Version May 2024
INTRODUCTION — Many survivors of critical illness experience impairment in cognition, mental health, and physical function, known as post-intensive care syndrome (PICS). The mental health of caregiver/family members may also be adversely affected, which is termed PICS-family (PICS-F).
In this topic, we review the epidemiology, clinical manifestations, and diagnostic evaluation of PICS and PICS-F. The prevention, management, and prognosis of PICS and PICS-F, and outcomes in survivors of acute respiratory distress syndrome, cardiac arrest, and coronavirus disease 2019 (COVID-19) are discussed separately.
●(See "Post-intensive care syndrome (PICS): Treatment and prognosis".)
●(See "Prognosis and outcomes following sudden cardiac arrest in adults".)
●(See "Acute respiratory distress syndrome: Prognosis and outcomes in adults".)
DEFINITIONS
PICS — While there is no official definition for PICS, most clinicians agree that PICS constitutes new or worsening function in one or more of the following domains after critical illness (figure 1) [1]:
●Cognitive function
●Psychiatric function
●Physical function
This definition applies to adult patients who are discharged from the intensive care unit (ICU) and reside in long-term acute care rehabilitation units, in skilled nursing facilities, or at home but excludes patients admitted with traumatic brain injury and stroke.
PICS can also occur in pediatric patients (PICS-p) following critical illness but is not covered in this topic. The components are similar to adult PICS but also include a fourth domain of social health [2].
PICS-F — The term post-intensive care syndrome-family (PICS-F) has been coined to encompass the acute and chronic psychological morbidity among critically ill patients' caregiver/family members [1]. It is considered the caregiver/family response to the stress of critical illness in a loved one. It includes the symptoms that are experienced by caregiver/family members during the critical illness as well as those that occur following death or discharge of a loved one from the ICU. (See 'Post-intensive care syndrome-family' below.)
EPIDEMIOLOGY — Reported rates of PICS vary considerably due to differences in the study population, periods of follow-up, and methods of assessing impairment. Although the exact prevalence of PICS among survivors of critical illness is unknown, one-half or more will suffer from some component of PICS (cognitive, psychiatric, physical dysfunction) [3-8]. In an observational cohort study of survivors of critical illness who received life support in the intensive care unit, a significant proportion had newly acquired cognitive impairment, depression, and/or disability in activities of daily living at three months (64 percent) and 12 months (56 percent) [8].
The incidence of the individual components of PICS following critical illness (ie, cognitive, psychiatric, and physical dysfunction) is discussed in the respective sections below. (See 'Cognitive impairment' below and 'Psychiatric impairment' below and 'Physical impairment' below.)
The incidence of PICS-type symptoms following acute respiratory distress syndrome, extracorporeal membrane oxygenation, and COVID-19 and the incidence of PICS-family (PICS-F) are discussed in detail separately.
●(See 'Post-intensive care syndrome-family' below.)
RISK FACTORS — Risk factors for the development of PICS vary depending on the component of PICS that is studied [9]. These risk factors can be broadly categorized into the following (table 1):
●Pre-existing factors (eg, neuromuscular disorders, cognitive impairment, psychiatric illness, comorbid conditions, functional decline, frailty, socioeconomic disadvantage, older age [8,10-12]).
●Intensive care unit (ICU)-specific factors (eg, mechanical ventilation, acute delirium, sepsis, shock, hypoxemia, acute respiratory distress syndrome [ARDS], unintentional routine or home medication disruption, glucose dysregulation, sedative medications [13-15]).
The relative contribution of individual risk factors has not been addressed.
Risk factors for the three individual domains of PICS have also been identified. Major and minor risk factors for cognitive [5,8,16-23], psychiatric [24-34], and physical [18,35-42] domains of PICS are listed in the table (table 2). Data support similar risk factors in patients with ARDS. These data and general risk factors for cognitive dysfunction, depression, anxiety, posttraumatic stress disorder, and ICU-acquired weakness are discussed separately:
●(See "Evaluation of cognitive impairment and dementia", section on 'Causes'.)
●(See "Neuromuscular weakness related to critical illness", section on 'Epidemiology and risk factors'.)
The pathogenesis of PICS is likely complex and multifactorial. Possible mechanisms include ischemia, neuro- and systemic-inflammation, disruption of the blood-brain barrier and white matter integrity, and disuse muscle atrophy [43-48].
