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Cognitive Impairment After Critical Illness
7 Plays6 years ago
In this episode, we discuss the long term effects of critical illness on cognitive impairment. Our guest is Dr. James Jackson. Dr. Jackson is the Assistant Director of The ICU Recovery Center at Vanderbilt, a Research Associate Professor, and the lead psychologist for the Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center at the Vanderbilt University School of Medicine.
Additional Links:
The BRAIN-ICU Study, a seminal prospective study that established the prevalence of long term cognitive dysfunction in critical illness survivors: https://bit.ly/2InupDw
Cognitive outcomes after critical illness. A recent review article on the topic: https://bit.ly/2NLIuR1
Link to the CIBS Center website, which contains a wealth of resources for intensivists: https://bit.ly/2HfdQ0n
Books Mentioned in This Episode:
Fly Fishing Through the Midlife Crisis by Howell Raines: https://amzn.to/2OX9Bqp
Recommended
Transcript
Introduction to Intensive Care Topics
00:00:09
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Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:17
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And now your host, Dr. Sergio Zanotti.
ICU Survivor's Journey: Recovery and Challenges
00:00:22
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A couple of years at a dinner party talking with an acquaintance,
00:00:26
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I was told by him of the experience him and his family had had in the ICU with his elderly father in his 80s being intubated, delirious after heart surgery for several days, and ending up staying in the hospital for almost 70 days.
00:00:40
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What was remarkable about this conversation was that this gentleman eventually left the rehab place, got home, and went back to work.
00:00:50
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And at the time, my acquaintance was referring to me that they were very excited because he was back running his business and was actually taking a business trip to Cape Town.
00:01:01
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Several months later, almost a couple of years later, I bumped into my friend again and about inquiring about his father was very saddened to hear that after a series of problems at his business, the family had decided to close the business and now his father was retired and not doing as well since he was quite depressed.
00:01:19
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At the time, I thought that what an unfortunate series of events and what an unfortunate coincidence that
00:01:26
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However, after our conversation today, I think you might agree with me that maybe this was something that could have been prevented or could have been foreseen in terms of what could have happened with this person after such a severe illness going back to running a business.
Cognitive Impairment Post-Critical Illness
00:01:40
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So today, we will take a little bit of a deeper dive into the cognitive impairment after critical illness.
00:01:48
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We spoke earlier this year with Dr. Wes Ely about
00:01:51
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delirium in the ICU.
00:01:53
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And it is obvious to me now that diagnosing delirium in our ICU patients is only a tip of the iceberg.
00:01:58
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Over the last years, we have recognized that the impact of delirium and of critical illness on cognitive function in survivors of critical care is an enormous problem and a huge challenge.
00:02:09
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Today, we will discuss the problem of cognitive impairment after critical illness.
00:02:13
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Our guest is Dr. James Jackson.
00:02:15
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Dr. Jackson is the Assistant Director of the ICU Recovery Center at Vanderbilt, a research associate professor, and the lead psychologist for the Critical Illness, Brain Dysfunction, and Survivorship Center at the Vanderbilt University School of Medicine.
BRAIN ICU Study Insights
00:02:28
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A licensed psychologist and active researcher and clinician, he is one of the world's leading authorities on depression, PTSD, and cognitive dysfunction in survivors of critical illness.
00:02:38
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He has authored over 90 scientific publications and leading scientific journals.
00:02:42
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It's a true pleasure to have him today on the podcast.
00:02:45
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Jim, welcome to Critical Matters.
00:02:48
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Thanks so much.
00:02:48
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I'm really happy to be here, and I'm really excited to engage these important topics with you.
00:02:54
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And I think as we were discussing before we started recording, I think most ICU doctors are very focused on what happens in the ICU.
00:03:01
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But once the patient leaves the ICU, and even worse, when they leave the hospital, we're really not aware of a lot of the struggles that our patients might be encountering.
00:03:09
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And I think that this is an area that we have learned a lot lately.
00:03:13
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There's still a lot to be learned and to be done, but I think it's a good place to start.
00:03:16
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So why don't you tell us about the BRAIN ICU study?
00:03:19
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I find this study that was published in the New York Journal of Medicine a couple of years ago to be a landmark study that really started making people think a little bit different of what happens to people who survive critical illness.
00:03:32
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I'm glad to tell you about the BRAIN ICU study.
00:03:35
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It was published, I think, in 2013.
00:03:37
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It's hard to believe how quickly time is flying.
00:03:41
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Published in 2013 and conceived long before that.
00:03:46
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Nearly 20 years ago, we scratched our head as we began to interact with ICU survivors, and we began to ponder how significant the cognitive deficits might be that they had.
00:03:59
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People anecdotally were certainly reporting real difficulties in areas like memory and executive functioning and attention.
00:04:08
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And there were a number of important studies, but relatively smaller studies, that had documented
00:04:14
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cognitive deficits, but none of them had a really large N, which of course is important, and many of them had been done with specialized populations, that is with people with acute respiratory distress syndrome and people with sepsis, but our view had been that the challenges were not unique to people with sepsis or with ARDS, that really regardless of what brought you to the ICU, you were likely at risk for
00:04:43
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developing cognitive dysfunction.
00:04:45
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So that's what we decided to study in the context of the BRAIN ICU study, a cohort study, where we enrolled hundreds of patients, I think 800 or so patients, and we followed them up for about a year.
00:05:01
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In general, we tried hard to enroll patients with cognitive intactness.
00:05:07
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We tried to exclude people with pre-existing dementia because we were interested in
00:05:12
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in new cognitive deficits.
00:05:14
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It's no simple thing to do that, but we tried our best.
00:05:17
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And we tracked these people at three months and at a year using relatively comprehensive methods of neuropsychological testing.
00:05:27
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We used a battery called the repeatable battery for the assessment of neuropsychological status.
00:05:32
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I don't want to get into the weeds here.
00:05:34
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I could get overly detailed, I think.
00:05:37
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But suffice it to say, we found out that between a third and half
00:05:43
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ICU survivors in this large study had really meaningful really clinically significant cognitive deficits and we found that the severity of these deficits was worse than what you would see in moderate traumatic brain injury often worse than what you would see in mild cognitive impairment and in some cases it was as severe as you would see in mild Alzheimer's disease which is not to say that
00:06:10
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that these patients had Alzheimer's disease, that's an open question.
Hidden Cognitive Deficits in Daily Life
00:06:14
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But it is to say that the severity they had was really quite profound, enough to impact their daily life.
00:06:21
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So in publishing the BRAIN ICU study, we highlighted what I think people increasingly recognize is a public health problem.
00:06:30
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It's a major public health problem that millions of people are discharged from the ICU around the world every year.
00:06:38
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Those people who had cognitive problems before often have much worse cognition after, and in many cases, people who were normal before are quite impaired.
00:06:50
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And we have been struck by the feedback that we've received in recent years since the publishing of that paper, patients coming out of the woodwork to talk about their own difficulties and many other investigators beginning to explore this important area.
00:07:07
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And I think, Jim, that when I read the study, and obviously I reread it recently in preparation for the podcast, there's a couple of things that really struck me and made me reflect on my own practice.
00:07:18
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I think that number one is that for most intensivists, I think that a alert-oriented times three, able to follow commands is a thumbs up and the patient's intact.
00:07:30
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And that seems to be a gross overestimation, right?
00:07:34
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It very much is that.
00:07:36
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I can tell you just a really quick anecdote.
00:07:40
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Years ago, I was up in the ICU interacting with a patient, an elderly woman, and her daughter was sitting in the chair.
00:07:48
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And I said to her daughter, how's your mom doing?
00:07:51
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And her daughter said, she's fine.
00:07:53
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She's as sharp as a tack.
00:07:55
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It was some such thing.
00:07:57
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And she appeared that way, docile and together.
00:08:00
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And then we started to do
00:08:03
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fairly basic assessing of her using the mini mental state exam and various things.
00:08:12
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And she thought it was 1968 and she thought that Theodore Roosevelt was president and she couldn't remember very simple things.
00:08:22
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And there were these huge problems that existed under the surface.
00:08:26
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And I remember the look on her daughter's face.
00:08:29
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It was really shock.
00:08:30
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because her mother appeared so normal.
00:08:33
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So I think this is really a dynamic, and I think it's very relevant because all too often what happens both in the ICU and at the time of discharge is that a resident or a fellow or a physician, social worker, they're talking to a patient, and the patient's nodding their head, affirming agreement, and it seems
Persistent Cognitive Deficits After ICU
00:08:53
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all good.
00:08:53
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You know, they're getting it.
00:08:55
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And then I think many times if you were to say to that patient 10 minutes later,
00:09:01
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Well, what did Dr. Jones explain to you?
00:09:04
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They would have no idea, less than no idea.
00:09:07
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So people are often, in the context of the ICU, not as intact as they look.
00:09:13
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I think that's the assumption people should start with.
00:09:15
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It's really important to put the cookies on the shelf where people can reach them.
00:09:20
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That's the analogy I often use to engage things in a way that would be digestible for these patients, because
00:09:28
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Characteristically, they're quite a bit more limited cognitively than they seem to be.
00:09:35
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And the second thing that really struck me from the brain ICU study was that there's the severity or the amount of abnormalities that were identified at three months.
00:09:48
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but also how long it takes for these patients to maybe get better.
00:09:52
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Or at 12 months, the proportion of patients that still have significant problems, I think that the stats said that one out of four, 25% of patients at 12 months had a cognitive functioning that was similar to Alzheimer's, which is striking.
00:10:07
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And I think something that we never really thought about before.
00:10:11
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It is striking.
00:10:12
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For the people who improve, improvement really is slow.
00:10:16
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We have a cohort of
00:10:19
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a few hundred patients now that we have followed over a more extended period of time here at Vanderbilt.
00:10:25
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And even with them, we see really persistent challenges.
00:10:29
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And it's an issue that cuts across a lot of domains.
00:10:35
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One thing we find is that often these patients have it in their head, there's no particular reason they think this, but they have it in their head that they'll be better
00:10:45
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by a year or they'll be better by their birthday.
00:10:48
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They have some arbitrary timeframe that they use.
00:10:53
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They'll be better by then cognitively.
00:10:55
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And when that year comes and they're not, that's often when we see pretty significant depression and anxiety ensue because for some reason they think that their improvement was certain, even though we don't suggest that.
00:11:10
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So I think we're still learning what the arc
00:11:14
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of recovery looks like in ICU survivors still learning who the people are that tend to get better, who the people are that tend to get worse.
00:11:23
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I think it's an open question who exactly those people are.
00:11:26
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But to be sure, this recovery is a long process and undoubtedly there are a meaningful percentage of people, perhaps the majority, who never quite return to baseline.
00:11:38
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And I think that as we move on within the topic, just as a take-home, I think three important things that I want to make sure our audience takes from this paper is one, that the prevalence of cognitive dysfunction is real and is very high in ICU survivors.
00:11:56
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Number two is that
00:11:59
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the time frame is prolonged, and at 12 months, still a large proportion of patients have severe cognitive impairment.
00:12:08
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And number three is that we probably need a little bit of a deeper dive in terms of using more sophisticated testing than just asking people how are they feeling and having very superficial conversations to start to identify
Risk Factors for Cognitive Decline
00:12:20
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these.
00:12:20
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And we'll talk a little bit more about that a little bit later.
00:12:24
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Great.
00:12:25
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Jim, let me ask you a little bit about pathophysiology, and I'm sure that there's still much that we need to learn here, but it's interesting that some people have this and others don't, right?
00:12:38
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And do we know what are some of the issues behind the pathophysiology of developing this cognitive dysfunction?
00:12:46
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I'm not sure we know a great deal about that.
00:12:50
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We certainly know much less than we'd like to.
00:12:53
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One hypothesis that people often talk about in aging research generally is the cognitive reserve hypothesis.
00:13:01
Speaker
And the cognitive reserve hypothesis, and this is putting it crudely, the cognitive reserve hypothesis would suggest that your brain is a lot like a muscle, a lot like a battery, if you want to think of it that way.
00:13:14
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And the better charge the battery is, the bigger the bicep, if you will, is,
00:13:21
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the more that can withstand and the more that acts as a buffer against cognitive decline.
00:13:27
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Again, I'm really simplifying.
00:13:29
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So we think that it is likely the case that if you have more education, more intellect naturally, you probably can survive a relatively harder hit or a series of hits before undergoing this steep decline
00:13:48
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although that's not always true because sometimes we see people who have a relatively minor cognitive insult who really struggle.
00:13:58
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But we think cognitive reserve is important, and we think resilience is certainly important.
00:14:03
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We think there probably are genetic predispositions.
