Memories for ICU and Post Traumatic Stress Disorder

1
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

2
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)

3
Psychological problems within ICU
4
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-op
• Dyer CB et al Arch Intern Med 1995 155461-465
• Common related to illness severity
• Not been shown to induce psychosis

5
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

6
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 (p0.006)

Ely EW et al (Nashville, USA) Int Care Med. 2001
271892-1900
7
Delirium in ICU patients

• 19 developed delirium (gt 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 2001271297-1304.

8
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 appreciated
• Zauner C et al. Crit Care Med 2002 30 1136-1139
• Sharshar T et al. Crit Care Med 2002 30
  2371-2375
• Sharshar T et al (France) Lancet 2003
  3621799-805
• 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

9
Assessing Cognitive function in ICU
Stockings of Cambridge test Percentage of age
sex matched norms
T Slater et al Intensive Care Medicine 2004 30
(1) S199 (ESCIM 770)
10
Importance of memory for ICU
11
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

12
Recall memory of ICU at 2 months
159 patients in clinic Emergency admissions With
ICU stay gt 4 days
Paranoid delusions of being killed by staff
Data from clinical experience running a general
ICU follow-up service in UK Jones C et al Br J
Intensive Care 1994 246-53
13
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
14
Memory study

• Emergency admissions with ICU stay gt 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 nightmares
• C. Jones et al. Clinical Intensive Care
  200011(5)251-255.
• Hospital Anxiety and Depression Scale (HAD)
• Assessment Post traumatic stress disorder
  symptoms at 8 weeks
• Impact of Events Scale (IES)

15
Post Traumatic Stress Disorder (PTSD)

• DSM IV R
• American 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 gt 1 month
• Must cause significant impairment in functioning
• Once symptoms gt 3 months chronic PTSD

16
PTSD related symptoms ICU memories
30 ICU patients recall tested at 2 weeks IES at
8 weeks post ICU
Impact of Events Scale at 8 weeks
worse
P0.001
Delusions but No recall of ICU
IES gt 19
Delusions but can recall ICU
No delusions
Jones C, Griffiths RD, Humphris G, Skirrow PM.
Critical Care Medicine 2001 29573-580
17
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.

18
Post ICU PTSD

• 27 incidence of PTSD following ARDS
• Retrospective (10yr) of patient experiences after
  ARDS
• Schelling 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
  272678-2683
• Cardiac Surg Schelling et al Biol Psychiatry
  2004 55627-633
• 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
  paralysis
• Nelson, Weinert, Bury, Marinelli Crit Care Med
  200028(11)3626-3630

19
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

20
Questionnaires used

• CAM-ICU (in ICU)
• Ely et al. Crit Care Med. 2001291370-1379
• 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 19979445-451.
• PTSD interview tool

21
Recruitment
22
Memory of Illness
23
Factors associated with PTSD

• In ICU
• Physical restraint (23 of restrained patients)
• Combined with no sedation
• Deep sedation/large sedative doses
• Recall of delusional memories
• Patient 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

24
Structural equation Modelling
Chi-square 7.88 df 11 p 0.72 Comparative fit
1.00 Root mean square error of approximation
0.001
PTSD
Delusions
0.368
0.172
Restraint
0.464
Sedation
Psych health
25
Daily sedative withdrawal

• Not a new RCT
• Follow up of earlier study after gt 1 year
• Only 30 of survivors studied
• ? Selection bias
• Waking group
• Less Ventilation
• Less ICU stay
• Fewer stress symptoms
• No PTSD

Kress JP et al (Chicago) Am J Respir Crit Care
Med 2003 168 1457-1461
26
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
  Feb44-47
• Symptoms of Post-traumatic stress disorder in
  relatives
• Risk predicted by high anxiety at 2 weeks 2
  months
• p0.007 p0.05
• Close correlation between High PTSD-related
  symptoms in the patient relative
• Jones C et al Inten Care Med 2004, 30 456-460

27
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

28

• 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 patients perspective
• Delirium Confusion
• Psychological stress
• Paediatric issues
• Cognitive impairment
• Photo-diary
• Staff stress