Page 84 - ACCCN's Critical Care Nursing

Recovery and Rehabilitation 61

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symptoms. Constructs that relate to an individual high, specificity (ability to correctly identify all patients
during a critical illness episode also include without the condition) is less easy to determine, and
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agitation, and confusion/delirium (discussed further in therefore the incidence of psychological distress may be
Chapter 7). over-stated. This makes estimation difficult and is one of
the challenges in establishing the actual magnitude of
Assessment for ongoing neuro-cognitive dysfunc-
tions 17,61,62 is recommended for some survivors, with the psychological distress after a critical illness. Other chal-
beginning of research on cognitive rehabilitation for lenges include the recruitment of different cohorts or
survivors of a critical illness evident. 15,17-19,63 Cognitive subgroups of patients (e.g. patients with Adult Respira-
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executive functioning includes attention, planning, tory Distress Syndrome or Acute Lung Injury ). Varia-
problem-solving and multi-tasking. 64 tions in the international provision of ICU services also
means that differences may exist in case mix in the areas
of illness severity, planned or unplanned admissions,
ages and reasons for admission. For example, in a sample
PSYCHOLOGICAL RECOVERY of studies mean age ranged from 40 –59 years, mean
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APACHE II scores ranged from 15 –24.9, and median
Psychological responses to a critical illness and patients’ 83 87
memories of experiences during an ICU admission have length of ICU stay from 3.7 –34 days.
been explored using quantitative 57,65-69 and/or qualitative
approaches. 70,71 Some survivors reported increased anxiety, ANXIETY AND DEPRESSION
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including transfer anxiety (discharge from ICU); depres- Reported prevalence of anxiety and depression after ICU
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sion; post-traumatic stress; 14,72-74 hallucinations; 58,75,76 discharge varies depending upon the questionnaire and
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and continuing cognitive dysfunction. A range of ‘cut-off’ scores used, and the research design (see Table
memories and experiences were also noted after ICU 4.4). For example, one study of an intensive care follow-up
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transfer and hospital discharge, 58,70,79 including power- clinic reported anxiety prevalence of 7% three months
lessness, reality–unreality, reactions and acceptance, and after discharge; much less than a similar study where
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comfort–discomfort. 85
anxiety was 18% one year after discharge. Both studies
For some patients, recovery from a critical illness results used the HADS with scores of ≥11 to indicate an anxiety
in short- and long-term psychological dysfunction (e.g. or depressive problem. Prevalence of depression in these
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anxiety, depression and posttraumatic stress symp- studies was more equivalent, 10% and 11%. Table 4.4
toms). 8,80 Our understanding of these sequelae has provides a summary of studies reporting the prevalence
improved over the last decade in part due to increased of anxiety and depression. These differences may be
research activity and evaluations of intensive care explained by differences in case mix or timing of
follow-up clinics in the UK (discussed in a later section). assessment.
Importantly, negative psychological consequences of Patients often exhibit high levels of distress at time of
intensive care can result in poorer health status and per- hospital discharge and these tend to reduce in the first
ceptions of HRQOL. 81
year after discharge. 85,90 However the episodic timing of
Assessment of psychological outcomes has mainly relied assessments may not fully capture patterns of anxiety and
on self-report questionnaires administered via either a depression, and establish whether full resolution is
postal survey or a structured interview format. These achieved. For example, in patients with ARDS, levels of
screening, rather than diagnostic, strategies enable iden- depression increased from 16% at 1 year after discharge
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tification of individuals at risk of developing a significant to 23% at 2 years. This may reflect prolonged recovery
clinical problem. A number of standardised question- in general for this subgroup of patients, who tend to be
naires have demonstrated reliability and validity in this among the most critically ill patients, with a mean ICU
patient group, but the use of different questionnaires stay of 34 days noted. A rise in depression scores may
makes it difficult to generalise findings. Studies that therefore be a reflection of that prolonged physical
assessed anxiety and depression used the Hospital Anxiety recovery.
and Depression Scale (HADS), 57,82-86 Beck Anxiety Inven- What is emerging from the literature is that certain patient
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tory, State Trait Anxiety Inventory (STAI), and the Beck demographic and clinical characteristics predict subse-
Depression Inventory. 68,87 Posttraumatic stress has been quent anxiety and depression, although not consistently.
assessed using the Impact of Event Scale (IES), 57,68,84,85 Women tend to be more anxious than men 83,85 and
Post-Traumatic Stress Syndrome 10-Questions Inventory younger patients more anxious than older patients.
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(PTSS-10), Davidson Trauma Scale, and the Experience Other consequences of being in intensive care such as
after Treatment in Intensive Care 7 (ETIC-7) item scale. 88
neuropsychological impairment can also predict signifi-
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These instruments often include ‘cut-off’ or ‘threshold’ cantly higher depression scores. Sicker patients, those
scores that enable screening for the presence or severity with a longer length of ICU stay, and also a longer dura-
of a disorder. For example, a score of 8–10 on either sub- tion of sedation and mechanical ventilation are more
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scale of the HADS indicates possible presence of a disor- likely to have measurable depression. This is perhaps
der, while a score of 11 or above indicates probable not surprising as patients who are in intensive care longer
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presence of such a condition. One limitation of these tend to have more prolonged hospital stay and recovery
self-report measures is that while sensitivity (ability to period. What is also evident in the emerging literature
correctly identify all patients with the condition) can be is the effect of patients’ subjective intensive care