00:14:07
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We're still learning about those.
00:14:10
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We think there likely are some patients who have some kind of prodromal
00:14:17
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dementia that has been percolating, hasn't really been identified yet, and you add to the recipe hypoxia and delirium and inflammation associated with sepsis and all of that, and we think that could accelerate a process that normally might have taken a decade.
00:14:38
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That process really gets ramped up in the context of critical illness and perhaps cognitive decline
00:14:46
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emerges in the context of months as opposed to years.
00:14:50
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These are all things that we think about.
00:14:54
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Delirium is certainly problematic, and that's a risk factor that we look at a lot.
00:14:59
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We're not exactly sure what happens mechanistically that links delirium and subsequent cognitive decline.
00:15:08
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We continue to grapple with whether delirium is
00:15:12
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simply a marker of cognitive decline or whether it's fundamentally injurious.
00:15:18
Speaker
But the reason I mentioned delirium in particular is because there are some risk factors that presumably are modifiable.
Diagnosing Cognitive Impairments: Challenges and Solutions
00:15:28
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Delirium would be one.
00:15:29
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We could potentially reduce that.
00:15:31
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There are others that really aren't.
00:15:33
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For instance, sepsis is probably a risk factor for decline, but you come in with sepsis or you don't.
00:15:41
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So many research efforts are really being directed toward trying to engage what you might call low-hanging fruit, things that we could potentially modify with the hope that if we reduce those, we'd reduce the likelihood of cognitive impairment.
00:15:58
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We're engaging in neuroimaging.
00:16:00
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Some people are engaging in the development of animal models to try to get underneath what this linkage between critical illness and cognitive impairment is.
00:16:11
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but that's still very much a work in process.
00:16:14
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And I think that some of the things that you mentioned, I wanted to dive a little bit deeper in.
00:16:18
Speaker
When you say a cognitive reserve, I guess that refers mostly to the health of your brain.
00:16:25
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So somebody who has mild dementia, for example, has mild cognitive impairment at baseline, after critical illness probably have a much accelerated or worse outcome, correct?
00:16:36
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We do think that if they have
00:16:40
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mild cognitive impairment, for instance, they're at heightened risk of worsening cognitive decline, yes.
00:16:47
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So that's clearly something that is a concern.
00:16:51
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The other thing that complicates all of this, by the way, is that many of our ICU patients, I'm not sure if it's most, but many of them have medical issues that have cognitive implications already, that is,
00:17:08
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They may have heart failure.
00:17:10
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They may have sleep apnea.
00:17:12
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They may have diabetes.
00:17:13
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They may have kidney failure.
00:17:15
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All these sorts of things.
00:17:16
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And all of those conditions have whatever cognitive baggage they have.
00:17:22
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So when you take an individual with multiple medical challenges, numerous critical illnesses, they are already at a bit of a tipping point.
Preventing Cognitive Impairments in ICU Patients
00:17:35
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And I think the way we think about it is
00:17:37
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The critical illness sometimes is the push, unfortunately, that shoves them over the ledge and sometimes enters those people into a season of extended decline.
00:17:49
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I had experience, I remember as an intern, admitting a judge who was very well known in Chicago.
00:17:59
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And admitted him, it seemed like a normal admission, he was coming in for some procedure.
00:18:04
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And I was very surprised when the primary care physician came by later and was telling me that he was severely demented, and I had not picked that up.
00:18:13
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What about the level of function or education?
00:18:16
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Is that also something you would consider being part of maybe cognitive reserve?
00:18:21
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Very much, yeah.
00:18:22
Speaker
Cognitive reserve is closely related to things like education.
00:18:26
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Cognitive reserve is closely related to formative educational experiences.
00:18:34
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So we think in general that people with more reserve can endure a larger dose of critical illness, but as you've noted, that isn't always true in every time and every place.
00:18:47
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And there are people who are already
00:18:50
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experiencing a greatly diminished reserve by the time they get to the ICU.
00:18:55
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They're already vulnerable and for them sometimes things that we would think would even be quite benign, modest amount of delirium, some fairly minor changes in sleep-wake cycle, things of that sort, a pneumonia,
00:19:15
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relatively minor things on a spectrum of severity are all that it takes to knock them down in contrast to their younger, more robust counterparts who characteristically, although not always, characteristically can endure a critical illness hurricane and come out okay.
00:19:38
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For some of these vulnerable ones that we interact with, it's really just a pinch of critical illness if there's such a thing.
00:19:45
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that can topple them over.
00:19:47
Speaker
And I want to ask you a little bit more, Jim, about the risk factors specifically.
00:19:50
Speaker
So you initially classified them into modifiable and non-modifiable, and obviously they're both important.
00:19:57
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I think the non-modifiable ones might be helpful for our audience in terms of recognizing patients who are at a higher risk of having cognitive impairment, which might lead to more aggressive testing.
00:20:07
Speaker
Could you start with what are the, and you mentioned some of them, but just to summarize the non-modifiable risk factors that you've identified in your research so far?
00:20:15
Speaker
Yeah, absolutely.
00:20:16
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And I'll mention them in a moment.
00:20:18
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But before I do, I would just affirm what you had to say.
00:20:22
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That is, you know, I think a goal of ours and perhaps even a holy grail would be to try to develop a quick and dirty profile that we could use that could say this patient
00:20:35
Speaker
scored a 30 on a given metric and they are highly vulnerable to impairment, this patient scored a 15 and they're not.
00:20:44
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We don't have such a tool necessarily, but I think as we're able to develop some kind of prediction rule, it would be really useful.
00:20:53
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So when we think of non-modifiable risk factors, those things would include age, obviously very important, education, very important
00:21:05
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In addition to those things, IQ, what level of cognitive capacity you come to the ICU with, those are things that are relatively fixed, that can't be changed.
00:21:19
Speaker
Interestingly, while old age is probably typically a risk factor for cognitive decline, what we saw in the BRAIN ICU study was that
00:21:32
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rates of cognitive impairment in elders were only minimally higher than rates of cognitive impairment in the young and the middle age.
00:21:41
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So this very much is a condition that impacts older people, but not older people only, because it also impacts younger counterparts.
00:21:54
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But to return, age, education, cognitive ability,
00:22:01
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those things would all be non-modifiable risk factors.
00:22:05
Speaker
And modifiable, the big one that you mentioned is delirium.
00:22:10
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Are there others?
00:22:13
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Delirium, hospital length of stay, I think that is probably modifiable.
