We face a profound and emerging public health problem in the form of acute and chronic brain dysfunction. This affects both young and elderly intensive care unit survivors and is altering the landscape of society. Two-thirds of intensive care unit patients develop delirium, and this is associated with longer stays, increased costs, and excess mortality. In addition, over half of intensive care unit survivors suffer a dementia-like illness that impacts their physical and cognitive functional abilities and which appears to be related to the duration of their intensive care unit delirium. A new paradigm of how intensivists handle the brain is required. We propose a three-step approach to address this emerging epidemic, which includes Screening, Prevention, and Restoration of brain function (SPR). Screening combines risk factor identification and delirium assessment using validated instruments. Prevention of acute and chronic brain dysfunction requires implementation of a core model of care that combines evidence-based practices: awakening and breathing, coordination with target-based sedation, delirium monitoring, and exercise/early mobility (ABCDE). Restoration introduces strategies of ongoing screening and treatment for intensive care unit survivors at high risk of ongoing brain dysfunction. This practical system applying many evidence-based concepts incorporates personalized medicine, systems-based practice, and continuing research and development toward improving acute and chronic cognitive outcomes.
From the Center for Health Services Research (EEV, TDG, EWE), Division of General Internal Medicine and Public Health (EEV), and the Division of Allergy, Pulmonary, and Critical Care Medicine (TDG, EWE) in the Department of Medicine; and the Division of Critical Care in the Department of Anesthesiology (PPP) at the Vanderbilt School of Medicine, Nashville, TN; and the Geriatric Research, Education and Clinical Center (GRECC) Service (EEV, TDG, EWE), Clinical Research Training Center of Excellence (CRCoE) (EEV), and the Anesthesiology Service (PPP), at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN.
Dr. Vasilevskis was supported by the Veterans Affairs Clinical Research Center of Excellence and the Geriatric Research Education and Clinical Center, Veterans Affairs, Tennessee Valley Healthcare, Nashville, TN. Dr. Girard is supported by the National Institutes of Health (AG034257) and the VA Geriatric Research, Education and Clinical Center. Dr. Ely has received grant support and honoraria from Eli Lilly and Company, Pfizer, Hospira Inc., Aspect Medical Systems, and GlaxoSmithKline. Dr. Pandharipande has received honorarium from Hospira Inc. and GlaxoSmithKline. Dr. Girard has received honoraria from Hospira Inc. Dr. Vasilevskis has not disclosed any potential conflicts of interest.
The work was performed at Vanderbilt University Medical Center and the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System in Nashville, TN.
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