Diagnosis and management of NMS and its differentiation from catatonia

While much of this book has been focused on describing post-intensive care syndrome (PICS) in objective terms, is if often the personal stories of survivors of critical illness and their loved ones that are so much more revealing than the distance walked during 6 minutes or a score on a cognitive test. It was not until I began seeing patients in my ICU follow-up clinic that I truly appreciated how life-changing an experience surviving critical illness could be. Understanding the real-life impact of the physical, functional, cognitive, psychiatric, and social impairments that those suffering from PICS face is a profoundly moving and motivating experience. For that reason, I wanted to close this book with stories of survivors of critical illness and their loved ones, allowing the reader to synthesize and contextualize the objective data that has heretofore been presented in neatly parsed, individual chapters and to more deeply appreciate how that data translates into a much more impactful lived experience.

Intensive care unit (ICU) admissions create immense psychological challenges for patients and their loved ones. With increasing recognition of the psychological impact of an ICU admission, qualified psychologists have been incorporated into the care team both to address acute psychological stress during the admission and to help prevent continuing psychological difficulties after hospital discharge. This chapter describes the direct work that ICU psychologists do with patients, the support they provide for families, and other indirect ways they contribute to improving communication, psychological understanding, and the therapeutic environment in the ICU. Psychologists use a range of evidence-based approaches in their ICU work, including interventions based on cognitive behavioral therapy (CBT). Research into the most effective ways of delivering psychological interventions in the ICU is still in its infancy and should be prioritized now that psychological professionals are increasingly engaged with ICU teams.

Delirium, which is an important risk factor for post-intensive care syndrome (PICS), is common during critical illness, affecting between 20% and 80% of patients. It is associated with numerous adverse outcomes, including longer time on mechanical ventilation, longer time in the intensive care unit (ICU) and hospital, death, and long-term cognitive impairment. Delirium in the ICU can be reliably detected using multiple tools, including the Confusion Assessment Method in the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC). The exact cause of delirium, however, remains elusive even though there are many purported mechanisms, including neuroinflammation, metabolic insufficiency, neuronal dysfunction, and neurotransmitter disturbances. Due to knowledge gaps regarding the mechanism(s) of delirium, effective medical treatments for delirium also remains elusive. Current practice involves the prevention of delirium through the recognition and management of modifiable risk factors. The well-studied ABCDEF bundle is one such strategy, which is primarily non-pharmacologic, to prevent or mitigate delirium and thus limit its adverse outcomes. Unfortunately, delirium still occurs at a high rate, and the work to understand the underlying mechanism and its varied manifestations and to develop an effective treatment continues.

More than five million individuals in North America experience an episode of critical illness annually, and among those who survive, as many as a third experience substantial cognitive impairment, which often lasts long after discharge and can be permanent. While cognitive impairment after critical illness has been widely studied for two decades, much remains unknown, and the insights that have been generated by research often fail to inform clinical care. Key issues germane to understanding and optimally treating ICU survivors with cognitive deficits include: improving methods of early detection and screening, honing and implementing cognitive rehabilitation strategies, and better understanding the trajectories of impairments observed in patients. Prioritizing the brain health of individuals after critical care both through prevention and thoughtful interventional efforts remains a key public health goal and one that can only be accomplished through careful and deliberate interdisciplinary efforts.

An intensive care unit admission (ICU) can have a profound impact on patients and their families and loved ones. Most people experience heightened emotions, both negative and positive, during their time in the ICU. We know that the experiences that patients have in the ICU affect their psychological recovery and quality of life after hospital discharge. Risk factors for later psychological difficulties include acute stress and disturbing memories associated with the ICU; clinical factors, such as duration of sedation and delirium; and socio-demographic factors, such as age, gender, and socio-economic status. Patients have to deal with a range of challenges in the ICU, including illness-related, environment-related, and interpersonal stressors. ICU staff, including psychologists, should recognize common sources of distress and aim to alleviate patients’ stress through enhanced communication techniques and psychological interventions. Studying the coping strategies of patients who have a more positive experience during their time in the ICU is a promising way to help reduce stress and improve outcomes of intensive care.

Sleep disruption is common in intensive care unit (ICU) patients and contributes to Post-Intensive Care Syndrome (PICS). Patients frequently report poor sleep quality during ICU stays, highlighting the need for intervention. ICU patients experience fragmented and insufficient sleep, exacerbated by preexisting sleep difficulties, enviromental factors (e.g., ambient light and noise), clinical interventions, and patient discomfort. Sleep deprivation may increase the risk of delirium, complicating patient care. Non-pharmacological approaches such as noise reduction, light management, and circadian rhythm promotion show promise, but further research is needed to fully understand their impact. Addressing sleep disruption in the ICU is crucial for improving patient experiences and outcomes.