00:22:21
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I think level of activity in the ICU, there's some thought that the
00:22:30
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wake up and breathe protocols and the early mobilization protocols that have such meaningful benefits on physical functioning, for instance.
00:22:39
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There's some thought that those equally have a benefit on cognition.
00:22:44
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I think we need to push a little further to explore that, but it may well be that if you take someone who is
00:22:53
Speaker
relatively inactive in the ICU, if that's the norm, and you're mobilizing him or her, you're activating their body and their brain a bit more, you're decreasing the likelihood for them to develop cognitive problems.
00:23:08
Speaker
So those would be things that we think of as low-hanging fruit, areas to target, delirium, levels of sedation, quality of sedation,
00:23:21
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degree of exercise in the ICU, mobility in the ICU, things of that sort, cognitive activity in the ICU.
00:23:28
Speaker
And when you talk about delirium, obviously it's a syndrome, but is the phenotype or the cause that led to delirium impact the outcome with cognitive impairment, or is that something that we don't know yet?
00:23:44
Speaker
I don't think we know that as fully as we might.
00:23:47
Speaker
You know, delirium can be
00:23:50
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induced or caused by so many different factors, metabolic, drug-related, et cetera, et cetera.
00:24:01
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And I think it remains to be seen whether the outcomes are very much different based on those respective expressions of delirium or whether, in general, delirium is problematic with respect to outcomes.
00:24:19
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regardless of where you find it.
00:24:23
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My colleague, Tim Gerard, who used to be at Vanderbilt but now is at the University of Pittsburgh, is someone who is exploring this question in real earnest.
00:24:32
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That is, trying to get out a microscope and drill down and look at delirium, not only in the context of ever-never, but in the context of the dynamics that foment the development of that syndrome.
00:24:49
Speaker
we'll continue to learn a lot about whether all expressions of delirium are created equal or whether there are some forms that might be particularly neurotoxic.
00:25:00
Speaker
Yeah.
00:25:01
Speaker
So we talked about these risk factors, and we'll talk about treatment or what are the things that we can do a little bit later, but I wanted to first focus on diagnosis.
00:25:10
Speaker
So we spoke, Jim, earlier and stated that the assessments that most intensivists do at the bedside are very primitive, and obviously we'll have a lot of false negatives in terms of we think the patient's okay, but there really might be a lot of problems underneath.
00:25:26
Speaker
What do you recommend for us to do in the hospital, and what is the proper follow-up for patients who we identify as being either high-risk or having some evidence of cognitive impairment?
00:25:38
Speaker
It's a really good question, and it's a really complicated question.
00:25:42
Speaker
Complicated because if we referred or did a consult with every cognitively impaired patient in the ICU in a given hospital, much less the country,
00:25:56
Speaker
I think we would completely overwhelm our referral system pretty immediately.
00:26:03
Speaker
We did a study years ago, the ABC trial.
00:26:06
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Again, Tim Gerard, who I referenced earlier, led that study.
00:26:09
Speaker
And the ABC trial, I did cognitive testing on 150 odd patients while they were still in the ICU.
00:26:18
Speaker
And about 97% of those patients that I assessed while they were in the ICU
00:26:24
Speaker
had quite profound cognitive impairment.
00:26:27
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And in many cases, that impairment resolved, even though in other cases it didn't.
00:26:34
Speaker
So cognitive impairment is more the norm than the exception in the ICU.
00:26:41
Speaker
With that being said, I do think involving professionals who are more expert, perhaps, than we might be in doing assessments is appropriate.
00:26:52
Speaker
And those often could include
00:26:54
Speaker
Occupational therapists, those could include neuropsychologists, if there is one, consulting in a given unit, those could include rehabilitation psychologists who are increasingly integrated into trauma ICUs, for instance.
00:27:09
Speaker
I think that's really useful.
00:27:11
Speaker
I think the value, though, partly of doing a little more of a deep dive in the ICU, and that could be using a mini mental state exam, it could be using another exam called the MOCA,
00:27:24
Speaker
I think the value of doing a deep dive partly has to do with what I mentioned earlier, which is it's really useful to know if a patient is impaired because it's useful to base the way you're communicating with them on that fact, and it's useful to make decisions about how well they make decisions based on what their cognitive status is.
00:27:52
Speaker
So I think linking in
00:27:55
Speaker
occupational therapists, neuropsychologists, if available is appropriate.
00:28:00
Speaker
When we see people at our ICU follow-up clinic, and again, there aren't clinics all over the country, but there are more and more.
00:28:07
Speaker
There probably are 20-some now, I think, last count.
00:28:11
Speaker
When we see patients at ICU recovery centers, that then becomes a very appropriate avenue to do more of a deep dive, and we frequently refer people
00:28:23
Speaker
that we see at the ICU Recovery Center to a clinical neuropsychologist to get a more comprehensive evaluation.
00:28:34
Speaker
When I refer patients for a more comprehensive evaluation, our clinic isn't designed to do truly comprehensive cognitive assessments, so I sometimes refer these patients to a neuropsychology colleague.
00:28:48
Speaker
When I do that, I typically try not to do it until patients have been
00:28:53
Speaker
three or so months out of the ICU because in the early days of returning home, things are really in flux.
00:29:03
Speaker
I tend to feel quite confident that when patients are quite impaired at three months, it's a lingering enough problem that we really have to attend to it.
00:29:14
Speaker
So in terms of some actionable recommendations for the audience and for myself as a clinician, it seems that the timing probably should be towards discharge as a screening.
00:29:27
Speaker
And in terms of referral to like heavy duty neuropsychology support, probably within months of leaving the hospital, they're still having problems.
00:29:36
Speaker
That probably be the time to do it because if we did it the first day they're extubated, everybody would probably have issues and we probably would not be identifying the right
Emotional Toll on Families and Support Needs
00:29:45
Speaker
patients.
00:29:45
Speaker
Correct?
00:29:46
Speaker
Yeah.
00:29:47
Speaker
You said it much more succinctly than I. That's exactly what I would suggest.
00:29:52
Speaker
Yes.
00:29:52
Speaker
Excellent.
00:29:53
Speaker
So what about treatment?
00:29:55
Speaker
what are the things that we can do?
00:29:57
Speaker
So I think you identified very, very clearly a lot of modifiable risk factors.
00:30:03
Speaker
And I think all those risk factors we know are impacted in a positive way when we are successful in implementing the A to F bundles.