CLINICAL FEATURES — The clinical presentation of PICS includes a constellation of cognitive, psychiatric, and physical signs and symptoms with the hallmark feature that they are newly recognized or worsened after a critical illness. Common symptoms include poor concentration, fatigue, anxiety, depressed mood, symptoms of posttraumatic stress disorder (PTSD), generalized weakness, and poor mobility. Symptoms are corroborated by examination, formal testing (eg, cognitive and psychiatric questionnaires), and appropriate consultation (eg, occupational and physical therapist, neuropsychologist, psychiatrist).
A complex relationship exists between the three individual domains of PICS, with impairment in one domain frequently being associated with new or worsening function in a separate domain [7,49,50]. A more detailed description of the clinical manifestations of the individual domains of PICS are described in the sections below. (See 'Cognitive impairment' below and 'Psychiatric impairment' below and 'Physical impairment' below.)
Data that describe PICS-type symptoms in acute respiratory distress syndrome (ARDS) and COVID-19 are provided separately. (See "COVID-19: Evaluation and management of adults with persistent symptoms following acute illness ("Long COVID")", section on 'Persistent symptoms' and "Acute respiratory distress syndrome: Prognosis and outcomes in adults", section on 'Morbidity among survivors'.)
Cognitive impairment
Incidence — Cognitive impairment after critical illness has been reported to occur in approximately 25 percent of survivors with some studies reporting an incidence as high as 78 percent [4,5,16,18,51,52]. The incidence of cognitive impairment was best illustrated by a prospective study of 821 patients that examined the long-term cognitive effects of critical illness in patients admitted to medical or surgical intensive care units (ICUs) with shock and/or respiratory failure requiring mechanical ventilation (the BRAIN-ICU Study) [5]. While at baseline 6 percent had cognitive impairment, at three months post-discharge 40 percent had deficits that were similar to patients with moderate traumatic brain injury and 26 percent had deficits that were similar to mild dementia. At 12 months post-discharge, the deficits persisted in most patients.
Symptoms and signs — The severity of cognitive impairment varies from subtle difficulties in accomplishing complex executive tasks to a profound inability to conduct activities of daily living (ADLs).
The areas of cognition that are commonly affected in PICS include the following:
●Attention/concentration
●Memory
●Mental processing speed
●Executive function
Memory and executive function are domains that frequently prohibit individuals from engaging in purposeful, goal-directed behaviors that are necessary for effective daily functioning and complex cognition [53]. For example, these functions are critical to effectively carry out a discharge plan, further impairing recovery (eg, medication adherence, dietary restrictions, scheduling and maintaining appointments).
Further details regarding the clinical manifestations of cognitive impairment are provided separately. (See "Evaluation of cognitive impairment and dementia", section on 'Clinical presentation'.)
Psychiatric impairment
Incidence — Reported rates of psychiatric illnesses are common among survivors of critical illness, but rates vary, ranging from 1 to 62 percent, depending on the type of disorder reported [5,25-27,43,54,55]. Several older observational cohorts of critical illness survivors reported rates of depressive and PTSD symptoms as 28 and 22 percent, respectively [56,57]. Subsequent studies have reported that 37 percent of patients experience symptoms of depression [5] and 10 percent experience symptoms of PTSD [27].
Symptoms and signs — The mood disorders most commonly encountered in patients with PICS include anxiety, depression, and PTSD [25-27,56-58].
Common symptoms of each disorder are discussed in the linked topics:
●Anxiety – Excessive worry, irritability, restlessness, and fatigue (table 3). (See "Comorbid anxiety and depression in adults: Epidemiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)
●Depression – Fatigue, loss of interest, poor appetite, sense of hopelessness, and insomnia (table 3). (See "Comorbid anxiety and depression in adults: Epidemiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations' and "Unipolar depression in adults: Clinical features".)
●PTSD – Affective and behavioral responses to stimuli that provoke flashbacks, hyperarousal, and severe anxiety; sexual dysfunction; and intrusive recollection and avoidance of experiences that evoke symptoms. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Clinical manifestations'.)
