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2005_memory_PTSD.ppt

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  • 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; 155:461-465 – 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 (p=0.006) Ely EW et al (Nashville, USA) Int Care Med. 2001; 27:1892-1900
  • 7. 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.
  • 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; 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
  • 9. 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” test Percentage of age & sex matched norms
  • 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 No memory of ICU 52% Dreams Delusions 23% ICU procedures 23% Full recall 2% 159 patients in clinic Emergency admissions With ICU stay > 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; 2:46-53
  • 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 > 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 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)
  • 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 > 1 month Must cause significant impairment in functioning Once symptoms > 3 months chronic PTSD
  • 16. PTSD related symptoms & ICU memories Delusions but No recall of ICU Delusions but can 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 of Events Scale at 8 weeks P=0.001 worse IES > 19
  • 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; 27:2678-2683 Cardiac 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 paralysis Nelson, Weinert, Bury, Marinelli Crit Care Med 2000;28(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. 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
  • 21. Recruitment Centre Recruited 3 months PTSD 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%)
  • 22. 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%)
  • 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 E16 PTSDICUPTSD E14 Delusions Delusions 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
  • 25. 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
  • 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 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
  • 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 patient’s perspective – Delirium & Confusion – Psychological stress – Paediatric issues – Cognitive impairment – Photo-diary – Staff stress