00:30:11
Speaker
So that's one thing that it sounds like we could do on a daily basis.
00:30:15
Speaker
But what are other things that you would suggest for the clinician at the ICU with a patient right now who's very sick in terms of thinking, if I do these things,
00:30:24
Speaker
very well, I might mitigate or decrease the chances of this patient having cognitive problems down the road?
00:30:32
Speaker
It's a great question, and I would say the following.
00:30:36
Speaker
Trying to activate the brains of those patients as much as possible, we think, is really important.
00:30:41
Speaker
And for us, that often means family involvement, if there are family around, cognitive stimulation, anything that
00:30:53
Speaker
is better than sitting in the bed, watching paint dry, really engaging people's brains in the same way that our physical therapy colleagues are encouraging us to engage these patients' muscles.
00:31:11
Speaker
So anything you can do to promote stimulation is important.
00:31:15
Speaker
If a patient is a reader and they left their favorite book at home, we always encourage
00:31:23
Speaker
their wife or children to bring that book in or new books.
00:31:27
Speaker
If they like to do the New York Times crossword puzzle, they should be working on that.
00:31:31
Speaker
If they like to play Sudoku, that's something they should be doing.
00:31:36
Speaker
We're exploring somewhat more formal interventions that are still in the research stage, but we think really merit some consideration.
00:31:45
Speaker
There are some brain training programs that we think are potentially promising.
00:31:51
Speaker
In many cases, those programs
00:31:53
Speaker
can be done on an iPad, for instance.
00:31:57
Speaker
So if a patient is able to in the ICU, engaging some of these programs which provide brain training exercises, we think that's really important.
00:32:09
Speaker
The more vigorous exercise people can do in the ICU, the better clearly getting blood flowing, engaging people physically as a general principle.
00:32:22
Speaker
has positive implications for their cognition.
00:32:26
Speaker
So we're all about that.
00:32:28
Speaker
Those would be two simple things.
00:32:31
Speaker
Physical engagement via physical therapy, and I think perhaps even more important, promoting physical stimulation and engagement with hobbies and other activities that could be done in the ICU as much as possible.
00:32:47
Speaker
And talking to families,
00:32:49
Speaker
to enlist them in an effort to help with this.
00:32:53
Speaker
We get emails, I just got one yesterday, from family members whose loved ones are critically ill in the ICU.
00:33:00
Speaker
And this is always the question that comes back to, what can I do with my mom or dad, with my husband or wife in the ICU right now to help them?
00:33:11
Speaker
And the more we can enlist these folks to engage these patients, I think the better off we're going to be.
00:33:18
Speaker
Amy Wojnarski is a researcher in economics from Harvard Business School, and she has done a lot of research on a purpose in the workplace and did a very interesting paper, Jim, on studying how she could identify hospital janitors that found purpose in their job versus those who were very disengaged.
00:33:41
Speaker
And she came up with this concept of job crafting.
00:33:44
Speaker
But one of the most remarkable examples she gave was of a hospital janitor that worked in a TBI unit.
00:33:50
Speaker
And this hospital janitor, on a regular basis, would change the artwork of each room because she felt that would help the recovery of her patients.
00:34:01
Speaker
And it seems that that intuition obviously probably has some basis in science from what you're telling me.
00:34:08
Speaker
Absolutely.
00:34:09
Speaker
Anything to stimulate patients.
00:34:12
Speaker
I think that notion of purpose is also important.
00:34:15
Speaker
I think it's unclear how that impacts differentially mental health outcomes versus cognitive outcomes.
00:34:24
Speaker
But I think imparting to patients that what they do in the ICU as they're battling their critical illness matters, imparting to families that the more actively they can be engaged,
00:34:40
Speaker
in the care of their loved one, the better.
00:34:44
Speaker
Those are really important urgings.
Post-Discharge Support and Rehabilitation
00:34:49
Speaker
And, you know, the more we can mobilize people to assist us, the better.
00:34:54
Speaker
I think what we're learning parenthetically is, and this is a different topic, but I think we're learning that however traumatic critical illness is, and I just discussed this yesterday with one of our patients, however traumatic critical illness is,
00:35:09
Speaker
for our patients, it often is at least as traumatic and sometimes more so for family members who frequently will say to me, you know, dad doesn't remember much of the ICU, but I remember every second of it.
00:35:27
Speaker
It was horrifying for me.
00:35:29
Speaker
And I think generally as clinicians, we need to do a little better job recognizing that
00:35:36
Speaker
you know, truly the patient is not just the person that we're caring for in the hospital bed, but in some ways the patient is also the mother, the daughter, aunt, uncle, whatever, who is deeply traumatized by what's going on.
00:35:57
Speaker
And we need to be attentive to their needs as well, because often they bear the same scars from this experience as the patients do.
00:36:06
Speaker
Absolutely.
00:36:07
Speaker
And I think that we have mentioned some of the things that we can do on a daily basis while the patient's in the ICU.
00:36:13
Speaker
Based on our conversation, it also seems that an area of opportunity is providing more insight and information to patients and families as they leave the ICU or leave the hospital, whether it be in terms of things that they can expect or things they should look out for.
00:36:27
Speaker
And I guess the last part, which I wanted to ask you, Jim, about is what do we do for patients who are
00:36:32
Speaker
now gone from the hospital, they're three months out of this, and they're having significant problem.
00:36:38
Speaker
If they were to call us, how could we help them?
00:36:42
Speaker
It's a great question, and here's what I would say.
00:36:46
Speaker
We've talked a lot about dementia in the context of critical illness, and to be sure,
00:36:54
Speaker
one model of understanding what's happening with these patients is dementia.
00:36:59
Speaker
But another model that we could use to understand what's happening with these patients is a brain injury.
00:37:05
Speaker
When you think of a brain injury, you think of an individual who was moving along, minding their own business, if you will, and there was a discrete event that happened to them.
00:37:18
Speaker
It impacted their brain, and as a consequence, they're different.
00:37:23
Speaker
Often when we think of brain injuries, we think of traumatic brain injuries.
00:37:28
Speaker
Those might involve a fall from a roof.
00:37:32
Speaker
Those might involve an auto accident or an IED injury in Baghdad, let's say.
00:37:38
Speaker
But there's another form of a brain injury, not a TBI, but an ABI.
00:37:43
Speaker
And an ABI simply refers to an acquired brain injury.
