Delirium and long term cognitive impairment The Patient Survivors’ Stories

1. 2012 Delirium and long term cognitive impairmentThe Patient Survivors’ Stories

2. Disclaimer: The contents in this presentation does not represent the full product information of Precedex. In case of doubts or questions, you are welcome to contact the Hospira staff or medical department. Please refer to the full product prescribing information before using the drug. 2

3. A recap on Delirium Hyperactive delirium, 2% Adapted from Peterson JF et al. Delirium & its motor subtypes: a study of 614 critical ill patients. Journal of American Geriatrics Society 2006;54: 479-84.

4. A recap on Delirium (=Brain Dysfunction) • Hyperactive Delirium (e.g. Agitation, self extubation, fighting the ventilator etc.) • Hypoactive Delirium (e.g. Confusion, disorientated etc.) • Mixed Delirium • Other terms: ICU psychosis, brain dysfunction, altered mental status… • Prevalence : very common: Up to 80% of patients will suffer from Delirium in the ICU, it is the most frequent forms of organ dysfunction. • Impact on mortality, healthcare cost (longer ICU LOS), increase dementia risk in the elderly, leading to cognitive impairment persisting months to years after discharge, physical and mental disability • It has been postulated that benzodiazepines (midazolam, lorazepams) and propofol (GABA mimetics) is contributing to Brain dysfunction. • In SEDCOM study, Precedex is shown to reduce the incidence of Delirium by 23% (p<0.001).

5. A recap on Delirium Delirium & Precedex related clinical studies (DB, Randomized, placebo controlled studies) • In SEDCOM study involving 375 medical & surgical ICU patients, Precedex is shown to reduce the incidence ofdelirium by 23% (p<0.001) vs midazolam. • In PRODEX study involving 500 ICU patients, Precedex is shown to reduce neurocognitive adverse events (including delirium, anxiety and agitation (p<0.008) with Precedex group. • In both MIDEX & PRODEX study involving 1000 patients, time to extubation is significantly shorter in Precedex group (147 hrs in Midazolam group vs 101 hrs in Dex group; 93 hrs in Propofol group vs 69 hrs in Dex group) • Patient receiving Dex were more arousable, more cooperative and more able to communicate their pain than the patients receiving Midazolam or Propofol (p<=0.001)

6. Delirium in ICU and its impact in clinical studies • Independently associated with higher 6-month mortality rates (34% vs 15%, p=0.03) • Increase in Hospital LOS by 10 days (p<0.001) • Independently associated with longer post-ICU stay (p=0.009) • Higher incidence of cognitive impairment at hospital discharge (p=0.002) • The use of benzodiazepines, opiates and propofol has been contributing to brain dysfunction. References: • Ely EW, Shintani A, Truman B et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291(14):1753-1762. • Jakob SM, Ruokonen E, Grounds RM et al. Dexmedetomidine vs Midazolam or Propofol for sedation during prolonged mechanical ventilation. Two randomized controlled trials. JAMA 2012; 307(11):1151-1160. • Riker RR, Shehabi Y, Bokesch PM et al. Dexmedetomidine vs Midazolam for sedation of critically ill patients: A randomized trial. JAMA 2009;301(5):489-499.

7. Highlights of US SCCM 2012 PAD guideline recommendation • Analgesia first sedation • Patient’s self report on pain is the gold standard • Prioritize Non-benzos over benzos to improve clinical outcomes in mechanical ventilated adult ICU patients (+2B) • In mechanically ventilated patients at risk for developing delirium, Precedex may be associated with less delirium than benzos. • Recommend Light level of Sedation (+1B) • Recommend Early mobilization to reduce delirium • Recommend RASS to monitor depth of sedation

13. For more information about Delirium Our newsletter: Insights: An eye on Sedation Please visit www.icudelirium.org Delirium in Critical Care by Dr. Valerie Page & Dr. E. Wesley Ely

14. Video on delirium regarding Patients’ long term impact (The Patient Survivors’ Story) • Two patient videos selected (courtesy from Dr. E. Wesley Ely on approval in using the videos • 1st Patient: • A 49 year old Accountant The long term impacts: • IQ test : Before delirium: IQ = 145, After delirium: IQ = 110 • MRI scan on the brain shows a 80 year old woman after delirium • Suffering from day-to-day short term memory problems • Suffering from anxiousness, nervousness, depression • Originally an accountant, now cannot balance the check book. • Difficult to get concentrated  Cannot read a book • Working slowly every day, from 6:00 am to 10:00 pm • Eventually retire early because she cannot keep up with the workload

15. Video on delirium regarding Patients’ long term impact (The Patient Survivors’ Story) • 2nd Patient: • University graduate, a medical receptionist in trauma ICU The long term impacts: • Cannot check her 4th grade child homework • Problems in balancing check book • Did not remember having a baby girl Impacts on QoL: • Have to write down every single thing when go to shopping, however still missing • After the meeting, need to write down everything, otherwise forgot easily • Feel depressed • Can only work 30 hours a week (The doctor set the limit because of her ability to remember things and depression) • Great impact in her job and daily life

16. Last but not least • We have prepared the two materials written by two patients who have suffered from delirium: • Ms. Aneta Weinreich (Bridal costume designer, Henry Roth Worldwide) • The ICU Memoirs : 11 days of Intubation • Mr. David Aaronovitch (Journalist, The Times Magazine) • My Nightmare in hospital

17. End of Presentation Thank You!