU-
psychosis”
ICU environment “Stressors” weak and ambiguous– Noisy & painful – v – sensory deprived?– Hostile & frightening - v - safety and comfort?
Sleep deprivation & disturbed circadian rhythm– May be a result of delirium but not the cause
» Review of 80 studies in post-opDyer CB et al Arch Intern Med 1995; 155:461-465– Common & related to illness severity– Not been shown to induce psychosis
Delirium is a medical condition
Is an acutely changed or fluctuating mental state characterised by:
– Inattention, inability to focus– Disorganised thinking– Delusions and hallucinations– Altered levels of consciousness– Agitation or Passivity
Is sufficient explanation of “ICU syndrome” in the sick ICU population
Impact of delirium in ICU 48 medical ICU patients
»Excluded neurological/psychiatric disease
– 24/48 ventilated 81% (39/48) developed delirium
– 60% within ICU Onset 2.6 days lasted 3.4 days (means) Associated with increased LOS ICU Predictor of long hospital stay (p=0.006)
Ely EW et al (Nashville, USA) Int Care Med. 2001; 27:1892-1900
Delirium in ICU patients 19% developed delirium (> 24hr stay) Most within 36 – 72 hrs of admission Risk factors for ICU patients
– Pre-ICU»Smoking»Hypertension
– In ICU»Abnormal biochemistry»Opiate use in ICU»High doses of benzodiazepines
Dubois, Bergeron, Dumont, Dial, Skrobik. Delirium in an intensive care unit. Intensive Care Medicine 2001;27:1297-1304.
Delirium no great surprise due to cerebral pathology!
Drug related delirium states– Medication & Recreational– Toxic and withdrawal
Encephalopathy and cerebral injury– Occurs in sepsis, more common than appreciatedZauner C et al. Crit Care Med 2002; 30: 1136-1139Sharshar T et al. Crit Care Med 2002; 30: 2371-2375Sharshar T et al (France) Lancet 2003; 362:1799-805
Cognitive impairment– Anecdotally apparent for many years on ICU and after
» Now being formally characterised
– Frequent deficits in problem solving and executive functioning (making decisions)
» Half of these patients still show deficits 3-6 months later
Assessing Cognitive function in ICU
T Slater et al Intensive Care Medicine 2004; 30 (1): S199 (ESCIM 770)
0
20
40
60
80
100
ICU Ward 3 months 6 months
Pt 1 Pt 2 Pt 3 Pt 4 Pt 5 Pt 6
Pt 7 Pt 8
“Stockings of Cambridge” testPercentage of age & sex matched norms
Importance of memory for ICU
Memory of Illness-is it important?
Many ICU patients suffer amnesia– Memory disturbances are a threat to recovery– No true experience, gap in autobiography– Distorted perspective on illness & recovery – Conflicts with experience of relatives
Many ICU patients suffer delusions– For those with no recall of reality but memory of
paranoid delusions lead to high risk of PTSD Implications for how we sedate patients in ICU
Recall memory of ICU at 2 months
No memory of ICU52%
Dreams Delusions
23%
ICU procedures
23%
Full recall2%
159 patients in clinicEmergency admissionsWith ICU stay > 4 days
Paranoid delusions of being killed by staff
Data from clinical experience running a general ICU follow-up service in UKJones C et al Br J Intensive Care 1994; 2:46-53
The ICU patient experience: a review of 26 studies 1967-1997 from USA
No recall in 20% to 40%– Rest had both positive and negative experiences– Highly dependent on case mix
» Many post-operative studies Discomforts
– Sleep, talking, restrictions, pain, fear, anxiety Comforts
– Safety, security, emotional support Delirium in 20% - 40%
– Nightmares, distorted perceptions, Persecutory delusions
Stein-Parbury J et al. Am J Critical Care. 2000; 9: 20-27
Memory study Emergency admissions with ICU stay > 48 hours Previous psychological history recorded Initial assessment on the ward at 2 weeks post ICU discharge
– Interviewed using the ICU Memory Tool » proven factual events» feelings, such as panic and pain» delusional memories, such as paranoid delusions, hallucinations and
nightmaresC. Jones et al. Clinical Intensive Care 2000;11(5):251-255.
– Hospital Anxiety and Depression Scale (HAD) Assessment Post traumatic stress disorder symptoms at 8
weeks– Impact of Events Scale (IES)
Post Traumatic Stress Disorder (PTSD)
DSM IV – RAmerican Psychiatric Association 2000
17 symptoms divided into 3 symptom categories:– 1. Re-experiencing
» (e.g. nightmares, flashbacks; physiological reactions)
– 2. Avoidance » (e.g. not talk/think about event, memory loss)
– 3. Arousal » (e.g. sleep disturbance, irritability)
Symptoms must be present > 1 month Must cause significant impairment in functioning Once symptoms > 3 months chronic PTSD
PTSD related symptoms & ICU memories
Delusions butNo recall of ICU
Delusions butcan recall ICU
No delusions
30 ICU patients recall tested at 2 weeks & IES at 8 weeks post ICU
Jones C, Griffiths RD, Humphris G, Skirrow PM. Critical Care Medicine 2001; 29:573-580
Impact ofEventsScale
at 8 weeks
P=0.001
wor
se
IES > 19
Conclusions
Even relatively unpleasant memories of ICU may give some protection from anxiety and PTSD-related symptoms post ICU.