Survivors of critical illness may have increased risk of suicide and self-harm. One retrospective study reported that survivors of critical illness had a higher risk of suicide and self-harm compared with non-ICU hospital survivors (hazard ratio [HR] 1.22, 95% CI 1.11-1.33; HR 1.15, 95% CI 1.12-1.19, respectively) [59]. Factors associated with suicide or self-harm included previous depression, anxiety, or PTSD; invasive mechanical ventilation; and renal replacement therapy.
Physical impairment — Physical impairment in PICS is most often due to ICU-acquired weakness. Additional morbidities may compound or contribute to physical dysfunction, including contractures, poor lung function, malnutrition, and poor sleep.
ICU-acquired weakness
●Incidence – ICU-acquired weakness is the most common form of physical impairment occurring in 25 percent or more of ICU survivors. In a large cohort of ventilated patients, at three months 32 percent of patients were disabled in their ADLs and 26 percent were disabled in instrumental ADLs [5]. Disability was prominent in those with and without pre-existing functional disability. Disabilities persisted in most patients at 12 months.
●Symptoms and signs – This group of disorders encompasses patients with ill-defined generalized muscle weakness and poor mobility as well as patients with well-defined signs and symptoms of critical illness myopathy (CIM; flaccid quadriparesis), critical illness polyneuropathy (CIP; limb muscle weakness and atrophy), combined CIM/CIP, and prolonged neuromuscular blockade (quadriparesis). ICU-acquired weakness can result in prolonged mechanical ventilation and functional disability, including disabilities in regular ADLs (eg, personal hygiene),and instrumental ADLs (eg, ability to take medications, perform housework) [3,5,6,35,60,61].
Additional details regarding the clinical presentation of neuromuscular weakness related to critical illness is discussed in detail separately. (See "Neuromuscular weakness related to critical illness", section on 'Clinical manifestations'.)
Other — Other manifestations that may contribute to impaired physical dysfunction in PICS include the following:
●Contractures and limb function – Joint contractures develop as a complication of prolonged immobility. In a study of patients admitted for 14 days or more in the ICU, 34 percent of patients had a functionally significant contracture at ICU discharge, which persisted in the majority of these patients throughout the hospitalization [62]. The most commonly affected joints were the elbow and ankle, followed by the hip and knee. The use of glucocorticoids was found to be a protective factor in this study.
Upper limb disability, related to shoulder impairment, is also common after critical illness. In a study of patients receiving ICU care for three or more days, 47 percent of patients experienced upper limb dysfunction at six months [63].
●Reduced lung function – Reduced lung function in critically ill patients can occur due to mechanical ventilation-induced lung inflammation or respiratory muscle weakness (including undiagnosed diaphragmatic paralysis). While respiratory muscle weakness may be due to an underlying neuromuscular disorder, it is more commonly a form of ICU-acquired weakness that does not necessarily correlate with peripheral weakness. Reduced lung function from critical illness is best studied in patients with ARDS. ARDS-related lung dysfunction and the etiologies associated with respiratory muscle weakness are discussed separately. (See "Acute respiratory distress syndrome: Prognosis and outcomes in adults", section on 'Morbidity among survivors' and "Respiratory muscle weakness due to neuromuscular disease: Clinical manifestations and evaluation".)
In spontaneously breathing patients, symptoms of lung dysfunction include dyspnea and fatigue while in ventilated patients, it may present as failure to wean from mechanical ventilation. The clinical presentation of patients with respiratory muscle weakness is discussed separately.
•(See "Respiratory muscle weakness due to neuromuscular disease: Clinical manifestations and evaluation".)
●Malnutrition – Weight loss is common during critical illness, especially in patients receiving mechanical ventilation for ARDS [64]. Although the relationship is unproven, malnutrition likely contributes to the subjective weakness and reduction in exercise capacity in this population. Indicators of malnutrition are discussed separately. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription".)
●Poor sleep – Sleep disturbance is common following critical illness. One review of 22 studies reported that roughly 50 to 66 percent of critically ill patients experience sleep disturbance at one month after hospital discharge that improves over time [65]. The manifestations of excessive daytime sleepiness are provided separately. (See "Approach to the patient with excessive daytime sleepiness", section on 'History' and "Approach to the patient with excessive daytime sleepiness", section on 'Physical examination'.)
