Characterizing Critical Illness Recovery Trajectories: Exploring Risk Factors for Post Intensive Care Syndrome

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Abstract RATIONALE: Survivors of critical illness commonly develop long-term impairments in multiple domains of function as part of a chronic syndrome known as Post Intensive Care Syndrome (PICS). Little is known about the trajectory of these impairments. We aimed to investigate critical illness recovery trajectories using cognitive function, activities of daily living (ADLs), and instrumental activities of daily living (IADLs) and to identify risk factors for trajectories consistent with PICS. METHODS: We analyzed data from adults (≥18 years) with respiratory failure and/or shock in the combined BRAIN-ICU and MIND-ICU prospective cohorts who survived to hospital discharge and had at least 1 post-ICU assessment. At baseline (enrollment or hospital discharge), 3, and 12 months, we measured the Mini Mental State Exam (MMSE T-score), Katz Index of Independence in Activities of Daily Living (Katz ADL), and Functional Activities Questionnaire (FAQ/IADLs). To identify classes with distinct critical illness recovery trajectories, we performed multivariate joint latent class modeling and accounted for competing risk of death with joint survival analysis. We then used logistic regression to identify associations between demographic and clinical risk factors and class membership. RESULTS: In the combined cohort of 804 patients, we identified two patient classes with distinct recovery trajectories: Class 1 (N=620; median age=61.5 years) and Class 2 (N=184; median age=66.0 years). Patients in Class 1 had better recovery of cognitive function and less impairment in ADLs than did patients in Class 2. Those in Class 2 had persistently worse cognitive function (MMSE T-score) as well as progressively more ADL and IADL dependence through 12-months (FIGURE). Patients in Class 1 had better 12-month survival probability than those in Class 2 (78.0% vs 51.3%). The odds of being in Class 2 were greater for patients who were older (OR 1.35, P=0.02), had worse baseline cognition (OR 1.19, P<0.01), and greater frailty at ICU admission (OR 4.56, P<0.01), whereas mean severity of illness and delirium duration were not associated with class membership. CONCLUSION: We identified two critical illness recovery trajectories, one of which was consistent with PICS. Patients who were older with worse baseline cognition and greater baseline frailty were more likely to have the Class 2 (PICS) recovery trajectory. Future studies are needed to develop a validated prediction tool to identify critically ill patients at risk of being in the PICS class and to determine if targeted interventions such as cognitive, physical, and occupational therapy might improve their recovery trajectory.

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