Music is associated with reduced pain, anxiety, and sedative requirements in ICU patients. Slow-tempo music (60 to 80 beats per minute) in particular has been associated with a neuromodulatory effect. The minimum duration of music listening associated with decreased pain may be as brief as 20 to 30 minutes, resulting in a nearly 2-point decrease in self-reported pain scores (on a 0-10 scale). Longer duration of music listening (i.e., more than 45 minutes) is associated with improved sleep quality and less depressive symptoms after critical illness. Through its interaction with various cortical areas, music may also offer beneficial effects on cognition. Neurocognitive processing of music invokes brain centers related to emotion, perception, cognition, and the autonomic nervous system. In EEG and functional MRI studies, music increased communication between the functional neural networks typically disrupted in delirium and dementia. Whether music listening in ICU patients with delirium can improve long-term cognitive function is not clearly understood but is being evaluated in randomized controlled trials. Ongoing clinical and scientific work will lay the groundwork to identify the neuroprotective mechanisms by which music may reduce the risk of ICU delirium and long-term cognitive impairments.

The Society of Critical Care Medicine (SCCM) launched the Intensive Care Unit (ICU) Liberation Campaign in 2014 as a project to improve patient- and family-centered care that packaged key concepts from 2013 and 2018 clinical practice guidelines into a six-element bundle delivered by an interprofessional team at the bedside. The goals of the bundle include: optimizing pain management, shortening the duration of mechanical ventilation, minimizing the use of sedating medications, and reducing the incidence and duration of delirium and ICU-acquired weakness, largely by keeping the patient as physically and cognitively engaged as possible through early mobilization and family engagement. In addition to these short-term goals, incorporation of the ABCDEF bundle is one major strategy to decrease the risk of PICS. The ABCDEF bundle includes: Assess, prevent, and manage pain, Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT), Choice of analgesia and sedation, Delirium: assess, prevent, and manage, Early mobility and exercise, and Family engagement and empowerment. The bundle, whose elements are interdependent and synergistic, has demonstrated significant efficacy in improving several outcomes in critically ill patients, but compliance with the bundle is still suboptimal worldwide. Accordingly, many institutions utilize ‘checklists’ as cognitive aides to enhance bundle adherence with modest success.

Delirium is an acute disturbance in mental status characterized by fluctuations in cognition and attention that affects more than 2.6 million hospitalized older adults in the United States annually, a rate that is expected to increase with the aging population. Delirium is associated with a myriad of poor outcomes, including prolonged hospital stay and readmission, loss of independence, new or accelerated cognitive impairment, and death. The relationship between delirium and dementia is complex, as dementia is one of the most significant risk factors for delirium, and delirium is independently associated with an increased risk of subsequent cognitive decline. Here, we provide a current review on the epidemiology, evaluation and management of older adults with delirium, focusing on those instances where it can be mistaken for a dementing illness.

Galen system is based on three pillars: the affected body part, the type of qualities imbalanced, and the degree of imbalance. Therefore, he only distinguishes between mental illness and impaired consciousness when there is a difference between these two entities in any of these three pillars. Thus, he distinguishes phrenitis from melancholia but not from mania. The emphasis on the system, on the other hand, enables him a very tight notion of disease, where symptoms, mechanisms, affected organ and treatment are closely linked.

4 Post-Hellenistic authors present a more compartmentalised idea of diseases in general and of impaired consciousness in particular. Unlike the Hippocratics, who barely discussed mental illness, these authors did distinguish impaired consciousness from mental illness through a classificatory system of dichotomic oppositions, additionally they discussed new conditions which are not mentioned in the HC. In most theorisations, perceptions play an increasingly relevant role to understand these conditions.

A diachronic look at the contrast between mental illness and impaired consciousness among these ancient doctors shows a trend towards a more compartmentalised idea of these conditions, a stronger notion of disease, and a progressive abstract framing of clinical findings into theoretical classificatory models and comprehensive pathophysiological systems.

This introductory chapter presents and contextualises the main sources under study, and addresses the problems of a definition of consciousness. Given the vagueness of the notion, a working definition is proposed, which is based on cognitive model that uses three prototypical clinical presentations of impaired consciousness: delirium, sleep and fainting.

Contrary to mainstream scholarship’s opinion, the Hippocratic corpus presents many cases of impaired consciousness, but only a few of mental illness. By looking at three study cases, this chapter describes how these doctors understood conditions where patients act weirdly or were not their usual selves, and how they construed the notion of disease.

In face of the difficulty of establishing clear biological boundaries between sleep and the other forms of impaired consciousness, the sociological and anthropological analyses can provide hints as to where those limits were set in real life. The terminological analysis suggested a common feature that persisted throughout the different authors and periods: different levels of consciousness (from drowsy to hyperactive, and from delirium to koma) where always related to the impairment of mental capacities, regardless of the way in which each medical writer grouped or understood them.

Unlike mental disease, which presupposes a strongly theory-laden concept, impaired consciousness or delirium is currently conceived in medicine as a cluster of symptoms. This chapter contrasts these two constructs, and discusses our current idea about the notion of disease.