Semin Respir Crit Care Med 2013; 34(02): 216-222
DOI: 10.1055/s-0033-1342984
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Cognitive Impairment after Critical Illness: Etiologies, Risk Factors, and Future Directions

James C. Jackson
1   Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
2   Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee
,
E. Wesley Ely
1   Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
2   Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee
› Author Affiliations
Further Information

Publication History

Publication Date:
28 May 2013 (online)

Abstract

Mortality rates have declined substantially among critically ill populations in recent years, resulting in increasing numbers of individuals with significant physical, cognitive, and psychiatric morbidities due to the effects of their illness. A consensus has begun to develop regarding the nature of the difficulties experienced by intensive care unit (ICU) survivors, including physical, cognitive, and psychiatric decrements. This article focuses primarily on wide-ranging aspects of cognition and discusses potential mechanisms, risk factors, and recovery and rehabilitation of post-ICU cognitive impairment.

 
  • References

  • 1 Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010; 376 (9749) 1339-1346 . doi: 10.1016/S0140-6736(10)60446-1
  • 2 Iwashyna TJ. Survivorship will be the defining challenge of critical care in the 21st century. Ann Intern Med 2010; 153 (3) 204-205 . doi: 10.1059/0003-4819-153-3-201008030-00013
  • 3 Needham DM, Davidson J, Cohen H , et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med 2012; 40 (2) 502-509
  • 4 Hopkins RO, Jackson JC. Long-term neurocognitive function after critical illness. Chest 2006; 130 (3) 869-878
  • 5 Kapfhammer HP, Rothenhäusler HB, Krauseneck T, Stoll C, Schelling G. Posttraumatic stress disorder and health-related quality of life in long-term survivors of acute respiratory distress syndrome. Am J Psychiatry 2004; 161 (1) 45-52
  • 6 Girard TD, Jackson JC, Pandharipande PP , et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med 2010; 38 (7) 1513-1520 . doi: 10.1097/CCM.0b013e3181e47be1
  • 7 Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme Jr JF. Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2005; 171 (4) 340-347
  • 8 Jones C, Griffiths RD, Slater T, Benjamin KS, Wilson S. Significant cognitive dysfunction in non-delirious patients identified during and persisting following critical illness. Intensive Care Med 2006; 32 (6) 923-926
  • 9 Unroe M, Kahn JM, Carson SS , et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Ann Intern Med 2010; 153 (3) 167-175 . doi: 10.1059/0003-4819-153-3-201008030-00007
  • 10 Hopkins RO, Gale SD, Weaver LK. Brain atrophy and cognitive impairment in survivors of Acute Respiratory Distress Syndrome. Brain Inj 2006; 20 (3) 263-271
  • 11 Suchyta MR, Jephson A, Hopkins RO. Neurologic changes during critical illness: brain imaging findings and neurobehavioral outcomes. Brain Imaging Behav 2010; 4 (1) 22-34 . doi: 10.1007/s11682-009-9082-3
  • 12 Ehlenbach WJ, Hough CL, Crane PK , et al. Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA 2010; 303 (8) 763-770 . doi: 10.1001/jama.2010.167
  • 13 Wilson RS, Hebert LE, Scherr PA, Dong X, Leurgens SE, Evans DA. Cognitive decline after hospitalization in a community population of older persons. Neurology 2012; 78 (13) 950-956 . doi: 10.1212/WNL.0b013e31824d5894
  • 14 Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304 (16) 1787-1794 . doi: 10.1001/jama.2010.1553
  • 15 Hopkins RO, Jackson JC. Short- and long-term cognitive outcomes in intensive care unit survivors. Clin Chest Med 2009; 30 (1) 143-153, ix . doi: 10.1016/j.ccm.2008.11.001
  • 16 Sukantarat KT, Burgess PW, Williamson RC, Brett SJ. Prolonged cognitive dysfunction in survivors of critical illness. Anaesthesia 2005; 60 (9) 847-853
  • 17 Duning T, van den Heuvel I, Dickmann A , et al. Hypoglycemia aggravates critical illness-induced neurocognitive dysfunction. Diabetes Care 2010; 33 (3) 639-644 . doi: 10.2337/dc09-1740
  • 18 Jackson JC, Hart RP, Gordon SM , et al. Six-month neuropsychological outcome of medical intensive care unit patients. Crit Care Med 2003; 31 (4) 1226-1234