00:37:48
Speaker
This was acquired from
00:37:50
Speaker
from whatever non-traumatic cause, it was acquired.
00:37:54
Speaker
So, in general, when patients with brain injuries are identified as having brain injuries, there's a process through which they get treatment for those.
00:38:07
Speaker
They characteristically go to a speech and language pathologist.
00:38:12
Speaker
They characteristically receive some kind of cognitive assessment
00:38:18
Speaker
They often see a therapist who helps them learn to develop adaptive strategies to offset their new limitations.
00:38:26
Speaker
And that's what happens in the context of a brain injury.
00:38:30
Speaker
I think that model is in some ways a lovely model for what needs to happen with our cognitively impaired ICU survivors.
00:38:41
Speaker
They need to see a neuropsychologist or some similar individual
00:38:48
Speaker
who can characterize the magnitude and the nature of their cognitive deficits.
00:38:53
Speaker
They may well need to engage with a speech and language pathologist or a rehabilitation psychologist, depending on who might be available.
00:39:04
Speaker
And that person, while they may help them improve their cognition, will equally help them find ways to cope more effectively with it.
00:39:13
Speaker
That coping could be
00:39:15
Speaker
special accommodations, that coping could be telling a student, I know you really want to return to this really difficult college that you were going to before, but you've got challenges now that you didn't have before, and I think it might be more prudent for you to return to a college closer to home.
00:39:37
Speaker
It might take the form of, you know what, I know this promotion is really enticing at work, but
00:39:45
Speaker
I think you should pass on that right now because if you take it, you're probably setting yourself up for failure.
00:39:52
Speaker
You don't want to get fired.
Coping with Cognitive Mishaps in Daily Life
00:39:53
Speaker
So really leaning into the lives of these people from the vantage point of the lens of rehabilitation to help them adapt to new challenges and maximize strengths, that's what needs to happen with our ICU survivors who I would argue in effect have a brain injury even though they don't know it.
00:40:14
Speaker
And I think that it speaks to the story I shared at the beginning in terms that this is probably not a unique story and has happened multiple times in different shapes and forms, correct?
00:40:24
Speaker
Exactly.
00:40:25
Speaker
It's so common.
00:40:27
Speaker
And this really is why education is so important.
00:40:32
Speaker
We get emails.
00:40:33
Speaker
It would be hard to overstate how often Wes Ely and I get emails from people who basically say, I got home.
00:40:43
Speaker
I was pretty disengaged from my life.
00:40:46
Speaker
I wasn't taking on any challenges because I was recovering.
00:40:51
Speaker
So I thought I was fine.
00:40:53
Speaker
Once I tried to return to my old life, the cognitive problems I had were replete and they hit me in the face.
00:41:04
Speaker
And I'm really angry because nobody told me to expect them.
00:41:08
Speaker
So the more we can educate on the front end
00:41:12
Speaker
the better.
00:41:13
Speaker
And I think this is a simple thing.
00:41:14
Speaker
This often, I think, takes the form of Mrs. Johnson, you and your husband are about to leave the ICU.
00:41:23
Speaker
We know that you may do great, but we also know that about a third of ICU survivors really struggle with significant cognitive problems.
00:41:34
Speaker
And here's what those look like.
00:41:36
Speaker
If you're experiencing those symptoms, it's pretty normal
00:41:40
Speaker
but we want you to follow up with us because we want to attend to those.
00:41:45
Speaker
A simple conversation like that, putting that on the radar, even in a small way, really tends to diffuse people's anxiety greatly because when they notice these issues emerging, they have a context by which to frame them, and it's really empowering.
00:42:02
Speaker
Could you share with us, Jim, some ideas?
00:42:06
Speaker
daily life examples of cognitive dysfunction that patients may encounter.
00:42:10
Speaker
So the old one would be they can't close their check, but I don't think anybody has a checkbook anymore.
00:42:14
Speaker
So maybe that's not very, very, very good.
00:42:18
Speaker
You know, it's, it's really funny.
00:42:20
Speaker
I have a lot of coordinators and, and, and colleagues that I work with who are, who are much younger.
00:42:28
Speaker
They're in their twenties, let's say.
00:42:30
Speaker
And one of them just the other day to me, I said something about a checkbook.
00:42:34
Speaker
balancing a checkbook and that being an area of difficulty.
00:42:38
Speaker
And they said, just what you said, I don't think anybody has a checkbook.
00:42:42
Speaker
And I thought, golly, that's right, no one does have a checkbook.
00:42:47
Speaker
So I think it's a great point.
00:42:49
Speaker
I've got a really great example that I'll share from a patient who's become a good friend of ours.
00:42:56
Speaker
And he is a gentleman who was in the ICU
00:43:00
Speaker
for a very long time, had a very complicated stay, really bright guy, but has clearly had significant life challenges since his discharge.
00:43:10
Speaker
And here's what happened.
00:43:13
Speaker
He has multiple medical issues currently, and as a result of that, he takes 20-some medications a day.
00:43:23
Speaker
And the way he manages those is perhaps not the most efficient
00:43:29
Speaker
He won't mind me saying.
00:43:31
Speaker
He takes all those medications and he puts them in a bottle and he takes all the medications in the bottle at a given time of day.
00:43:41
Speaker
Let's say three o'clock, he takes his 20 medications in the bottle.
00:43:46
Speaker
So he recently had been to the hospital pharmacy where he had received a month's supply of the medicine of Warfarin.
00:43:59
Speaker
He had his daily bottle of pills in his left pocket.
00:44:04
Speaker
He had his monthly dose of Warfarin in his right pocket.
00:44:09
Speaker
He wasn't paying attention.
00:44:12
Speaker
He felt the bottle in his right pocket, the Warfarin.
00:44:16
Speaker
He took the lid off and he swallowed a month's worth of pills, thinking he was taking his daily dose of 20 pills.
00:44:27
Speaker
He felt the pill bottle in his other pocket horrified, and he realized what he had done.
00:44:35
Speaker
The ambulance came, called 911, they took him to the ER.
00:44:40
Speaker
Thankfully, he survived.
00:44:41
Speaker
He was in the ICU for about a week.
00:44:44
Speaker
That could have been fatal.
00:44:45
Speaker
So that kind of example of inattention of problems processing, this is very common in our ICU patients.
00:44:56
Speaker
When people have these difficulties, they have real-world consequences.
00:45:02
Speaker
And those consequences sometimes are mild, but they're sometimes very serious.
