Elsevier

General Hospital Psychiatry

Volume 23, Issue 2, March–April 2001, Pages 90-96
General Hospital Psychiatry

Law, ethics, and psychiatry
The relationship between cognitive performance and employment and health status in long-term survivors of the acute respiratory distress syndrome: results of an exploratory study

https://doi.org/10.1016/S0163-8343(01)00123-2Get rights and content

Abstract

Survivors of acute respiratory distress syndrome (ARDS) are at risk for long-lasting cognitive decline due to hypoxemia, sepsis and/or psychological sequelae associated with aggressive supportive care in the intensive care unit (ICU). We conducted an exploratory study to assess cognitive performance in long-term survivors of ARDS and to investigate how cognitive functioning is related to employment status and health-related quality of life (HRQOL). At median time of 6.0 years after ICU discharge, forty-six ARDS survivors were tested with SKT, a short cognitive performance test for assessing deficits of memory and attention. A measure of HRQOL (SF-36 Health Status Questionnaire) was also administered, and in a brief psychiatric interview, employment status was rated. 23.9% (n=11) of the patients showed cognitive impairments. However, no extreme and severe cognitive deficits were recorded. They primarily revealed low levels of cognitive function in various tasks assessing attention skills. Disability was found in 41.3% (n=19) of the patients. All ARDS survivors with cognitive deficits were disabled, whereas only 22.9% (n=8) of the cognitively not impaired patients gave evidence of disability. The SF-36 values of the ARDS survivors indicated impaired health status on seven out of eight domains when compared to normative population data. Patients with cognitive deficits described the lowest HRQOL with major limitations in the domains role-physical and social functioning when compared to patients without cognitive impairments. In conclusion, long-term ARDS survivors exhibit impaired health status and the presence of cognitive deficits is associated with disability and considerable impairments in HRQOL. More detailed psychiatric research is required to establish the etiology of these cognitive impairments.

Introduction

During the past 30 years, intensive care treatment of critically ill patients has tremendously improved associated with significant advances in modern technology. Apparently, these exciting medical achievements have fundamental implications for modern consultation-liaison psychiatry, as they have an important impact on the survivors’ psychosocial outcome [9]. Hence, the success of intensive care management of severe diseases such as acute respiratory distress syndrome (ARDS) is no longer judged solely by its effects on survival but by its influence on patients’ psychosocial well-being [6].

Outcome studies of ARDS survivors mainly focus on survival rates and pulmonary function outcomes (e.g. [27]), whereas studies on health-related quality of life in these patients are rare [20], [23]. Moreover, only one study has investigated cognitive and psychological outcomes in ARDS survivors [14]. This prospective 1-yr outcome study has shown that 100% of these patients experienced cognitive impairments at hospital discharge, and 30% of them still exhibited generalized cognitive decline at 1 year-follow-up. The pathogenesis of these cognitive problems was not clear. The authors found that the studied ARDS survivors suffered prolonged hypoxemia while on ICU that could lead to brain injury. Alternately, it was discussed whether sepsis that represents a principal reason for the development of ARDS might result in cognitive decline due to its brain-injuring toxic effects.

To our knowledge, no study has examined cognitive performance and its influence on employment status and health-related quality of life in long-term survivors of ARDS. As ARDS survivors are more concerned about quality of life than longevity [23], comprehensive measurements targeting psychosocial adaptation after recovery from ARDS in the long-term course are of paramount importance. C/L-psychiatrists and other health-care providers thus will be able to enhance appropriate counseling of ARDS survivors and their relatives.

The main purpose of this exploratory study was to assess cognitive performance in long-term ARDS survivors admitted to a 20-bed multidisciplinary ICU of a tertiary care university hospital, and to investigate how cognitive functioning is related to employment status and health-related quality of life.

Section snippets

Subjects

Of 192 ARDS patients consecutively admitted to the Department of Anaesthesiology at the Klinikum Grosshadern (Ludwigs-Maximilians University, Munich, Germany), a major referral and tertiary care center, 119 patients survived and were discharged between January 1985 and January 1995. On retrospective analyses, all patients met the ARDS criteria of the American-European Consensus Conference for ARDS founded in 1994 [4].

In 1998, this C/L–psychiatric exploratory study was conducted to assess

Cognitive outcome

Based on thorough history taking of the patients’ educational and vocational levels, two different levels of premorbid intelligence could be determined in the entire sample: 37 of 46 ARDS survivors (80.4%) were assigned an IQ from 90 to 110, 9 of them (19.6%) were given an IQ over 110. Considering these retrospectively assessed levels of premorbid intelligence and taking into account the four age groups (aged from 18 to 44; 45 to 54; 55 to 64; and older than 65 years of age; see Table 1), we

Discussion

To summarize, first, we found that over three-fourths of patients in our sample of ARDS survivors did not display signs of cognitive impairments at median time of 6.0 years after ICU discharge. This was a main finding in terms of the natural history of cognitive performance following ARDS. As we know from the only study published in the literature targeting cognitive sequelae after ARDS as the primary outcome variable, the prevalence rate of cognitive impairments was 100% at the time of

Acknowledgements

The authors wish to thank Hartmut Lehfeld, Ph.D., for providing age-related reference scores from the SKT data bank available at GEROMED GmbH, Erlangen, Germany.

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    This study was supported by grants from the Eli-Lilly Foundation, Bad Homburg, Germany.

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