Cognitive Impairment And Affective Disorder In Critical Patients And Its Intervention

Background and Objective: The survival rate of critical patients was improved with the development of intensive medical technology,but recent research has reported that ICU survivors suffer from a prevalence of cognitive impairments(Memory,orientation ability,executive ability,etc)and affective disorder(depression and anxiety)after recovery from critical illnesses because of the environmental factors and patient factors.Cognitive impairment and affective disorder not only reduce the quality of life of critical patients after discharge,but also increase the burden of the social health expenditure and getting more and more attention.There were some studies had report the risk factors of cognitive impairment and affective disorder in ICU,but lack of large-scale clinical trials,however,the correlation between the different types of ICU care and the extent of cognitive impairment observed in the patients remains poorly studied,and little research has been conducted on the effects of intervention on cognitive function and affective disorder recovery.Firstly,this research aims to investigate the characteristics of cognitive impairment in patients after intensive care admission and the effects of cognitive intervention to treat the long-term impairments observed among these patients.Secondly,this research aims to the effects of cognitive intervention on improving cognitive function in populations of different types of ICU and different ages of ICU survivors;Finally,to investigate the incidence rate and characteristics of psychiatric symptoms(depression and anxiety)in patients after intensive care admission.and to identify it's risk factors after discharge;investigate the association between 5-hydroxy tryptamine levels and psychiatric symptoms,cognitive level and delirium rate ofpatients in ICU and further explore the effect of application of selective serotonin reuptake inhibitor on the incidence of psychiatric symptoms in patients of ICU.Methods:(1)Study 1: In total 332 patients who received ICU care from January 2013 to September 2013 in MICU and NICU of the Hefei NO.2 People Hospital,NICU of The First Affiliated Hospital of Anhui Medical University and ICU of The Second Affiliated Hospital of Anhui Medical University were included in this research.The patients were randomly divided into two groups: 165 patients were included in the control group and 167 in the cognitive intervention group.Cognitive function was assessed 72 hours after discharge with a professional neuropsychological screening instrument.The patients in the intervention group received a series of scientifically designed cognitive training sessions(playing electronic musical keyboard,learning simple spanish,clock-drawing,psychological intervention)while patients in thecontrol group did not undertake any cognitive training.After 3 months the cognitive function of patients in bothgroup were assessed with a neuropsychological screening instrument.(2)Study 2:250 patients with normal consciousness and intelligence treated in ICU were enrolled for a prospective study.Potential risk factors such as Gender,age,education level,severity of disease,APACHE II score,ventilator days,daily sleep time,ICU stay time etc were collected.Hospital Anxiety and Depression Scale(HADS)was used to evaluate the incidence of anxiety and depression in 4 days after admission.Two months after discharge from ICU,195 survivors of our group received the HADS to estimate the degree of psychological problem.Using multiple linear regression analysis to identify the related risk factors.(3)Study 3: Three hundred patients who met the criteria treated in ICU were enrolled for a prospective study from January 2010 to December 2015.In all patients,the levels of 5-HT were measured at the time of admission atday 4,day 7 after admissio n,scores of MMSE scale and HADS scale,the incidence of delirium was also collected.Four hundred patients were divided into depression group(115)and control group(185)according to HADS at day 4,the score >8 points can be diagnosed as psychiatric conditions.Compare the 5-HT level at day 4,day 7 after admission.At last,eight patients were excluded because of contraindication,the remaining 115 patients were randomly divided into the experimental group(53)and the control group(54),selective serotonin reuptake inhibitor was used in experimental group.The HADS ?SDS and Mo CA scale were measured again to people of the two group two month later after discharge.Results:(1)Study 1: 1.General information:The mean age of the patients was 51.23±18.52years(range 21–78 years),and 132 were female.The mean duration of ICU care patients received was 28 + 15.35 days,and the physical condition of the patients was assessed to ensure they met the criteria for discharge from ICU..167 in the cognitive intervention group,the mean age of the patients was 50 years(range 21–78 years).165 patients in the control group,the mean age was 52 years(range 21–77 years),.Statistical analysis was conducted to ensure no significant difference was found in the age,gender,type of illnesses and proportions of patients between the control and cognitive intervention groups.2.Seventy two hours after discharge from ICU,no significant difference was observed between patients in the control group and the intervention group(26.61±6.50 vs 26.45±8.06,P >0.05).3.After 3 months of intervention,The intervention group had a long-term cognitive impairment rate of only 59%,whereas 82% of the patients in the control groups were identified as having impaired cognitive function.The average total score on the Mo CA of the intervention group was 25.18±6.42,whereas patients in the control group scored an average of 16.47±8.88(p =.043).Cognitive training had significant effects on the protection of memory,attention and language(3.95±0.59 vs.2.01±0.22;4.29±0.41 vs.3.25±0.39;4.22±0.60 vs.2.53±0.23).The questionnaire score of the patients and caregivers in the cognitive intervention group was 12.31±2.80 and13.40±2.15.In the control group,the patients gave a mean score of 7.81±4.26 and the average score of the caregivers was 6.75±3.49.Statistics indicated that both patients and caregivers in the cognitive intervention group considered the cognitive intervention training could improve patients' cognitive function and the living ability after intensive care admission.4.After 3 months of cognitive intervention,the average scores of the patients from the NICU and MICU subgroups only fell 0.71 and 0.86,suggesting that cognitive training efficiently impeded the