00:45:07
Speaker
And part of what we try to do, and we've done this with this gentleman, this friend of ours as well, we try to help people understand that they are vulnerable to making mistakes.
00:45:19
Speaker
And we try to help them understand
00:45:21
Speaker
when they are most vulnerable and why that is.
00:45:25
Speaker
We use a technique from something called goal management training, and that technique is stop and think.
00:45:31
Speaker
And basically what that boils down to is before you take your pills, before you leave the house, before you leave the car to go into the store, stop a second, think about what you're doing, attend to what you're doing, and then proceed.
Traumatic Experiences and Personal Growth
00:45:49
Speaker
Often that simple act of stopping and checking in, thinking very deliberately, is all it takes to avoid these mistakes.
00:45:57
Speaker
But when people don't do that, when they're tired, they're worn down in a hurry, they make what people call cognitive slip-ups.
00:46:07
Speaker
And our ICU survivors make them all the time.
00:46:11
Speaker
And sadly, sometimes they're catastrophic.
00:46:14
Speaker
And I think that for those who go back to work or those who go back to studying, those cognitive slip ups as they add up and become incremental can usually lead to months later than being in big trouble.
00:46:26
Speaker
Well, they do.
00:46:27
Speaker
And not only do they lead to a person being in big trouble, but
00:46:33
Speaker
Importantly, over time, they begin to create a self-perception that is very negative.
00:46:41
Speaker
That is, someone who was really bright and capable begins to form a very negative narrative about themselves.
00:46:51
Speaker
And then that becomes a problem in its own right.
00:46:54
Speaker
So helping people find a way to avoid that by, I would say, respecting
00:47:01
Speaker
their limitations and over time accepting them is one of the most important things I think that we can do.
00:47:09
Speaker
I think this would be a good place to stop.
00:47:12
Speaker
And as I mentioned at the beginning of the podcast before we were recording, at the end, we like to close with some questions that are unrelated to the topic we were discussing, but I think do tap into the wisdom of our guests.
00:47:25
Speaker
Would that be okay, Jim?
00:47:27
Speaker
That'd be terrific.
00:47:28
Speaker
Excellent.
00:47:29
Speaker
So the first question relates to books.
00:47:31
Speaker
Is there a book that has influenced you the most or a book that you have gifted most often to others?
00:47:38
Speaker
There are so many books.
00:47:41
Speaker
There are a long list, but I'll mention one in particular.
00:47:47
Speaker
There's a lovely book by a gentleman, Howell Raines.
00:47:50
Speaker
Howell Raines, once upon a time, I think was the editor of the
00:47:55
Speaker
New York Times before he became quite a celebrated author.
00:47:59
Speaker
But he wrote a really moving, really tender book called Fly Fishing Through a Midlife Crisis.
00:48:06
Speaker
I don't know if you've heard of that book at all.
00:48:07
Speaker
I have not.
00:48:10
Speaker
I love to fish, but the book really isn't about fishing.
00:48:13
Speaker
It's about how Howell Reigns learned over time that the beauty of fishing wasn't really in catching, if you will,
00:48:25
Speaker
the beauty was in the process.
00:48:27
Speaker
The beauty was in the fishing, interacting with friends, enjoying the landscape around you.
00:48:33
Speaker
It was really in the process.
00:48:35
Speaker
And reading that book, Fly Fishing Through a Midlife Crisis, caused me to really reflect on that.
00:48:42
Speaker
And the relevance, I think, as it relates to our patients, is this, that as they think about their recovery, the value for them, I think,
00:48:53
Speaker
is not necessarily in the catching.
00:48:58
Speaker
That is, it's not necessarily in whether they can attain or obtain the specific goals that they achieved before, whether they can hit the milestones that they hit before.
00:49:11
Speaker
It's not really in the catching.
00:49:14
Speaker
The ebb and flow for these patients, the beauty of the lives of these patients
00:49:22
Speaker
particularly those who tend to recover well, is that they learn that I can't catch, to use this metaphor, I can't catch what I did before, but I'm finding value in fishing.
00:49:36
Speaker
I'm finding value in living.
00:49:38
Speaker
I'm finding value in being.
00:49:41
Speaker
And that's a message in our ICU support group.
00:49:44
Speaker
We have a terrific ICU support group here at Vanderbilt.
00:49:49
Speaker
And I think these patients are really impacted by one another as they come.
00:49:54
Speaker
But the lesson they impart so much is, I'm not doing the things that I used to do, but that's okay.
00:50:02
Speaker
My value is not primarily in that.
00:50:04
Speaker
My value is in trying.
00:50:06
Speaker
My value is in reflecting.
00:50:10
Speaker
Those sorts of things.
00:50:11
Speaker
So that message of fly fishing through a midlife crisis is really relevant, I think, to the challenges
00:50:19
Speaker
experienced by these patients and to the way of recovery, if you will.
00:50:24
Speaker
And I think it speaks highly to a truth in medicine, but also in life, is that we control the process, not the outcome.
00:50:31
Speaker
And as long as we focus on that, I think there's tremendous purpose in that effort.
00:50:38
Speaker
The second question... I agree completely with that.
00:50:41
Speaker
I think the...
00:50:44
Speaker
The goal clinically for us, among many others at the ICU Recovery Center, is often to help patients become, dare I say, a little less focused on these temporal outcomes.
00:50:57
Speaker
They want to know, am I going to be better at six months?
00:51:02
Speaker
Am I going to be back to normal at a year?
00:51:05
Speaker
The people who recover a bit better are able eventually to let go of those arbitrary
00:51:13
Speaker
milestones and they're able to say it takes as long as it takes.
00:51:19
Speaker
I'm going to hold on to this lightly.
00:51:22
Speaker
When I do better, I'm going to be happy, but I'm not going to get too high.
00:51:27
Speaker
When I struggle, I'm going to feel it, but I'm not going to get too low.
00:51:31
Speaker
I'm going to let the process
00:51:34
Speaker
unfold in whatever way it unfolds and mindfully I'm going to be accepting of that and that's what fly fishing through a midlife crisis talks about and that's what we try to promote in the lives and the minds of our patients and excellent so I'll definitely put this in the show notes and I will pick up a copy sounds like a very interesting read I've got an extra copy so I'll drop one in the mail for you excellent thanks Jim
00:52:01
Speaker
Yep.
00:52:01
Speaker
The second question is, what do you believe to be true in medicine or in life that most other people don't believe?