DIAGNOSTIC EVALUATION — A high index of suspicion is critical for the identification of PICS. PICS can be identified in the immediate period following a critical illness. However, because symptoms are long-lasting (6 to 12 months or longer) and the condition is underrecognized [66], PICS may not be detected for a prolonged period after critical illness has resolved [1]. Increased health care utilization is very common in the first 90 days after discharge, which is an opportunity for clinicians to evaluate patients with this diagnosis in mind.
Timing of evaluation — In our practice, we follow the Society of Critical Care Medicine (SCCM) consensus statement recommendations regarding the detection of PICS [9].
●Who to evaluate – We evaluate every survivor of critical illness for the cognitive, psychiatric, and physical signs and symptoms of PICS. However, those considered at the highest risk of PICS should be prioritized for evaluation and are listed in the table (table 4).
●When to evaluate – We perform early and serial assessment. This begins during intensive care unit (ICU) admission and continues as part of the ICU to floor handoff through to pre- and post-discharge assessment (ie, within two to four weeks of hospital discharge and continued throughout recovery) (figure 2).
Beginning evaluation in the ICU is particularly important for those with suspected ICU-acquired weakness. Early assessment identifies those with weakness who might begin therapy early in their course (ie, during ICU admission). Subsequently, patients should be reassessed in the rehabilitation setting or at home to determine functional disabilities that affect activities of daily living (ADLs; eg, bathing and dressing) and eating (eg, swallowing function) as well as disabilities that require medical or social support [67,68]. (See "Office-based assessment of the older adult" and "Comprehensive geriatric assessment".)
Initial clinical evaluation — In survivors of critical illness, we assess for the three domains of PICS.
●Cognitive assessment – Following critical illness, we perform clinical assessment for cognitive deficits, if feasible. The rationale for this approach is based upon the benefits of cognitive rehabilitation in those with traumatic brain injury and stroke and the potential to improve executive dysfunction in survivors of critical illness [69-71].
Our approach is similar to that in other patients who have suspected cognitive dysfunction. Every patient should be asked about memory deficits, concentration, and ability to perform executive tasks. However, in some patients following critical illness, impaired communication may contribute to this assessment. Thus, obtaining a collateral history from the caregiver or medical chart is particularly important. Details regarding essential components of this history and examination are discussed separately. (See "Evaluation of cognitive impairment and dementia", section on 'History' and "Evaluation of cognitive impairment and dementia", section on 'Physical examination'.)
●Psychiatric assessment – For every patient, we also assess for the most common symptoms of anxiety and depression (table 3) and posttraumatic stress disorder (PTSD) (see 'Symptoms and signs' above). Further details regarding these assessments are provided separately.
•Anxiety – (See "Comorbid anxiety and depression in adults: Epidemiology, clinical manifestations, and diagnosis", section on 'Assessment and diagnosis'.)
•Depression – (See "Unipolar depression in adults: Assessment and diagnosis" and "Suicidal ideation and behavior in adults", section on 'Patient evaluation'.)
●Physical weakness assessment – Our initial assessment involves a preliminary history and examination for physical strength, mobility, ADLs, joint contractures, as well as a neurologic and cardiopulmonary system examination. The components of this evaluation are discussed in detail separately. (See "Neuromuscular weakness related to critical illness", section on 'Initial evaluation'.)
We also enquire about dyspnea that may be limiting their exercise tolerance. (See "Approach to the patient with dyspnea", section on 'Clinical assessment'.)
We also assess nutritional status and ask patients about their sleep habits and sleep quality that may be contributing to daytime fatigue. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription" and "Insufficient sleep: Evaluation and management".)
Subsequent testing — Clinical findings of suspected dysfunction are typically corroborated by formal testing (eg, cognitive and psychiatric rating tools), and appropriate consultation (eg, occupational and physical therapist, neuropsychologist, psychiatrist) that may involve the following:
●Cognitive rating tools – In those with suspected cognitive dysfunction during clinical evaluation, we use validated cognitive impairment screening tests to formally assess cognition. Consultation with neuropsychology is also appropriate in select patients. Our approach is, in general similar to other patients with suspected cognitive dysfunction. However, we agree with the SCCM and prefer the Montreal cognitive assessment (MoCA) score for the evaluation of patients with suspected cognitive dysfunction following a critical illness [9]. We do not use the modified mini-mental state examination or Mini-Cog since in ICU survivors these tests perform poorly [72]. (See "Evaluation of cognitive impairment and dementia", section on 'Cognitive testing' and "Mental status scales to evaluate cognition" and "The mental status examination in adults".)
