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Friday, November 29, 2013

Brain dysfunction persists long after a serious illness

A sudden life-threatening illness is every family's nightmare. A loved-one suddenly develops an overwhelming infection or is in a terrible accident. She is rushed to the ICU and is put on a ventilator. Many medications are started or she is rushed to surgery for her traumatic injuries. To the family, the first day or two is a blur of life-saving treatments, painfully waiting for the next update. The patient is on strong sedatives and non-communicative. She survives the worst days. The infection improves, or the surgeries fix the worst injuries. The ventilator is removed and the sedation is stopped. It looks like she's going to make it. Families are usually unprepared for this next stage. In the movies the patient might spring out of bed and return home or a musical montage would convey her complete recovery over the next few days.

In reality the patient spends days in the ICU weak, confused and agitated. She doesn't sleep. She recognizes loved ones only intermittently and has conversations with people who aren't there. Other times she's very lethargic and only answers questions with a word or two. Her family is terrified.

Doctors call this syndrome delirium, and it's very common in critically ill patients. Delirium manifests in disorientation, agitation and a level of alertness that can change quickly over time. Though delirium affects all mental process, the primary deficit is in attention. Delirious patients can't focus on a task or on a question from one moment to the next.

The brain is usually an innocent bystander in delirium. Delirium is almost never caused by a primary brain problem, a stroke or a brain tumor, for example. Delirium is caused by a problem elsewhere that is disorganizing brain function, respiratory failure that is sending the brain too little oxygen or too much carbon dioxide, kidney or liver failure that is sending the brain too many waste products, or an infection that is sending the brain bacterial toxins.

In my training I was taught that once the cause of delirium is found and treated, the delirium might take days or weeks to improve, but that the improvement would be complete. I've discussed with many families preparing to take home a loved one that the patient's periods of confusion would be shorter and the periods of lucidity would be longer, and over the next few weeks her mental status would return to normal. It turns out that's not true.

A study published in this week's New England Journal of Medicine (NEJM) sought to measure the long-term mental effects of critical illness. The study enrolled over 800 patients who were admitted to an ICU for respiratory failure, overwhelming infection, or cardiovascular failure (cardiogenic shock) for any medical or surgical reason. The vast majority of them had no cognitive deficits prior to this illness. Their average age was 61. This was an extremely sick group. They spent an average of 3 days on a ventilator and 10 days in the hospital. 74% had delirium, and on average delirium lasted for 4 days. The survivors were followed and underwent a broad battery of neurocognitive tests administered by psychologists 3 months and 12 months after their hospitalization. (For a sense of how desperately ill these patients were, 31% died between their ICU admission and the 3 month follow-up.)

The results were surprisingly poor. Three months after hospitalization 40% of patients had cognition scores that would be typical for a patient with a moderate traumatic brain injury. 26% were even worse and had scores similar to patients with mild Alzheimer's disease. Twelve months after hospitalization those percentages were only slightly better, 34% and 24% respectively. More shocking was that the rate of prolonged cognitive impairment did not depend on age; young people did as poorly as old. The deficits did correlate, however, with the duration of delirium while they were hospitalized.

This study highlights several gaps in our current care of critically ill patients. Measures are already taken in ICUs to minimize the likelihood and duration of delirium. These measures must be redoubled with the knowledge that delirium may harm patients' mental function even a year later. Ambulation as early as possible and re-establishing the sleep cycle with daytime alertness and stimulation and nighttime sleep (which requires darkness and quiet) have been two of the more promising methods to protect patients' mental status.

Patients and families should be warned that deficits in thinking and memory may persist for a long time. Just as we prescribe physical therapy for a weak patient going home from the hospital, perhaps we should also be recommending cognitive testing and rehabilitation. And we should keep in mind that patients and their families may require more help than we've appreciated for longer than we thought.

Learn more:

Intensive-Care Units Pose Long-Term Brain Risk, Study Finds (WSJ)
Delirium In The ICU May Pose Ongoing Risk Of Thinking Problems (Shots, NPR health news)
Brain problems can linger months after ICU stay (Reuters)
Long-Term Cognitive Impairment after Critical Illness (NEJM article)
Disability after Critical Illness (NEJM editorial)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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