Covert Critical Illness Encephalopathy: Impairments That Escape Detection by Guideline Recommended, Protocolized Assessments

Ruhi Shirodkar, Isaac J. Bourgeois, Minjee Kim, Eyal Y. Kimchi, Eric M. Liotta, Matthew Brandon Maas*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

Objectives: To determine whether cognitive impairments of important severity escape detection by guideline-recommended delirium and encephalopathy screening instruments in critically ill patients. Design: Cross-sectional study with random patient sampling. Setting: ICUs of a large referral hospital with protocols implementing the Society of Critical Care Medicine's ICU Liberation Bundle. Patients: Patients with a heterogeneous mix of primary organ system conditions leading to critical illness and with no abnormal findings scored in Confusion Assessment Method for the ICU (CAM-ICU) screening, Richmond Agitation-Sedation Scale (RASS) 0, and Glasgow Coma Scale (GCS) 15, indicating they were alert, fully oriented, and following commands with no delirium or findings to indicate subsyndromal delirium. Interventions: None. Measurements and Main Results: We evaluated 50 patients, age 54 ± 16 years. Trained critical care nurses assessed patients at regular intervals using the CAM-ICU, RASS, and GCS per a protocol. We performed a battery of psychometric cognitive tests using the NIH Toolbox. Executive functions linked to attention and inhibitory control, and processing speed were 1.5 sd below population norm (both p < 0.01). Working memory and cognitive flexibility were also significantly, but less severely, impaired (p < 0.01 and p = 0.026). Nearly two-thirds (64%) of the patients scored at least 1.5 sd worse than demographically adjusted means in two or more cognitive domains, a commonly used diagnostic criterion for cognitive impairment. Conclusions: Substantial cognitive impairment is present among critically ill patients with no abnormalities detected by standard delirium and encephalopathy assessments.

Original languageEnglish (US)
JournalCritical care medicine
DOIs
StateAccepted/In press - 2024

Funding

Dr. Kim\u2019s institution received funding from Genentech. Drs. Kim and Maas received support for article research from the National Institutes of Health. Dr. Liotta received funding from Quinn Johnston Law Firm. Dr. Maas\u2019 institution received funding from the U.S. National Institute of Neurological Disorders and Stroke. The remaining authors have disclosed that they do not have any potential conflicts of interest. This work reported here was supported by U.S. National Institute of Neurological Disorders and Stroke grant K23NS092975.

Keywords

  • cognition
  • critical illness
  • delirium
  • encephalopathy

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

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