This preference is based upon the observation that the MoCA score, which incorporates an assessment of executive function abilities, is a more sensitive test for mild impairment [73]. A MoCA score <26 indicates mild cognitive impairment and a score <18 indicates moderate to severe cognitive impairment consistent with dementia. Whether cognitive impairment identified using the MoCA score predicts long-term impairment is unknown. Detailed discussion of MoCA is found separately. (See "Mental status scales to evaluate cognition", section on 'Montreal Cognitive Assessment (MoCA)'.)
●Psychiatric rating tools – Our approach is, in general, similar to other patients with suspected psychological dysfunction. When anxiety, depression, or PTSD are suspected, we use anxiety, depression, and PTSD "screening" questionnaires. Formal consultation with psychiatry is also appropriate in select patients and those who "screen" positive.
No optimal questionnaire exists [6,74-82]. Based upon our clinical experience and supported by the SCCM [9], our preferred mental health screening scales are the following:
•Hospital anxiety and depression scale (HADS) – We use HADS to assess for symptoms of depression and anxiety [9,79]. As an alternative, the Beck Depression Inventory and Beck Anxiety Inventory may also be used.
•Impact of events scale-revised (IES-R) and the six-item impact of event scale-6 (IES-6) – We use IES tools to evaluate for PTSD since they are reliable screening tools for PTSD symptoms and have been validated in patients with acute respiratory distress syndrome [9,83,84]. Alternatively, posttraumatic stress syndrome 10-questions inventory (PTSS-10) may be used.
Additional tools that have been validated in other populations are in the tables (table 5 and table 6 and table 7) and are discussed separately.
•Anxiety – (See "Comorbid anxiety and depression in adults: Epidemiology, clinical manifestations, and diagnosis", section on 'Rating scales'.)
•Depression – (See "Screening for depression in adults", section on 'Screening tests'.)
●Physical function testing
•Suspected ICU-acquired weakness – In cases of suspected ICU-acquired weakness, we use the six-minute walk test (6MWT) or EuroQol-5D-5L to assess physical function, as supported by the SCCM. Rarely is neurophysiologic testing or muscle biopsy performed unless another important neuromuscular disorder is suspected. Consultation with occupational and physical therapy is key to this evaluation. The components of this evaluation are discussed in detail separately. (See "Neuromuscular weakness related to critical illness", section on 'Evaluation and diagnosis'.)
•Suspected lung dysfunction – For all mobile patients reporting symptoms, we perform exercise tolerance with a 6MWT. Full cardiopulmonary exercise testing is not typically performed. (See "Overview of pulmonary function testing in adults", section on 'Six-minute walk test'.)
For select patients, particularly those who are extubated following mechanical ventilation or those with previous underlying lung dysfunction, we perform a full set of pulmonary function tests (spirometry, lung volumes, and diffusing capacity), most often as an outpatient. (See "Overview of pulmonary function testing in adults".)
Additional tests for the detection of respiratory muscle weakness including diaphragmatic testing are discussed separately. (See "Respiratory muscle weakness due to neuromuscular disease: Clinical manifestations and evaluation", section on 'Respiratory muscle strength testing' and "Diagnosis and management of nontraumatic unilateral diaphragmatic paralysis (complete or partial) in adults", section on 'Diagnostic evaluation' and "Diagnostic evaluation of adults with bilateral diaphragm paralysis".)
•Suspected malnutrition – We typically have patients evaluated by a nutrition expert to assess level of nutrition for future goal setting. Nutritional needs vary over the course of recovery such that multiple assessments are typically needed. (See "Dietary assessment in adults" and "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription".)
•Poor quality sleep – Rarely is a sleep study needed unless obstructive sleep apnea or other sleep disturbance is suspected on clinical evaluation. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Diagnostic tests'.)