Factual memories may allow patients to recognise that nightmares etc are not real.
Post ICU PTSD 27% incidence of PTSD following ARDS
– Retrospective (10yr) of patient experiences after ARDSSchelling et al Crit Care Med 1998; 26: 651-659
– Patients recall of adverse experiences » Terrifying nightmares (64%), Anxiety (42%), Pain (40%),
Respiratory Distress (38%), None in 21%
– Suggested less symptoms in steroid treated groups ?ICU: Schelling et al Crit Care Med 1999; 27:2678-2683Cardiac Surg: Schelling et al Biol Psychiatry 2004; 55:627-633
5 -14% incidence after general ICU– Relationship to duration of ventilation
Cuthbertson BH et al Int Care Med 2004, 30: 450-455 Drug usage in ICU
– PTSD correlated with days of sedation and paralysisNelson, Weinert, Bury, Marinelli Crit Care Med 2000;28(11):3626-3630
RACHEL project (2002-2004) Aims of study
– To determine the ratio of patients suffering from post traumatic stress disorder (PTSD).
– To record a detailed description of patients’ stay in ICU »delirium, sedation depth, opiate and sedation doses,
withdrawal symptoms»Memories for ICU
– To investigate the relationship between:-»the psychological outcome of patients after ICU, the
ICU environment and patient care practice, e.g. sedation or physical restraint
– To examine the psychological outcome where patient receives an ICU diary
Questionnaires used CAM-ICU (in ICU)
Ely et al. Crit Care Med. 2001;29:1370-1379
– Delirium test ICU Memory Tool (2 weeks)
– Memory for hospital admission– Memory for ICU
» factual events » Feelings» delusional events (nightmares, hallucinations, paranoid
delusions)
PTSS-14 (2 and 3 months)– Short PTSD symptom screening tool
Posttraumatic Diagnostic Scale PDS (3 months) Foa et al Psych Assess 1997;9:445-451.
– PTSD interview tool
RecruitmentCentre Recruite
d3
monthsPTSD
Whiston 52 50 5 (9.6%)
Norrkoping 31 31 1 (3%)
Bergen 34 27 2 (5.8%)
Gotenburg 43 42 2 (4.8%)
Ferrara 81 81 12 (14.8%)
Memory of Illness
Centre Recall hospital
admission
Recall some
factual ICU memories
Delusional memories
Whiston 21 (44%) 39 (81%) 28 (54%)
Norrkoping 20 (64%) 26 (84%) 24 (77%)
Bergen 12 (42%) 18 (65%) 15 (44%)
Gotenburg 28 (65%) 29 (67%) 23 (53%)
Ferrara 73 (90%) 77 (95%) 37 (46%)
Factors associated with PTSD
In ICU Physical restraint (23% of restrained patients)
– Combined with no sedation Deep sedation/large sedative doses Recall of delusional memoriesPatient factors Recall of delusional memories for ICU
– More common where history of previous psychological problems
» Depression, anxiety, panic attacks, phobias
– Deep sedation/large sedative doses
Structural equation Modelling
E16
PTSDICUPTSD E14
DelusionsDelusions
E12
PHYSREST
MEANHRRE
Restraint
E18
E20
DAYSLORA
DAYSMORPH
Sedation
E3
E5
D1
PREVPSYCPsych health
PTSD
Delusions
Restraint
Sedation
Psych health
Chi-square 7.88 df = 11 p = 0.72
Comparative fit = 1.00
Root mean square error of approximation = 0.001
0.368
0.172
0.464
Daily sedative withdrawal Not a new RCT
– Follow up of earlier study after > 1 year
– Only 30% of survivors studied
– ? Selection bias Waking group
– Less Ventilation– Less ICU stay– Fewer stress
symptoms– No PTSD
0
5
10
15
20
25
30
Vent d ICU d Hosp d IES PTSD
Control Waking
Kress JP et al (Chicago) Am J Respir Crit Care Med 2003; 168: 1457-1461
ICU relatives at risk of PTSD
Relatives highly anxious in ICU– ICU nurses important source of confiding support.
Jones C & Griffiths RD Brit. J. Int. Care 1995 Feb:44-47
Symptoms of Post-traumatic stress disorder in relatives– Risk predicted by high anxiety at 2 weeks & 2 months
p=0.007 & p=0.05
Close correlation between High PTSD-related symptoms in the patient & relative
Jones C et al Inten Care Med 2004, 30: 456-460
Long-term significance of psychological problems
• Alcohol abuse for symptom numbing• Not returning to work or socialising
– Social isolation– Stressful for other family members
»May only leave the house if with someone»Marriage breakdown
• Chronic physical problems– Chronic pain– Psychosomatic illnesses
ISBN 0-7279-1794-3 www.bmjbooks.com € 26, £ 15.95 Multi author text from an
ICS Focus meeting– Episodic memory– Risk of PTSD– Delirium, the patient’s
perspective– Delirium & Confusion– Psychological stress– Paediatric issues– Cognitive impairment– Photo-diary– Staff stress
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