title: Brain dysfunction: another burden for the chronically critically ill.
abstract: BACKGROUND
  Chronic critical illness is a devastating syndrome of prolonged respiratory failure and other derangements. To our knowledge, no previous research has addressed brain dysfunction in the chronically critically ill, although this topic is important for medical decision making.
  
  
  METHODS
  We studied a prospective cohort of 203 consecutive, chronically critically ill adults transferred to our hospital's respiratory care unit (RCU) after tracheotomy for failure to wean. We measured prevalence and duration of coma and delirium during RCU treatment using the Confusion Assessment Method for the Intensive Care Unit with the Richmond Agitation-Sedation Scale. To assess survivors (at 3 and 6 months after RCU discharge), we used a validated telephone Confusion Assessment Method.
  
  
  RESULTS
  Before hospitalization, most (153 [75.4%]) of the 203 patients in the study were at home, completely independent (115 [56.7%]), and cognitively intact (116 [82.0%]). In the RCU, 61 (30.0%) were comatose throughout the stay. Approximately half of patients (66 of 142) who were not in coma were delirious. Patients spent an average of 17.9 days (range, 1-153 days) in coma or delirium (average RCU stay, 25.6 days). Half of survivors (79 of 160) had one of these disturbances at RCU discharge. At 6 months, three fourths (151) of the study patients were dead or institutionalized; of 85 survivors, 58 (68.2%) were too profoundly impaired to respond to telephone cognitive assessment, and 53 (62.4%) were dependent in all activities of daily living.
  
  
  CONCLUSIONS
  Severe, prolonged, and permanent brain dysfunction is a prominent feature of chronic critical illness. These data, together with previous reports of symptom distress and rates of mortality and institutionalization, describe burdens for chronically critically ill patients receiving continued life-prolonging treatment and for their families.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA. judith.nelson@mountsinai.org
authors.forename: Judith E
authors.initials: JE
authors.lastname: Nelson
authors.forename: Nidhi
authors.initials: N
authors.lastname: Tandon
authors.forename: Alice F
authors.initials: AF
authors.lastname: Mercado
authors.forename: Sharon L
authors.initials: SL
authors.lastname: Camhi
authors.forename: E Wesley
authors.initials: EW
authors.lastname: Ely
authors.forename: R Sean
authors.initials: RS
authors.lastname: Morrison
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014150:Antipsychotic Agents / Q000627:therapeutic use; D002908:Chronic Disease; D003072:Cognition Disorders / Q000453:epidemiology*; D003128:Coma / Q000453:epidemiology*; D016638:Critical Illness; D003693:Delirium / Q000453:epidemiology*; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007326:Institutionalization / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009294:Narcotics / Q000627:therapeutic use; D009483:Neuropsychological Tests; D009518:New York / Q000453:epidemiology; D011446:Prospective Studies; D012124:Respiratory Care Units; D014140:Tracheotomy
chemical_list: D014150:Antipsychotic Agents; D006993:Hypnotics and Sedatives; D009294:Narcotics