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Delirium in the ICU and Subsequent Long-Term Disability Among Survivors of Mechanical Ventilation*

Brummel, Nathan E. MD, MSCI1,2,3; Jackson, James C. PsyD1,2,4,5,6; Pandharipande, Pratik P. MD, MSCI7,8; Thompson, Jennifer L. MPH9; Shintani, Ayumi K. PhD, MPH9; Dittus, Robert S. MD, MPH4,10; Gill, Thomas M. MD11; Bernard, Gordon R. MD1; Ely, E. Wesley MD, MPH1,2,3,4; Girard, Timothy D. MD, MSCI1,2,3,4

doi: 10.1097/CCM.0b013e3182a645bd
Clinical Investigations

Objective: Survivors of critical illness are frequently left with long-lasting disability. The association between delirium and disability in critically ill patients has not been described. We hypothesized that the duration of delirium in the ICU would be associated with subsequent disability and worse physical health status following a critical illness.

Design: Prospective cohort study nested within a randomized controlled trial of a paired sedation and ventilator weaning strategy.

Setting: A single-center tertiary-care hospital.

Patients: One hundred twenty-six survivors of a critical illness.

Measurements and Main Results: Confusion Assessment Method for the ICU, Katz activities of daily living, Functional Activities Questionnaire (measuring instrumental activities of daily living), Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score, and Awareness Questionnaire were used. Associations between delirium duration and outcomes were determined via proportional odds logistic regression with generalized estimating equations (for Katz activities of daily living and Functional Activities Questionnaire scores) or via generalized least squares regression (for Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score and Awareness Questionnaire scores). Excluding patients who died prior to follow-up but including those who withdrew or were lost to follow-up, we assessed 80 of 99 patients (81%) at 3 months and 63 of 87 patients (72%) at 12 months. After adjusting for covariates, delirium duration was associated with worse activities of daily living scores (p = 0.002) over the course of the 12-month study period but was not associated with worse instrumental activities of daily living scores (p = 0.15) or worse Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score (p = 0.58). Duration of delirium was also associated with lower Awareness Questionnaire Motor/Sensory Factors scores (p 0.02).

Conclusion: In the setting of critical illness, longer delirium duration is independently associated with increased odds of disability in activities of daily living and worse motor-sensory function in the following year. These data point to a need for further study into the determinants of functional outcomes in ICU survivors.

1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

2Center for Health Services Research, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

3Center for Quality of Aging, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

4Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.

5Department of Psychiatry, Vanderbilt Medical Center, Nashville, TN.

6Clinical Research Center of Excellence, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.

7Division of Critical Care, Department of Anesthesiology, Vanderbilt School of Medicine, Nashville, TN.

8Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.

9Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN.

10Institute for Medicine and Public Heath, Vanderbilt University School of Medicine, Nashville, TN.

11Department of Internal Medicine, Yale School of Medicine, New Haven, CT.

* See also p. 466.

Dr. Brummel, Dr. Jackson, Dr. Pandharipande, Ms. Thompson, Dr. Shintani, Dr. Dittus, Dr. Bernard, Dr. Ely, and Dr. Girard designed the study. Ms. Thompson and Dr. Shintani analyzed the data. Dr. Girard and Dr. Jackson collected the participant data. All authors interpreted the data, critically revised the article, and approved the final version of the article.

Supported, in part, by the Saint Thomas Foundation (Nashville, TN).

Presented, in part, at the American Thoracic Society International Meeting, Denver, CO, May 2011.

Dr. Brummel and his institution received support from the National Institutes of Health (NIH) (T32HL087738). Dr. Jackson is supported by the NIH (AG031322). Dr. Pandharipande is supported by the VA Clinical Science Research and Development Service (VA Career Development Award) and received honoraria from Hospira. Ms. Thompson is supported, in part, by the NIH (AG027472). Dr. Shintani and her institution are supported, in part, by NIH (AG027472). Dr. Dittus is supported, in part, by the Vanderbilt Clinical-Translational Science Award (2UL1TR000445-06) from the National Center for Advancing Translational Sciences (NCATS)/NIH, the NIH (AG027472 and AG035117), and the Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC). He received support for travel from the KaroLinska Institute for keynote address and has board membership with the RWJ Foundation and University of Michigan. His institution received grant support from VA, NIH, Centers for Medicare and Medicaid Services, and the Robert Wood Johnson Foundation. Dr. Gill is the recipient of a Midcareer Investigator Award in Patient-Oriented Research (K24AG021507) from the National Institute on Aging and is supported, in part, by the Yale Claude D. Pepper Older Americans Independence Center (P30AG21342). He and his institution received grant support from the NIH. Dr. Bernard is supported, in part, by the Vanderbilt Clinical-Translational Science Award (2UL1TR000445-06) from the NCATS/NIH. His institution received grant support from the NIH. Dr. Ely is supported by the VA Clinical Science Research and Development Service (VA Merit Review Award), the NIH (AG027472 and AG035117), the Veterans Affairs Tennessee Valley GRECC, and Lilly. He received honoraria from Hospira and consulted for Cumberland and Masimo. Dr. Girard is supported by the NIH (AG034257) and Veterans Affairs Tennessee Valley GRECC and received honoraria from Hospira. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute, the National Institute on Aging, or the NIH.

For information regarding this article, E-mail: nathan.brummel@vanderbilt.edu

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins