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; 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 “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 > 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 30 ICU patients recall tested at 2 weeks & IES at 8 weeks post ICU Impact of Events Scale at 8 weeks worse P=0.001 Delusions but No recall of ICU IES > 19 Delusions but can recall ICU No delusions Jones C, Griffiths RD, Humphris G, Skirrow PM. Critical Care Medicine 2001; 29:573-580

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; 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

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 0.368 Delusions 0.172 Restraint 0.464 Sedation Psych health

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 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