2005_memory_PTSD.ppt

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2005_memory_PTSD.ppt

  1. 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. 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. 3. Psychological problems within ICU
  4. 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. 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. 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. 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. 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. 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. 10. Importance of memory for ICU
  11. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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