  • 19 Mikkelsen ME, Christie JD, Lanken PN , et al. The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury. Am J Respir Crit Care Med 2012; 185 (12) 1307-1315 . doi: 10.1164/rccm.201111-2025OC
  • 20 Jackson JC, Obremskey W, Bauer R , et al. Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage. J Trauma 2007; 62 (1) 80-88 . doi: 10.1097/TA.0b013e31802ce9bd
  • 21 Pelati O, Castiglioni S, Isella V , et al. When Rey-Osterrieth's complex figure becomes a church: prevalence and correlates of graphic confabulations in dementia. Dement Geriatr Cogn Dis Extra 2011; 1 (1) 372-380
  • 22 Hopkins RO, Weaver LK, Chan KJ, Orme Jr JF. Quality of life, emotional, and cognitive function following acute respiratory distress syndrome. J Int Neuropsychol Soc 2004; 10 (7) 1005-1017
  • 23 Hopkins RO, Suchyta MR, Snow GL, Jephson A, Weaver LK, Orme JF. Blood glucose dysregulation and cognitive outcome in ARDS survivors. Brain Inj 2010; 24 (12) 1478-1484 . doi: 10.3109/02699052.2010.506861
  • 24 Elenkov IJ, Iezzoni DG, Daly A, Harris AG, Chrousos GP. Cytokine dysregulation, inflammation and well-being. Neuroimmunomodulation 2005; 12 (5) 255-269
  • 25 Lutz PL, Nilsson GE. The Brain without oxygen. Austin, TX: Chapman and Hall; 1997
  • 26 Michenfelder JD, Sundt Jr TM. Cerebral ATP and lactate levels in the squirrel monkey following occlusion of the middle cerebral artery. Stroke 1971; 2 (4) 319-326
  • 27 Siesjö BK, Bengtsson F, Grampp W, Theander S. Calcium, excitotoxins, and neuronal death in the brain. Ann N Y Acad Sci 1989; 568: 234-251
  • 28 Schurr A, Lipton P, West CA, Rigor BM. The role of energy in metabolism and divalent cations in the neurotoxicity of excitatory amino acids in vitro. In: Krieglstein J, , ed. Pharmacology of Cerebral Ischemia. Boca Raton, FL: CRC Press; 1990: 217-226
  • 29 Biagas K. Hypoxic-ischemic brain injury: advancements in the understanding of mechanisms and potential avenues for therapy. Curr Opin Pediatr 1999; 11 (3) 223-228
  • 30 Floyd RA. Role of oxygen free radicals in carcinogenesis and brain ischemia. FASEB J 1990; 4 (9) 2587-2597
  • 31 Johnston MV, Nakajima W, Hagberg H. Mechanisms of hypoxic neurodegeneration in the developing brain. Neuroscientist 2002; 8 (3) 212-220
  • 32 Sonneville R, den Hertog HM, Güiza F , et al. Impact of hyperglycemia on neuropathological alterations during critical illness. J Clin Endocrinol Metab 2012; 97 (6) 2113-2123 . doi: 10.1210/jc.2011-2971
  • 33 Katsura K, Kristián T, Smith ML, Siesjö BK. Acidosis induced by hypercapnia exaggerates ischemic brain damage. J Cereb Blood Flow Metab 1994; 14 (2) 243-250
  • 34 Nabeshima T, Katoh A, Ishimaru H , et al. Carbon monoxide-induced delayed amnesia, delayed neuronal death and change in acetylcholine concentration in mice. J Pharmacol Exp Ther 1991; 256 (1) 378-384
  • 35 Dietrich WD, Alonso O, Busto R. Moderate hyperglycemia worsens acute blood-brain barrier injury after forebrain ischemia in rats. Stroke 1993; 24 (1) 111-116
  • 36 McCall AL. The impact of diabetes on the CNS. Diabetes 1992; 41 (5) 557-570
  • 37 Levine SR, Welch KM, Helpern JA , et al. Prolonged deterioration of ischemic brain energy metabolism and acidosis associated with hyperglycemia: human cerebral infarction studied by serial 31P NMR spectroscopy. Ann Neurol 1988; 23 (4) 416-418
  • 38 Rosner MJ, Newsome HH, Becker DP. Mechanical brain injury: the sympathoadrenal response. J Neurosurg 1984; 61 (1) 76-86
  • 39 Siesjö BK, Siesjö P. Mechanisms of secondary brain injury. Eur J Anaesthesiol 1996; 13 (3) 247-268
  • 40 Feuerstein GZ, Liu T, Barone FC. Cytokines, inflammation, and brain injury: role of tumor necrosis factor-alpha. Cerebrovasc Brain Metab Rev 1994; 6 (4) 341-360
  • 41 Ely EW, Shintani A, Truman B , et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291 (14) 1753-1762
  • 42 Jackson JC, Gordon SM, Hart RP, Hopkins RO, Ely EW. The association between delirium and cognitive decline: a review of the empirical literature. Neuropsychol Rev 2004; 14 (2) 87-98
  • 43 Morandi A, Rogers BP, Gunther ML , et al; VISIONS Investigation, VISualizing Icu SurvivOrs Neuroradiological Sequelae. The relationship between delirium duration, white matter integrity, and cognitive impairment in intensive care unit survivors as determined by diffusion tensor imaging: the VISIONS prospective cohort magnetic resonance imaging study. Crit Care Med 2012; 40 (7) 2182-2189 . doi: 10.1097/CCM.0b013e318250acdc
