Neuropsychiatric assessment and management of the ICU survivor

Erin A. Dean; Michelle Biehl; Kathryn Bash; Jeremy Weleff; Leopoldo Pozuelo

doi:10.3949/ccjm.88a.20169

Article Figures & Data

Figures

Tables

Download figure
Open in new tab
Download powerpoint
Figure 1
The multidisciplinary team approach used in the Cleveland Clinic Post-ICU Recovery Clinic (PIRC).

Tables

Figures

View popup

TABLE 1

Screening instruments for post-intensive care unit cognitive impairment

Screening tool	Number of questions	Interpretation of results	Further information
Montreal Cognitive Assessment (MoCA)	30	26-30 Normal cognitive function < 26 Ninety percent sensitive for mild cognitive impairment and 100% sensitive for dementia of Alzheimer (although scores for Alzheimer disease are typically much lower) < 18 Cutoff typically used for dementia of Alzheimer Note: If patient has < 12 years of education, add 1 point to score	Promising, larger studies needed for validation in critical illness patients Excellent reliability independent of intensive care unit setting

MoCA-blind (MoCA without visual elements)	22	> 18 No cognitive impairment < 17 Suggestive of cognitive impairment	Scoring is only suggestive and has not been validated

Mini-Mental State Examination	30	24-30 No cognitive impairment 18-23 Mild cognitive impairment 0-17 Severe cognitive impairment Note: Ranges may vary based on education level	Poor sensitivity in survivors of acute respiratory illness

Based on information in references 40–44.

View popup

TABLE 2

Screening instruments for post-intensive care unit emotional impairment

Screening tool	Number of questions	Interpretation of results	Further information
Depression
Hospital Anxiety and Depression Scale (HADS)	14 total, 7 focusing on depression symptoms	0-7 Normal 8-10 Borderline abnormal (borderline case) 11-21 Abnormal	Validated in ICU population
Hamilton Depression Rating Scale (HAM-D)	21 items, scoring based on first 17 items	10-13 Mild 14-17 Mild to moderate > 17 Moderate to severe
Beck Depression Inventory-II	21 items (13-item short-form available)	0-14 Minimal 14-19 Mild 20-28 Moderate > 29 Severe
Patient Health Questionnaire-9 (PHQ-9)	9	1-4 Minimal 5-9 Mild 10-14 Moderate 15-19 Moderately severe 20-27 Severe

Anxiety
Hospital Anxiety and Depression Scale (HADS)	14 total, 7 focusing on depression symptoms	0-7 Normal 8-10 Borderline abnormal 11-21 Abnormal	Validated in ICU population
Hamilton Anxiety Rating Scale (HAM-A)	14	0-13 Minimal 14-17 Mild 18-24 Moderate 25-30 Severe
Generalized Anxiety Disorder 7-item (GAD-7)	7	0-4 Minimal 5-9 Mild 10-14 Moderate 15-21 Severe

PTSD
Impact Event Scale-Revised (IES-R)	22	24-32 Clinical concern for PTSD 33-38 Clinical cutoff for probable PTSD diagnosis > 39 Significant enough symptoms to suppress immune system (even 10 years after impact event)	Validated in ICU population
Impact Event Scale-6 (IES-6) (abbreviated IES-R)	6	Calculated as mean of 6 questions with higher scores representing more-severe PTSD symptoms	Validated in ARDS survivors⁴⁷
Posttraumatic Symptom Scale, 10 items (PTSS-10)	10	Cutoff score > 35 predicts PTSD (PTSS-High)	Validated in ICU population Good reliability Detects PTSD symptoms but does not diagnose PTSD
PTSD Checklist for DSM-5 (PCL-5)	20	Total score of 31-33 or higher suggests patient may benefit from PTSD treatment
Abbreviated Posttraumatic Checklist (PCL-C)	6	> 14 suggestive of difficulties with posttraumatic stress

ARDS = acute respiratory distress syndrome; DSM = Diagnostic and Statistical Manual of Mental Disorders; ICU = intensive care unit; PTSD = posttraumatic stress disorder
Based on information in references 5, 40, and 45–47.

View popup

TABLE 3

The ICU Liberation Bundle (A–F)

Assessment, prevention, and management of pain
Both spontaneous breathing trials and spontaneous awakening trials
Choice of analgesia and sedation
Delirium: assessment, prevention, and management
Early mobilization and exercise
Family engagement and empowerment

Adapted from information in references 27, 28, and 48.

View popup

TABLE 4

Cleveland Clinic Post-ICU Recovery Clinic: Inclusion and exclusion criteria

Inclusion criteria	Shock (requiring vasopressor support) Acute respiratory distress syndrome Mechanical ventilation ≥ 3 days Prolonged intensive care unit (ICU) stay (≥ 7 days) Delirium present during intensive care unit stay Cardiac arrest COVID-19 with intensive care unit stay > 48 hours
Exclusion criteria	Hospice care Discharged to skilled nursing facility Significant cognitive impairment Long-term mechanical ventilation before intensive care unit admission (eg, for chronic respiratory failure)