00:52:09
Speaker
That's a really complicated question and one that I've done quite a bit of reflecting on.
00:52:19
Speaker
I was at a workshop seminar just yesterday and it was really interesting.
00:52:26
Speaker
We were talking about the role of
00:52:31
Speaker
suffering and in particular whether suffering could be redemptive in the lives of ICU survivors.
00:52:40
Speaker
And there was a gentleman in the support group who had had a truly traumatic event happen to him that had led to his trauma ICU hospitalization, something pretty horrible.
00:52:54
Speaker
And he sat next to his wife, lovely wife, holding her hand.
00:53:00
Speaker
And he said, on some days, I genuinely believe that I'm a better person because this trauma happened to me, because this is the only way that I could have experienced this growth in my marriage and this growth in my life, even though it's been hard.
00:53:24
Speaker
He was very honest, and he said, on some days, I don't believe that.
00:53:29
Speaker
But on some days I do.
00:53:31
Speaker
On some days I'm happy that this happened because it's been a conduit for my growth.
00:53:38
Speaker
I think it's hard was for me to wrap my head around the idea, I think it is for many of us, that really traumatic, frankly terrible things can lead to good outcomes, lead to our growth.
00:53:55
Speaker
But I think time and time and time again,
00:53:58
Speaker
when we interact with patients, that's very much their message, that through the doorway of this trauma, they have experienced a quality of gratitude that they didn't have before.
00:54:10
Speaker
They have experienced a depth of relationship with others they didn't have before.
00:54:16
Speaker
And many of them, I think, sincerely say, I didn't want this to happen, but I wouldn't trade it.
00:54:24
Speaker
And that's really counterintuitive
00:54:26
Speaker
But I think I believe that, and I think many of our patients do too, that we don't need to be maudlin about it, we don't want to be sappy, but at the end of the day, paradoxically, there's beauty from ashes in the lives of many of these patients.
Importance of Listening in Patient Care
00:54:44
Speaker
And when you hear them engage that, it's truly very sobering and something to honor.
00:54:51
Speaker
And I think it also speaks to that whole concept of we have post-traumatic stress disorder, but there also is post-traumatic growth, right?
00:55:00
Speaker
Exactly.
00:55:01
Speaker
And plenty, I mean, opportunity.
00:55:03
Speaker
And I think it illustrates the point that it's not what happens to us in life, but how we react to what happens to us that ultimately defines how we do.
00:55:13
Speaker
And that's something that we do control.
00:55:15
Speaker
Exactly.
00:55:16
Speaker
And, um,
00:55:18
Speaker
A long discussion about research agendas is probably a discussion for another day, but high on the list of research agendas, I think, with ICU survivors is to try to figure out whether post-traumatic growth is something that just happens kind of miraculously in a subset of people, or whether post-traumatic growth is something that we can teach and facilitate in others
00:55:47
Speaker
in an orderly way, because if that's something we can help develop in people, we need to be all about that.
00:55:53
Speaker
And it would be much more effective than any magic pill.
00:55:56
Speaker
No doubt.
00:55:57
Speaker
No doubt.
00:55:58
Speaker
So the last question is, what would you want every listener, intensivist or a clinician who's listening to us today to know?
00:56:06
Speaker
Could be a quote or a fact or just a message.
00:56:10
Speaker
There's a phrase that a lot of our patients use, and I really love it.
00:56:15
Speaker
because I think it summarizes the challenges that they often have.
00:56:22
Speaker
And that phrase is twice as hard for half as much.
00:56:28
Speaker
This is the autobiography, if you will, of many ICU survivors that they are working, whether it has to do with physical functioning or whether it has to do with returning to work or their brains, whatever the case.
00:56:44
Speaker
They're working twice as hard as they ever did before.
00:56:48
Speaker
They're working overtime.
00:56:50
Speaker
And the frustration for them is that even as they're working twice as hard, that effort is yielding half as much.
00:56:59
Speaker
That's a phrase I think about a lot as I continue to learn to empathize with these patients because that's really what they're living, twice as hard for half as much.
00:57:10
Speaker
The other thing I would say
00:57:13
Speaker
related to the question is very often in the cognitive domain in particular, we will see patients who go back to their PCP, their internist, whatever the case, and they report these cognitive problems and a physician in a well-meaning way says, I think you're fine.
00:57:41
Speaker
Don't worry, I think you're fine.
00:57:43
Speaker
our patients uniformly react to that.
00:57:46
Speaker
They feel placated, they feel patronized a bit.
00:57:52
Speaker
I've been guilty of that exact certain thing, but I think what it highlights is that we all need to get better at listening, I think, before speaking.
00:58:03
Speaker
We need to get better at interacting with patients and allowing them to tell us what the problem is as opposed to
00:58:12
Speaker
transposing our notion on them.
00:58:17
Speaker
I've often referred to an analogy, I think the great business thinker, Stephen Covey, is the one who talked about this, I'm not sure, but he talked about the picture, and I'll wrap up with this, he talked about the picture of a ladder, of climbing a ladder up the wall of a building, and you get to the top,
00:58:40
Speaker
and you feel so happy because you've climbed the ladder, until, horror of horrors, you look around and you climbed up the ladder leaning against the wrong building.
00:58:52
Speaker
And what that has meant to me is that as we interact with our patients, whether it would be clinical or perhaps particularly in a research context, we need to make sure they are telling us
00:59:07
Speaker
where the ladder should be, what the ladder is, where the building is.
00:59:12
Speaker
They need to be telling us, I want them to help inform my understanding of them, my agenda, as opposed to taking my notion of things and putting it on them, which I think is congratulating myself for climbing up the ladder and then realizing that the issues I'm engaging with them are not even the issues that they are prioritizing.
Conclusion and Acknowledgments
00:59:35
Speaker
We need to make sure that doesn't happen.
00:59:37
Speaker
And I think that's a perfect place to stop.
00:59:40
Speaker
Jim, I really enjoyed the conversation.
00:59:42
Speaker
Thank you so much for your time and sharing all your insights and knowledge with us.
00:59:46
Speaker
I hope to have you back on the podcast soon to talk about this and other very important topics.
00:59:52
Speaker
Thanks so much.
00:59:53
Speaker
I really enjoyed it.
00:59:54
Speaker
Thank you.
00:59:57
Speaker
Thanks again for listening to Critical Matters.
01:00:00
Speaker
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