●Laboratory testing and chest imaging — There are no laboratory tests that diagnose or are characteristic of PICS. However, on initial evaluation, we routinely perform a complete blood count and differential, chemistries, iron and vitamin B12 levels, thyroid stimulating hormone, liver function tests, and chest radiography. This testing is aimed at detecting nutritional deficiencies and organic pathologies that need to be excluded before a diagnosis of PICS can be made. (See 'Differential diagnosis' below.)
DIFFERENTIAL DIAGNOSIS — Important conditions to distinguish from PICS include the following:
●Pre-existing illnesses – The presence and severity of prior existing cognitive, mental, or physical impairments needs to be evaluated to identify unchanged, as well as, new or worsening symptoms following a critical illness. Unchanged symptoms do not support a diagnosis of PICS. Examples of pre-existing illnesses include prior cognitive deficits from developmental defects, dementia or traumatic brain injury, other prior comorbidities such as anxiety or panic disorder, depression or schizoaffective disorder, substance abuse, and physical ailments including failure to thrive and neuromuscular disorders (eg, multiple sclerosis and amyotrophic lateral sclerosis).
We engage caregivers/family members since identifying the presence and nature of pre-existing disease can be challenging in the intensive care unit (ICU) survivor who may not have the cognitive capacity to compare their current status with symptoms prior to their admission or in whom a prior existing illness is not known (eg, cognitive deficit from chronic substance abuse or mild dementia). (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Differential diagnosis' and "Unipolar depression in adults: Assessment and diagnosis", section on 'Differential diagnosis'.)
●Organic causes of symptoms that mimic PICS – Conditions including stroke, hypothyroidism, hyperthyroidism, vitamin B12 deficiency, anemia, cancer, and obstructive sleep apnea occasionally mimic the cognitive, psychological, and neuromuscular weakness manifestations of PICS.
Some of these causes may be obvious on routine laboratory testing or imaging obtained during the ICU stay or subsequent testing performed during initial evaluation. Alternatively, others are more subtle (eg, sleep apnea). Testing for organic pathology should be directed by the clinical history and examination or prompted in those who respond atypically to rehabilitation and may include computed tomography or magnetic resonance imaging of the brain or a sleep study. Clinical manifestations of important organic disorders in the differential of PICS are discussed separately.
•(See "Treatment of vitamin B12 and folate deficiencies".)
•(See "Clinical manifestations of hypothyroidism".)
•(See "Overview of the clinical manifestations of hyperthyroidism in adults".)
•(See "Overview of paraneoplastic syndromes of the nervous system".)
•(See "Clinical presentation and diagnosis of obstructive sleep apnea in adults".)
●Muscle weakness disorders other than ICU-acquired weakness – Conditions including rhabdomyolysis, cachectic myopathy, and Guillain-Barré syndrome may be confused with ICU-acquired weakness. However, they are usually obvious on admission or identified as the initiating reason for ICU admission and, therefore, do not qualify as PICS.
If alternate etiologies are suspected, electrophysiologic neuromuscular testing and rarely, muscle biopsy or other confirmatory tests may be needed. The indication for testing is usually dependent upon the strength of the suspicion for another disorder and the identification of a disorder where management other than physical rehabilitation will affect the outcome (eg, glucocorticoids for polymyositis). (See "Neuromuscular weakness related to critical illness".)
●Post-hospital syndrome – PICS appears to be distinct from hospitalization-associated disability (also known as "post-hospital syndrome"). Hospitalization, particularly in older patients with noncritical illnesses, can be associated with a number of functional disabilities, which are often transient (days to weeks) [85-87]. In contrast, the manifestations of PICS are wide-ranging and are typically enduring rather than transient [85].
DIAGNOSIS — PICS is diagnosed following critical illness in a patient who has new or worsening function in one or more of the three domains that constitute PICS: cognitive, psychiatric, or physical dysfunction (figure 1). The identification should rely upon the elucidation of specific findings for each domain with confirmatory testing as needed (see 'Clinical features' above) and the exclusion of competing diagnoses. (See 'Differential diagnosis' above.)
The prevention, treatment, and prognosis of PICS are discussed separately. (See "Post-intensive care syndrome (PICS): Treatment and prognosis".)
POST-INTENSIVE CARE SYNDROME-FAMILY — Family members/caregivers of critically ill patients can be affected psychologically by critical illness in a loved one, with effects persisting for months or years after discharge. These effects are termed PICS-family (PICS-F) [88].
