Increasing role of post-intensive care syndrome in quality of life of intensive care unit survivors

Abstract

In this editorial we comment on the detrimental consequences that post-intensive care syndrome (PICS) has in the quality of life of intensive care unit (ICU) survivors, highlighting the importance of early onset of multidisciplinary rehabilitation from within the ICU. Although, the syndrome was identified and well described early in 2012, more awareness has been raised on the long-term PICS related health problems by the increased number of coronavirus disease 2019 ICU survivors. It is well outlined that the syndrome affects both the patient and the family and is described as the appearance or worsening of impairment in physical, cognitive, or mental health as consequence of critical illness. PICS was described in order: (1) To raise awareness among clinicians, researchers, even the society; (2) to highlight the need for a multilevel screening of these patients that starts from within the ICU and continues after discharge; (3) to present preventive strategies; and (4) to offer guidelines in terms of rehabilitation. An early multidisciplinary approach is the key element form minimizing the incidence of PICS and its consequences in health related quality of life of both survivors and their families.

Key Words: Intensive care unit acquired weakness; Physical impairment; Quality of life; Mental; Cognitive function

Core Tip: An early multidisciplinary approach is the key element form minimizing the incidence of post-intensive care syndrome and its consequences in health related quality of life of both survivors and their families. Step-by-step early assessment of physical, mental and cognitive impairment will assist in designing a personalized rehabilitation program from within the intensive care unit.

INTRODUCTION

During the past decades, scientific and technological innovation increased significantly the rate of survival in critically ill population, bringing clinicians confronted with a population with increased needs in rehabilitation. The sequel of survivorship was proved to be more challenging for both the patient and his/her family[1].

The last pandemic of coronavirus disease 2019 came as a reminder, that a lot needs to be done in order to facilitate the return of these survivors to society and a well living. The recognition of post-intensive care syndrome (PICS) and its multilevel manifestation was a significant step in a series that are needed in order to reduce its prevalence and impact[1]. A recent study by Tejero-Aranguren et al[2] raised the incidence of PICS to 56.3% with the mental health sphere to become the most frequently involved[3]. Physical impairments were well recognized through the presence of intensive care unit (ICU)-acquired weakness (ICUAW) with increased consequences in functionality and overall quality of life[4]. It is well documented that although cognitive manifestations are the most common ones, two out of ten patients had co-current problems in 2-3 domains (from physical, psychological and cognitive domain assessment)[3]. Besides the known risk factors that are related to the critical illness (i.e. duration of sepsis, surgical stress, trauma) and the ICU (i.e. hyperglycemia, delirium, mechanical ventilation, renal replacement therapy, extracorporeal membrane oxygenation), it has been found that pre-existent frailty is also an important prognostic factor. Although, frailty is a state that is linked to elderly population and chronic diseases, its presence during critical illness is strongly associated with reduced abilities to recover to their pre-illness status[3]. There is a great need of a plan for early recognition of patients at risk, implementation of preventive strategies and well organized programs for ICU survivors in order to improve their quality of life.

CLINICAL IMPLICATIONS

Screening tools

Early recognition of patients at risk of PICS is a key element to prevention. Besides the risk factors that should keep in mind, clinicians need specific tools to assess each domain (physical, mental, cognitive) and be able to identify early any further deterioration. Sedation protocols, delirium and pain control assessment, facilitate regularly screening. Yet, we need a consensus on the tools that we should use in order to increase reliable data that could improve our knowledge on the syndrome. A recent scoping review by Pant et al[5] identified 44 studies on the development and assessment of psychometric properties of PICS in ICU survivors or their families. More specifically, they were able to present 25 tools that assess only one aspect of PICS: five for cognitive impairment, seven for physical impairment, and 13 for mental health impairment and post-traumatic stress disorder (PTSD). There were still 5 that addressed all three aspects of PICS manifestations, one for both physical and mental aspects of, and five tools for quality-of-life. Mikkelsen et al[6] recommended the pre-admission assessment of patients functionality, mental and cognitive status as patients with pre-existing impairments are of high risk of PICS. From the screening tools that have been used in literature, the Montreal Cognitive Assessment and Hospital Anxiety and Depression Scale are strongly recommended for cognition, anxiety, and depression, respectively. Additionally, the Impact of Events Scale-Revised, 6-min walk, and/or EuroQol-5 dimensions-5 level, are recommended, as screening tools for PTSD and physical function, respectively. These tools were also recommended by a panel of experts reaching a consensus on a core outcome tools[7]. Yet, these tools were administered after ICU or even at hospital discharge. It remains however unanswered which of these tools could be used in the acute setting during ICU stay.

