Outcomes after Intensive Care Delirium

Web Site Introduction: www.icudelirium.org
ICU delirium and cognitive impairment education on the web

E. Wesley Ely, MD, MPH Department of Medicine, Center for Health Services Research and Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN; the Center for Health Services Research and the VA Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC)

Correspondence: E. Wesley Ely, M.D., MPH, FACP, Division of Allergy/Pulmonary/Critical Care Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN 37232-8300, USA. (E-mail and other contact info can be obtained from CWWJ's Editor-in-Chief).

The article also available in PDF: 94KB

"For many people in good physical condition, who succumb to an acute illness, cognitive decline is the main threat to their ability to recover and enjoy their favorite activities and for those whose physical activities are already limited, cognitive decline is a major additional threat to quality of life." (US National Research Council)

Another web source of education

As the outgrowth of a driving unmet need in critical care medicine, our ICU Delirium and Cognitive Impairment Study Group has created a web site <www.icudelirium.org>. Its aim is to publish educational material regarding the exceedingly common occurrence of acute brain dysfunction or delirium followed upon discharge by long-term cognitive impairment or an acquired "dementia" equivalent. We want to help readers understand the epidemiology and importance of these issues for our patients who succumb to this form of illness during their ICU experience and beyond.

To accompany the educational texts on cognitive dysfunction and brain monitoring in critically ill patients that appear in this issue of GE's Clinical Window, we want to introduce its readers to our internet site. Web pages of ICU Delirium are available for educational use at all levels (i.e., family, patient, healthcare professional, and industry). We hope that you find its contents educational and eye opening, as these issues apply to patients with a wide-variety of medical and surgical illnesses.

Introduction to the contents

On this web site, you will read about a newly recognized public health dilemma: delirium among critically ill patients, and long-term cognitive impairment among survivors. Considering the magnitude of the problem, it is notable that we have only recently begun to research mechanisms and treatments to help save the injured brain during and after the ICU experience. Every day, over 40,000 ICU patients in the United States alone (no telling how many worldwide) are suffering from acute brain dysfunction called delirium. Due to the aging of our population, this problem is getting bigger every year, and the growing number of critical care beds worldwide also has an impact. Traditionally, ICU delirium was called "ICU Psychosis," and healthcare professionals did not consider it to be clinically significant.

Using clinical tools designed and validated at Vanderbilt University and through the VA Geriatric Clinical Research Education Clinical Center (GRECC), our ICU Cognitive Impairment Study Group has now shown that delirium is associated with a three-fold increase in the risk of death within six months of ICU admission. Research data from different countries and patient populations, indicates that delirium occurs in about 50% - 80% of intensive care patients. Considering other factors such as age, severity of illness, duration of coma, and the use of psychoactive medications, each day ICU patient spent in delirium was associated with a 10% higher risk of death, and among survivors there was a 35% increased risk of long-term cognitive impairment.

Table: List of web site topics on http://www.icudelirium.org/

Rising hospital costs

Independent of age, medication, or severity of illness, the occurrence of severe vs. mild ICU delirium is associated with dramatically higher hospital costs. However, it is important not to forget the significant added costs and family burden of having patients unable to return home due to the ongoing neuropsychological deficits. We are finding such symptoms in a majority of younger and especially older survivors. We are only now learning about the relationships between the ICU delirium and the longer-term neuropsychological problems that plague thousands of ICU survivors, as these two appear to be closely linked.

Awareness increasing, assessment tools available

Awareness of these issues is reaching a tipping point among the medical and lay community. Hence, numerous ICUs around the world are now implementing routine bedside monitoring of all ICU patients for assessment of arousal levels and delirium. In addition, there is growing interest in post-ICU specialty clinics to help patients and families deal with the unique constellation of acquired problems involved in returning to a functional and whole human being.

The tools available on this web site (e.g., a sedation scale called the RASS and a well-validated and easy to conduct delirium instrument called the CAM-ICU) have been translated into over ten languages. There are international guidelines that have recommended delirium monitoring as standard of care. Ongoing clinical trials are now exploring the safest and most effective ways to prevent and treat ICU delirium in hopes that treatment will not only reduce delirium but also the high morbidity and mortality associated with it.

Our educational and research goals

The goals of ICU Delirium web pages are to enhance awareness of and improve monitoring for brain dysfunction as an acute and chronic ailment that most patients suffer when they develop critical illness. People are becoming increasingly concerned not only with ICU patient's staying alive, but also with survival quality. In large measure, it is the patient's neuropsychological outcome to define that quality. As the medical community strives to improve the outcomes of critically ill patients, it is imperative that we begin to focus on the brain as an important organ, one that may suffer great risk during the ICU stay and beyond.

Our study group is an interdisciplinary team of scientists and clinicians from a large variety of training specialties, and we plan to focus on this area of medical advancement during the upcoming years. As such, we are very open to constructive criticism of both our work and this web site, which we hope to be of service to the readers. If we may be of help, please do not hesitate to contact us.

Sincerely,
E. Wesley Ely, MD, MPH, FCCM, FACP
For the ICU Delirium and Cognitive Impairment Study Group

Last updated: 31 January 2006
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