Co-Occurrence of Post-Intensive Care Syndrome Problems Among 406 Survivors of Critical Illness

Abstract

Objectives: To describe the frequency of co-occurring newly acquired cognitive impairment, disability in activities of daily livings, and depression among survivors of a critical illness and to evaluate predictors of being free of post-intensive care syndrome problems.

Design: Prospective cohort study.

Setting: Medical and surgical ICUs from five U.S. centers.

Patients: Patients with respiratory failure or shock, excluding those with preexisting cognitive impairment or disability in activities of daily livings.

Interventions: None.

Measurements and main results: At 3 and 12 months after hospital discharge, we assessed patients for cognitive impairment, disability, and depression. We categorized patients into eight groups reflecting combinations of cognitive, disability, and mental health problems. Using multivariable logistic regression, we modeled the association between age, education, frailty, durations of mechanical ventilation, delirium, and severe sepsis with the odds of being post-intensive care syndrome free. We analyzed 406 patients with a median age of 61 years and an Acute Physiology and Chronic Health Evaluation II of 23. At 3 and 12 months, one or more post-intensive care syndrome problems were present in 64% and 56%, respectively. Nevertheless, co-occurring post-intensive care syndrome problems (i.e., in two or more domains) were present in 25% at 3 months and 21% at 12 months. Post-intensive care syndrome problems in all three domains were present in only 6% at 3 months and 4% at 12 months. More years of education was associated with greater odds of being post-intensive care syndrome free (p < 0.001 at 3 and 12 mo). More severe frailty was associated with lower odds of being post-intensive care syndrome free (p = 0.005 at 3 mo and p = 0.048 at 12 mo).

Conclusions: In this multicenter cohort study, one or more post-intensive care syndrome problems were present in the majority of survivors, but co-occurring problems were present in only one out of four. Education was protective from post-intensive care syndrome problems and frailty predictive of the development of post-intensive care syndrome problems. Future studies are needed to understand better the heterogeneous subtypes of post-intensive care syndrome and to identify modifiable risk factors.

Figure 1. Enrollment and Follow-up

Figure 2. Co-Occurring Post-Intensive Care Syndrome Problems at 3- and 12-Month Follow-Up

This diagram illustrates the co-occurrence of PICS problems at 3 and 12 months. The proportion of patients with PICS problems in each domain at 3 months is presented in the left panel and at 12 months in the right panel. Cognitive impairment is represented by the red circle. Disability in activities of daily living by the yellow circle. Depression by the blue circle. The overlap between the circles represents the co-occurrence of 2 or 3 problems. Overall, 6 out of 10 patients had PICS. The most common pattern at both 3 and 12 months was problems in a single domain and was present in 4 out of 10 patients. Co-occurring problems (i.e., in 2 or 3 domains) were present in 2 out of 10 patients.

Figure 3. Associations between Years of Education and Clinical Frailty Scale Score with the Adjusted Probability of being PICS-Free at Follow-up

These figures display the association between years of education and Clinical Frailty Scale score with the adjusted probability of being PICS-free at 3 months (left column) and 12 months (right column). For panels A and B the blue lines represent the association and blue shading represents the 95% confidence interval. For panels C and D, dots represent the point estimate and error bars the 95% confidence interval. The rug plot (just above the x-axes) shows the distribution of the exposure of interest. More years of education were associated with greater probability of being PICS-free (P<0.001 at 3 months, Panel A, and P<0.001 at 12 months, Panel B). Higher Clinical Frailty Scale scores, conversely, were associated with a lower probability of being PICS-free at 3 months (P=0.005, Panel C) and at 12 months (P=0.048, Panel D).