August 10, 2007

Study seeks to clear patients’ post-ICU cobwebs

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Wes Ely, M.D., M.P.H.

Study seeks to clear patients’ post-ICU cobwebs

James Jackson demonstrates cognitive therapy techniques being studied for patients after leaving the ICU. (photo by Neil Brake)

James Jackson demonstrates cognitive therapy techniques being studied for patients after leaving the ICU. (photo by Neil Brake)

Months after their experiences in intensive care units, patients across the country often describe residual cognitive and physical deficits such as memory loss, mobility issues and confusion that impact their ability to carry out daily tasks.

Recent studies estimate that more than a third of patients leave ICUs with significant neurocognitive deficits that last for months or years.

“When you go to the ICU with a life-threatening problem and go on a ventilator, you usually come in with one set of problems and you leave with another set of problems,” said Wes Ely, M.D., M.P.H., professor of Medicine.

With the Beeson Collaborative research grant from the American Federation for Aging Research (AFAR) and the Hartford Foundation, Ely and his colleagues in the ICU Delirium and Cognitive Impairment Study Group are studying what they can do to help restore cognitive and physical function once patients are discharged.

As a critical care specialist and a pulmonologist with a special interest in the problems facing older patients, Ely has seen firsthand the diminished capabilities of ICU patients after they get off of life support and leave the hospital.

“They can't balance a checkbook, plan a party, remember where they parked their car, or walk without support. Sometimes they can't return to work or school,” Ely said. “Patients and families ask what happened, and what is this private nightmare I'm living every day of my life right now?”

Ely and his team, working with Bob Dittus, M.D., M.P.H., and Gordon Bernard, M.D., have identified profound adverse effects from ICU care on cognitive and physical function and have developed techniques for care in the ICU that reduce, but do not eliminate, these deleterious effects.

The AFAR collaborative grant will enable the group to work closely with Helen Hoenig, M.D., M.P.H., of Duke University Medical Center and her team, to take the next important step to identify post-acute interventions to ameliorate these adverse events.

“We're going to try to exercise their bodies and exercise their brains using both physical and cognitive rehabilitation within the context of a randomized, controlled clinical trial,” Ely said.

The initial phase of the study will randomize patients into two groups: those who receive rehabilitation and those who do not. Cognitive therapy will involve goal management training to help restore organizational skills, which seem most affected by the ICU experience.

“We're looking to see if the patients who receive the combined rehab intervention have better executive and physical function at the end of three months in this pilot study,” Ely said. “We think both forms of rehab will combine to help the brain.”

The most common diagnosis that lands a person in the ICU is severe sepsis and respiratory failure due to infection or pneumonia. The average age of an ICU patient with these problems is about 65, but it can happen to anyone and often without any warning. Sepsis is the body's over-response to a bacterial infection, which results in inflammation and small blood clots that block blood flow to vital organs. This can lead to organ failure. A quick diagnosis can be crucial, because one-third of people who get sepsis die from it, according to NIH literature.

“Severe sepsis is probably the most oppressive illness the body can get because in a matter of hours your organs can shut down. While many patients develop infections over days, it is also true that this disease can be sudden and furious,” Ely said. “You're eating Cheerios in the morning and by the afternoon you're going to hell in a hand basket.”

Some ICU patients experience delirium, which seems to be a key marker of the subsequent loss of both cognitive and physical function.

“With between five to eight out of 10 ventilated patients experiencing delirium, this is one of the most frequent forms of organ dysfunction experienced,” Ely said.

Ely and his team of more than 30 collaborators will have their hands full for the next several years juggling multiple studies while trying to understand what happens to the brains of critically ill patients, what they can do to stop the slide into delirium and long-term cognitive impairment, and how they can restore a person to a pre-illness state of health.

“Our research group feels compelled to address what we see as a public health issue that has been 'secretly' suffered by millions of ICU survivors for years. So, we're going to spend the next 10-20 years trying to figure this out and improve the outcomes for these patients,” he said.