deterioration of cognitive function in these patients.the cognitive function of patients in the PACU subgroup improved after 3 months of cognitive training,with their Mo CA score increasing from 26.62 to 28.82,indicated that patients in the PACU enjoy the greatest benefits from cognitive intervention training.In the control group,the cognitive functions of the patients who survived from post-anaesthesia care unit(PACU),neurological intensive care unit(NICU)and medical intensive care unit(MICU)were all severely impaired after 3 months without cognitive intervention(15.92±2.48 vs 26.52±2.26;16.21±1.28 vs 26.35±1.26;16.11±2.36 vs 27.02±2.51).5.After 3 months of cognitive intervention,In the cognitive intervention group the cognitive functions of the younger sample recovered by 3.21 points,whereas without cognitive training the younger group improved their Mo CA score only by 1.02 points.Suggesting the intervention exerted significantly positive effects on the recovery of cognitive function in the younger sample population(aged from 20–40 years).In the middle-aged population(aged from 40–60 years)cognitive functions were mildly impaired and recovered slightly by 0.64 point with the assistance of cognitive intervention.The Mo CA scores of the older sample population(aged from 60–80 years)dropped by 2.93 points,which was significantly lower than the deterioration rate of the older population in the control group.However,the cognitive impairments in the older population seemed irreversible even with the assistance of cognitive training.(2)Study 2: 1.The incidence of depression and anxiety during hospitalization in ICUwas 24%.The incidence of anxiety and depression was 20% and 30% in patients who were discharged from ICU.2.Patients were divided into depression group and control group according to HADS at day 4..Single factor analysis showed that age,years of education,CCI scores,HADS scores,APACHE II scores,delirium and ICU length of stay showed statistical difference between the two groups.3.In multiple regression analysis,major pre-existing disease defined by CCI score(P<0.01),HADS score(P<0.05),ICU length of stay(P<0.01)were significant independent risk factors for depression of patients discharged from ICU.CCI score(P<0.01),HADS score(P<0.05),APACHEII score(P<0.05),in-ICU delirium(P<0.05),ICU length of stay(P<0.01)were significant independent risk factors for anxiety.4.Patients were divided into depression group and control group according to HADS at day 4.There were no significant differences about 5-HT level between two groups on admission and at day 7 after admission(95.89±62.06 vs.105.71±43.95;79.60±58.06 vs.99.99±46.16,P>0.05),Daily sleep time was significant positively correlated with levels of 5-HT(r=0.185,P<0.05)while HADS score was negatively correlated with it at day 4 after admission(r=0.302,P<0.05).Correlation analysis confirmed a strong positive relationship between the level of 5-HT and does of sedative?daily sleep time?score of MMSE scale ? score of HADS scale(r=0.192,0.182,0.172,P<0.05)while HADS score was negatively correlated with level of 5-HT at day 7 after admission(r=0.211,P<0.05).the 5-HT level in depression group was significantly lower than in control group(60.99±34.367 vs.95.43±47.294,P<0.05)(3)Study 3:1.The 5-HT levels in the blood was significantly negatively correlated with the HADS score at day 4after admission.The 5-HT levels had a significant positive correlation with MMSE score(r=0.172,P = 0.031),and showed a significant negative correlation with the HADS scores(r=-0.211,P = 0.013).2.Patients in the experimental group used 5-HT reuptake inhibitors for treatment,the HADS score and SDS score were significantly lower than the control group two months later after discharge(7.91±2.63 vs.9.15±2.72;45.85±11.76 vs.50.61±12.95,all P<0.05),There was not significant difference in Mo CA scale score between the two groups,but attention and memory scores in experimental groupwere higher than the control group(3.28±0.84 vs.2.72±0.81;1.87±0.73 vs.2.20±0.68,all P<0.05),Moreover,patients who were treated with 5-HT reuptake inhibitors at a standard dose during the period of hospitalization did not appear adverse drug reaction.Conclusions(1)Study1: 1.ICU survivors suffer from a prevalence of cognitive impairments after recovery from critical illnesses,50% of ICU survivors had cognitive impairments immediately after Discharge,especially in short-term memory.2.Cognitive intervention for 3months can efficiently impeded the deterioration of cognitive function in ICU survivors.Cognitive training had significant effects on the protection of memory(p =.012),attention(p =.021)and language(p =.045).3.Both patients and caregivers in the cognitive intervention group considered the cognitive intervention training for 3months could improve patients' cognitive function and the living ability after intensive care admission.4 Cognitive training efficiently impeded the deterioration of cognitive function in NICU and MICU patients.In particular,the cognitive function of patients in the PACU subgroup improved after 3 months of cognitive training.5 Cognitive intervention exerted significantly positive effects on the recovery of cognitive function in the younger sample population(aged from 20–40 years).In the middle-aged population(aged from 40–60 years)cognitive functions recovered slightly with the assistance of cognitive intervention.Cognitive intervention for 3months can prevent the deterioration of cognitive function in older sample population,However,the cognitive impairments in the older population still irreversible with cognitive training.(2)Study 2:1.Patients in ICU have a high incidence of psychological problems,psychiatric symptoms would influence the quality of life and also increase the cost and burden of familyafter discharge from ICU.these critically ill patients deserved attention.2.Patients who have heavy primary disease,psychiatric symptoms during admission or long length of stay are easy to be anxious after discharge;3.heavy primary disease,higher APACHEII score,psychiatric anddelirium symptoms during admission,long length of stay were significant independent risk factors for anxiety of patients discharged from ICU.(3)Study 3:1.There was a significant correlation between 5-HT levels and MMSE?HADS scores,suggesting that 5-HT levels can be used as a predictor of psychiatric symptoms in patients with ICU.2.Using 5-HT reuptake inhibitors early can reduce the incidence of long-term mental symptoms about patients with depression symptoms in ICU,improving the quality of life and reduce the burden on families and society.