Incidence — Over half or more of family members/caregivers of critically ill patients have symptoms of PICS-F by the time of death or discharge of their loved one from the intensive care unit (ICU). Rates decrease over time but remain persistent for months to years. Data to support the rate of individual psychological symptoms are discussed below. (See 'Symptoms and diagnostic evaluation' below.)
Risk factors — Risk factors for PICS-F include poor communication between staff, being in a decision-making role, adult child or spouse of the patient, lower educational level, requirement for long-term care, having a loved one who died or was close to death, and previous history of mental health disorders [89-95]. Risk factors for persistent depression include female sex, younger age, less social support, financial difficulty, lower sense of self-mastery, and lower personal growth scale scores [96,97].
Caregiver burden may also contribute to PICS-F. Between one-quarter and one-half of ICU survivors require long-term caregiver support [98-100]. In many respects, the psychological and financial impact of caring for ICU survivors resembles that of the caregiving burden of chronic illness [101].
Caregiver/family members of pediatric ICU patients compared with adults are less likely to develop the syndrome [88].
Symptoms and diagnostic evaluation — The most common problems experienced by caregiver/family members include anxiety, depression, and posttraumatic stress disorder (PTSD). Given that these symptoms begin in the ICU before discharge or death and may impair decision-making, we have a low threshold to identify PICS-F during the ICU stay [102] and encourage primary care physicians to screen patients at risk for PICS-F for anxiety, depression, and/or PTSD. Symptoms of PICS-F appear to last for months to years.
●Anxiety – At least one-half of caregiver/family members suffer symptoms of anxiety at and shortly after discharge [89,103-105]. The proportion of family members suffering these symptoms remains significant at six months [91,103,106]. These symptoms and the evaluation of anxiety are discussed separately. (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Clinical features and course'.)
●Depression – Depressive symptoms are common in caregiver/family members after discharge and may decrease over time [103,105-107]. Depression occurs among the majority of family members of patients receiving prolonged mechanical ventilation, with 16 percent having persistent and unremitting symptoms one year after discharge [96]. These symptoms and the evaluation of depression are discussed separately. (See "Unipolar depression in adults: Assessment and diagnosis".)
●PTSD – Among caregiver/family members, PTSD symptoms begin even before discharge. At three and six months after discharge, one-third or more of caregiver/family members continue to suffer from PTSD [91,103,105,106]. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis".)
●Others – Other symptoms include sleep deprivation, complicated grief, and financial stress. In one study, more than one-half of the families of ICU survivors had changes in employment; these included arranged leave, reduced work hours, change in employment, or giving up their jobs [3]. In another study, almost one-half of caregivers/family members suffered serious financial stress, which was strongly associated with anxiety and depression [108].
Diagnosis — We diagnose PICS-F in caregivers/family members of critically ill patients who have any psychological sequalae such as anxiety, depression, and/or PTSD that is directly attributed to critical illness in a loved one.
Prevention, treatment, and prognosis of PICS-F are discussed separately. (See "Post-intensive care syndrome (PICS): Treatment and prognosis", section on 'Post-intensive care syndrome-family'.)
Impact of COVID-19 — The COVID-19 pandemic response resulted in significant limitations on family/caregiver presence in the ICU [109]. Limited data suggest that two-thirds of caregiver/family members of patients with COVID-19 suffered symptoms of PTSD, anxiety, and depression especially when a family member died [110-112]. The absence of family presence may have contributed to increasing the duration of delirium among critically ill patients, a risk factor for cognitive dysfunction [113,114]. (See 'Risk factors' above.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Post-intensive care syndrome (PICS) (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition – Post-intensive care syndrome (PICS) is defined as new or worsening cognitive, psychiatric, and/or physical function occurring in a patient after a critical illness. (See 'Definitions' above.)
●Epidemiology – Although the exact prevalence of PICS among critical illness survivors is unknown, it is estimated that one-quarter to one-half or more will suffer from one or more of the three domains of PICS (cognitive, psychiatric, physical dysfunction). (See 'Epidemiology' above.)
●Risk factors – Commonly cited risk factors for the development of PICS are pre-existing conditions and intensive care unit (ICU)-specific factors, which are listed in the tables (table 1 and table 2). (See 'Risk factors' above.)