  • 44 Sharshar T, Carlier R, Bernard F , et al. Brain lesions in septic shock: a magnetic resonance imaging study. Intensive Care Med 2007; 33 (5) 798-806 . doi: 10.1007/s00134-007-0598-y
  • 45 van der Mast RC. Pathophysiology of delirium. J Geriatr Psychiatry Neurol 1998; 11 (3) 138-145 , discussion 157–158
  • 46 Flacker JM, Cummings V, Mach Jr JR, Bettin K, Kiely DK, Wei J. The association of serum anticholinergic activity with delirium in elderly medical patients. Am J Geriatr Psychiatry 1998; 6 (1) 31-41
  • 47 Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275 (11) 852-857
  • 48 Trzepacz PT. Delirium. Advances in diagnosis, pathophysiology, and treatment. Psychiatr Clin North Am 1996; 19 (3) 429-448
  • 49 Trzepacz PT. Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Semin Clin Neuropsychiatry 2000; 5 (2) 132-148
  • 50 Meagher DJ, Trzepacz PT. Motoric subtypes of delirium. Semin Clin Neuropsychiatry 2000; 5 (2) 75-85
  • 51 Arvin B, Neville LF, Barone FC, Feuerstein GZ. Brain injury and inflammation. A putative role of TNF alpha. Ann N Y Acad Sci 1995; 765: 62-71 , discussion 98–99
  • 52 Bellingan GJ. The pulmonary physician in critical care * 6: The pathogenesis of ALI/ARDS. Thorax 2002; 57 (6) 540-546
  • 53 Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990; 263 (8) 1097-1101
  • 54 De Kloet ER, Vreugdenhil E, Oitzl MS, Joëls M. Brain corticosteroid receptor balance in health and disease. Endocr Rev 1998; 19 (3) 269-301
  • 55 Corder EH, Saunders AM, Strittmatter WJ , et al. Gene dose of apolipoprotein E type 4 allele and the risk of Alzheimer's disease in late onset families. Science 1993; 261 (5123) 921-923
  • 56 Ely EW, Girard TD, Shintani AK , et al. Apolipoprotein E4 polymorphism as a genetic predisposition to delirium in critically ill patients. Crit Care Med 2007; 35 (1) 112-117
  • 57 Milbrandt EB, Angus DC. Potential mechanisms and markers of critical illness-associated cognitive dysfunction. Curr Opin Crit Care 2005; 11 (4) 355-359
  • 58 Sommer BR, Wise LC, Kraemer HC. Is dopamine administration possibly a risk factor for delirium?. Crit Care Med 2002; 30 (7) 1508-1511
  • 59 Fischer JE, Rosen HM, Ebeid AM, James JH, Keane JM, Soeters PB. The effect of normalization of plasma amino acids on hepatic encephalopathy in man. Surgery 1976; 80 (1) 77-91
  • 60 Morrison RS, Magaziner J, Gilbert M , et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003; 58 (1) 76-81
  • 61 Jackson JC, Girard TD, Gordon SM , et al. Long-term cognitive and psychological outcomes in the awakening and breathing controlled trial. Am J Respir Crit Care Med 2010; 182 (2) 183-191 . doi: 10.1164/rccm.200903-0442OC
  • 62 Stuss DT, Winocur G, Robertson IH , eds. Cognitive Neurorehabilitation: Evidence and Application. 2nd ed. Cambridge: Cambridge University Press; 2010
  • 63 Jackson JC, Ely EW, Morey MC , et al. Cognitive and physical rehabilitation of intensive care unit survivors: results of the RETURN randomized controlled pilot investigation. Crit Care Med 2012; 40 (4) 1088-1097 . doi: 10.1097/CCM.0b013e3182373115
  • 64 Cicerone KD, Dahlberg C, Kalmar K , et al. Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 2000; 81 (12) 1596-1615 . doi: 10.1053/apmr.2000.19240
  • 65 Winocur G. Introduction to principles of cognitive rehabilitation. In: Stuss DT, Winocur G, Robertson IH, , eds. Cognitive Neurorehabilitation: Evidence and Application. 2nd ed. Cambridge: Cambridge University Press; 2010: 3-5
  • 66 Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res 2008; 51 (1) S225-S239 . doi: 10.1044/1092-4388(2008/018)
  • 67 Bloss EB, Janssen WG, Ohm DT , et al. Evidence for reduced experience-dependent dendritic spine plasticity in the aging prefrontal cortex. J Neurosci 2011; 31 (21) 7831-7839 . doi: 10.1523/JNEUROSCI.0839-11.2011
  • 68 Dixon RA, Garrett D, Blackman L. Principles of compensation in cognitive neuroscience and neurorehabilitation. In: Stuss DT, Winocur G, Robertson IH, , eds. Cognitive Neurorehabilitation: Evidence and Application. 2nd ed. Cambridge: Cambridge University Press; 2010: 22-38
  • 69 Bäckman L, Dixon RA. Psychological compensation: a theoretical framework. Psychol Bull 1992; 112 (2) 259-283