Intensive Care Drives Some Patients Crazy, Literally

Intensive care in hospitals includes extreme measures that can induce delirium in many patients, and that, doctors are now discovering, don’t necessarily go away when the patient leaves the ICU.

About 3 in 4 ICU patients develop delirium, according to a story in the Philadelphia Inquirer, and delirium is associated with poorer survival rates and worse long-term outcomes.

It has long been known that ICU delirium sometimes includes delusions and hallucinations. Some ICU patients have believed that that they were being assaulted or imprisoned; that their nurses were plotting to kill them; that the walls were covered in blood; that huge spiders were riding bicycles in the room.

Medical professionals used to think patients left these disturbing adventures in the ICU, but now they acknowledge that sometimes they take their terrifying false memories home with them. A recent Johns Hopkins study found that 1 in 4 patients had post-traumatic stress symptoms two years after going home.

Many former ICU patients struggle with physical weakness, thinking problems, anxiety, depression and post-traumatic stress disorder (PTSD); you might be more familiar with that disorder as associated with soldiers returning from a war zone, or victims of sexual assault.

What’s unusual among hospital PTSD victims, the study said, is that their flashbacks are of delusions or hallucinations they had in the hospital, not events that actually occurred. “Having a life-threatening illness is itself frightening,” according to the Cambridge Journal blog, “but delirium in these patients – who are attached to breathing machines and being given sedatives and narcotics – may lead to ‘memories’ of horrible things that didn’t happen.”

Last year, the Society of Critical Care Medicine gave ICU PSTD its own name-post-intensive care syndrome (PICS). The society says that as many as 1 in 5 ICU patients might suffer from it. With a diagnosis, generally, comes a refocusing of professional resources on how not only to save lives in the ICU, but to address its effects after hospital care.

PICS can be tricky to fix because patients often look OK after they’ve been home for a while; their family and friends might not understand why they’re aren’t bouncing back. It’s also difficult to address, says The Inquirer, because it can take ICU doctors so long to notice the problem they often don’t see patients who recover enough to be moved to another floor.

So, critical care docs are learning how to educate their primary-care colleagues and others who manage a patient’s discharge and follow-up care.

Savvy ICU staff hope to minimize PICS with changes in how they care for their patients. The key is to reduce the delirium by administering less sedation, ensure 24-hour visitation, starting physical therapy sooner and making sure rooms are dark night to promote sleep.

An awareness of PICS, it’s thought, also can improve other ICU problems. Every year, approximately 1 million Americans are hooked to a ventilator in an ICU. That can lead to lung problems or sepsis, a serious infection. The PICS findings might translate to a broader group of delirious patients who were not in ICUs.

It’s estimated that at least half of ICU survivors have trouble with basic living activities a year after discharge. Of those with severe lung problems, 55 in 100 had cognitive impairment, according to one study, and 36 in 100 had depression.

But even if there’s no such diagnosis, former ICU patients still might be weak and tired long after they go home. They have trouble concentrating, making decisions and remembering; they might be emotionally fragile, and are plagued with upsetting memories.

Some of their delusions seem related to the patients’ legitimate care, such as placing catheters and breathing tubes. One patient who had gotten an MRI thought he was on a conveyor belt feeding into an oven.

If you have a breathing tube down your throat, you can’t even tell anyone what you believe is happening to you. Doctors have learned to suspect a trauma disorder if patients are particularly combative once the tubes are removed. And some ICUs now screen patients daily for delirium by asking questions such as: Can a stone float on water? Patients with delirium will say yes.

If your loved one is in ICU, make sure the staff knows you’re familiar with PICS, and ask what they know about the syndrome.

Also, visit as often as you can, and bring familiar objects from home. Hearing a familiar voice, said one expert interviewed by The Inquirer, is not only “vocal anesthesia,” but helps to anchor the patients in reality. Make sure the room is as dark and quiet as possible during normal nighttime sleeping hours. Find out how much sedation the patient is being given, and ask if it’s the lowest dose possible.

And when it’s time for discharge, ask transition care team members how to recognize and address the effects of delirium. Make sure they have a plan for treating its long-lasting effects.

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