●Clinical manifestations – Common presenting features of PICS include poor concentration, poor memory, fatigue, anxiety, depressed mood, symptoms of posttraumatic stress disorder (PTSD), muscle weakness, and poor mobility. Additional compounding factors include contractures, poor lung function, malnutrition, and poor sleep. PICS can be identified in the immediate period following a critical illness; however, symptoms are long-lasting (6 to 12 months, sometimes longer). (See 'Clinical features' above.)
●Diagnostic evaluation – PICS is often underrecognized. Thus, a high suspicion is key for diagnosis. (See 'Diagnostic evaluation' above.)
•Early and serial evaluation – Consistent with the Society of Critical Care Medicine consensus statement, we evaluate every survivor of critical illness for the cognitive, psychiatric, and physical signs and symptoms of PICS. However, those considered at the highest risk of PICS should be prioritized for evaluation and are listed in the table (table 4). We also perform early and serial assessment as outlined in the figure (figure 2). (See 'Timing of evaluation' above.)
•Initial clinical evaluation and formal testing – We perform a detailed history and examination for the three components of PICS and corroborate findings with formal testing and appropriate consultation (see 'Initial clinical evaluation' above and 'Subsequent testing' above):
-Cognitive evaluation – Our approach is similar to that in other patients who have suspected cognitive dysfunction. However, we use the Montreal cognitive assessment (MoCA) score as a formal assessment tool. This evaluation is discussed in detail separately. (See 'Initial clinical evaluation' above and 'Subsequent testing' above and "Evaluation of cognitive impairment and dementia".)
-Psychiatric evaluation – Our approach is similar to that in other patients with suspected psychiatric impairment. However, we use the Hospital Anxiety and Depression Scale (HADS) to assess patients with suspected anxiety and depression and the impact of events scale-revised (IES-R) and the six-item impact of event scale-6 (IES-6) to assess for suspected PTSD. This evaluation is discussed in detail separately. (See 'Initial clinical evaluation' above and 'Psychiatric impairment' above and 'Subsequent testing' above and "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis" and "Comorbid anxiety and depression in adults: Epidemiology, clinical manifestations, and diagnosis".)
-Physical evaluation – Our initial assessment involves a preliminary bedside clinical history and examination and a formal assessment by a medical professional trained in the identification of ICU-acquired weakness (usually a physical therapist and an occupational therapist). The components of this evaluation are discussed in detail separately. (See 'Initial clinical evaluation' above and 'Subsequent testing' above and "Neuromuscular weakness related to critical illness".)
For mobile patients reporting symptoms, we perform a six-minute walk test and for select patients, we perform a full set of pulmonary function tests (eg, patients extubated following mechanical ventilation or patients with previous underlying lung dysfunction). (See 'Initial clinical evaluation' above and 'Subsequent testing' above and "Overview of pulmonary function testing in adults".)
We typically have all patients evaluated by a nutrition expert and we also inquire about sleep habits and sleep quality but only perform sleep testing if patients are suspected to have a sleep disorder. (See 'Initial clinical evaluation' above and 'Subsequent testing' above and "Dietary assessment in adults" and "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription".)
•Laboratories and chest imaging – We routinely perform a complete blood count and differential, chemistries, iron and vitamin B12 levels, thyroid stimulating hormone, liver function tests, and chest radiography. This testing is aimed at detecting organic pathologies that need to be excluded before a diagnosis of PICS can be made. (See 'Subsequent testing' above.)
●Diagnosis – PICS is identified when new or worsening signs and symptoms are found in any one or more of the three affected domains following a critical illness: cognitive, psychiatric, and physical (figure 2). The identification of each component should rely upon the elucidation of specific findings for each domain with confirmatory testing, when needed and the exclusion of competing diagnoses. (See 'Differential diagnosis' above and 'Diagnosis' above.)
●PICS-F – PICS-family (PICS-F) is the term used when critical illness of a loved one adversely affects the mental health of caregiver/family members (figure 1). Over 50 percent of caregiver/family members suffer from PICS-F. Clinical manifestations of PICS-F include symptoms of anxiety, depression, and PTSD. The psychological effects may persist for prolonged periods after discharge of the loved one from the ICU. (See 'Post-intensive care syndrome-family' above.)
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