1 Section of Pulmonary, Critical Care, and Sleep Medicine, and.
2 Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
Ann Am Thorac Soc. 2018 May;15(5):622-629. doi: 10.1513/AnnalsATS.201709-702OC.
Cognitive impairment is common among older adults, yet little is known about the association of pre-intensive care unit cognitive status with outcomes relevant to older adults maintaining independence after a critical illness.
To evaluate whether pre-intensive care unit cognitive status is associated with post-intensive care unit disability, new nursing home admission, and mortality after a critical illness among older adults.
In this prospective cohort study, 754 persons aged 70 years or more were monitored from March 1998 to December 2013 with monthly assessments of disability. Cognitive status was assessed every 18 months, using the Mini-Mental State Examination (range, 0-30), with scores classified as 28 or higher (cognitively intact), 24-27 (minimal impairment), and less than 24 (moderate impairment). The primary outcome was disability count (range, 0-13), assessed monthly over 6 months after an intensive care unit stay. The secondary outcomes were incident nursing home admission and time to death after intensive care unit admission. The analytic sample included 391 intensive care unit admissions.
The mean age was 83.5 years. The prevalence of moderate impairment, minimal impairment, and intact cognition (the comparison group) was 17.3, 46.2, and 36.5%, respectively. In the multivariable analysis, moderate impairment was associated with nearly a 20% increase in disability over the 6-month follow-up period (adjusted relative risk, 1.19; 95% confidence interval, 1.04-1.36), and minimal impairment was associated with a 16% increase in post-intensive care unit disability (adjusted relative risk, 1.16; 95% confidence interval, 1.02-1.32). Moderate impairment was associated with more than double the likelihood of a new nursing home admission (adjusted odds ratio, 2.37; 95% confidence interval, 1.01-5.55). Survival differed significantly across the three cognitive groups (log-rank P = 0.002), but neither moderate impairment (adjusted hazard ratio, 1.19; 95% confidence interval, 0.65-2.19) nor minimal impairment (adjusted hazard ratio, 1.00; 95% confidence interval, 0.61-1.62) was significantly associated with mortality in the multivariable analysis.
Among older adults, any impairment (even minimal) in pre-intensive care unit cognitive status was associated with an increase in post-intensive care unit disability over the 6 months after a critical illness; moderate cognitive impairment doubled the likelihood of a new nursing home admission. Pre-intensive care unit cognitive impairment was not associated with mortality from intensive care unit admission through 6 months of follow-up. Pre-intensive care unit cognitive status may provide prognostic information about the likelihood of older adults maintaining independence after a critical illness.
认知障碍在老年人中很常见，但对于入住重症监护病房前的认知状态与老年人在重症疾病后保持独立相关的结局之间的关系知之甚少。
评估入住重症监护病房前的认知状态与重症疾病后入住重症监护病房的失能、新入住养老院和死亡之间的关系。
在这项前瞻性队列研究中，754 名年龄在 70 岁或以上的患者从 1998 年 3 月至 2013 年 12 月接受了每月一次的残疾评估。认知状态每 18 个月用简易精神状态检查（范围为 0-30）评估一次，评分 28 分或以上为认知正常（28 分或以上），24-27 分为轻度损害，低于 24 分为中度损害。主要结局是失能计数（范围为 0-13），在入住重症监护病房后 6 个月内每月评估一次。次要结局是入住重症监护病房后的新入住养老院和死亡时间。分析样本包括 391 例入住重症监护病房的患者。
平均年龄为 83.5 岁。中度损害、轻度损害和认知正常（对照组）的患病率分别为 17.3%、46.2%和 36.5%。多变量分析显示，中度损害与 6 个月随访期间失能增加近 20%相关（调整后的相对风险，1.19；95%置信区间，1.04-1.36），轻度损害与入住重症监护病房后失能增加 16%相关（调整后的相对风险，1.16；95%置信区间，1.02-1.32）。中度损害与新入住养老院的可能性增加两倍以上相关（调整后的优势比，2.37；95%置信区间，1.01-5.55）。三个认知组之间的生存情况差异显著（对数秩 P=0.002），但中度损害（调整后的危险比，1.19；95%置信区间，0.65-2.19）和轻度损害（调整后的危险比，1.00；95%置信区间，0.61-1.62）在多变量分析中均与死亡率无显著相关性。
在老年人中，入住重症监护病房前任何程度的认知障碍（即使是轻度障碍）都会导致重症疾病后 6 个月内失能增加；中度认知障碍使新入住养老院的可能性增加一倍。入住重症监护病房前的认知障碍与重症监护病房入住后 6 个月内的死亡率无显著相关性。入住重症监护病房前的认知状态可能提供关于老年人在重症疾病后保持独立的可能性的预后信息。