Regarding physical impairment, the use of muscle strength tests (handgrip and handheld dynamometers) and Medical Research Council scale should be used as early as possible. Muscle strength has been found to be related to functionality quality of life[4]. Interestingly, the use of maximal inspiratory pressure during the weaning phase from the ventilator could be used to reveal ICUAW in non-co-operative patients as we have previously shown[8]. Additionally, the Chelsea Critical Care Physical Assessment tool was designed especially for an acute setting, assessing in daily bases multiple components including respiratory function, cough, mobility, strength offering a wider spectrum assessment[9].

The early recognition of the presence of delirium is of particular importance as it affects early mobilization rates and is associated with both cognitive and psychological disorders within the context of PICS[10]. The use of ABCDEF bundle as a strategy to prevent PICS addresses also the risk of delirium. Among the screening tools that have been widely used is Confusion Assessment Method for ICU that has been validated in numerous languages and can be easily used by the entire ICU personnel with minimum training.

A more focused assessment regrading mental and cognitive impairments should target patients at increased risk of PICS, mainly with a prolonged ICU stay (usually more than 3 d). Becks Depression/Anxiety Inventory, Impact of Events Scale and Montreal Cognitive Assessment are the most used tools to assess psychological and cognitive impairment at ICU discharge[5].

Preventive strategies

As mentioned above the use of ABCDEF bundle has been identified as the most significant strategy of prevention for PICS. Daily awakening and implementation of spontaneous breathing trial, along with pain and delirium assessment are of high importance and should be adopted into daily practice. World Health Organization has lately introduced the “Rehabilitation 2030 initiative” in order to face the increasing burden of disability highlighting the need for strengthening health systems to promote and provide rehabilitation. ICU early mobilization seems to be a key component of both preventive and rehabilitative strategies[11]. From ICU admission, patients should be introduced to a rehabilitation program with a multidimensional approach enarmonizing with patients` current clinical conditions focusing to preserve muscle functional capacity and minimize ICUAW. Technological and medical evolution have offered a wide range of rehabilitation techniques and tools. Neuromuscular stimulation has been shown to be an alternative form of exercise preventing ICUAW, that could safely be applied by the first day of ICU admission[12]. This could be applied along with a cycloergometer targeting functional recovery as well; however the beneficial effects have not been demonstrated yet[13]. From a passive to an active assistive or even mixed protocol the therapist has the ability to fully prescribe the exercise regimen of every critically ill patient. Early progression to an active mobility program out of bed, enhanced with functional exercises could speed recovery, reduce physical impairments and improve their quality of life minimizing detrimental effects in activity of daily living[14]. It is often noted that although patients retrieve their muscle strength, even before hospital discharge, functional impairment persist and affect quality of life. As functional performance is closely related to cognitive function, we should take careful consideration cognitive assessment. The implementation of a multi-modal inter-professional rehabilitation program could positively influence long-term outcomes[14]. The rehabilitation team may often manage patients with dysphagia, implement strategies to enhance a safe removal of tracheostomy tube and may also incorporate cognitive rehabilitation along with physical training programs. Deficiencies in memory, attention, co-ordination and executive functions affect significantly quality of life of ICU survivors. Occupational and psychological assessment and intervention should be early applied, although require expertise and dedicated staff mainly within the well-organized follow-up ICU clinics.

CONCLUSION

PICS occurs frequently and affects quality of life of ICU survivors even years after their ICU discharge. PICS increasing role has an impact not only for ICU survivors, but also their next of kin and the health system as well. The ICU team needs to establish an Interdisciplinary strategy plan to prevent and reduce PICS incidence. Prevention and rehabilitation measures should include physical, cognitive and psychological interventions as early as possible to reduce its occurrence and maintain quality of life of ICU survivors. A strategic plan is needed to ensure that there is a specific pathway of services for critical illness survivors to reassure their quality of life. Although, follow up services have been increased, there is an increasing need for educational material, online and in-person support groups. These could inform not only health professionals but also family members, creating a supportive community. An interprofessional network could support the patients’ struggle to overcome impairments and to fully recover.