Consequences of Prolonged Immobility

Due to prolonged immobility, patients in the ICU face complications that can impact function including weakness, delirium, cognitive impairments, sensory deprivation, prolonged mechanical ventilation, prolonged hospitalizations, decreased quality of life, long-term disability, and increased mortality.1-14 Most critically ill patients in the ICU (up to 80%), develop some type of neuromuscular dysfunction or ICU delirium, both of which are associated with poor outcomes.15-18

Musculoskeletal System

Muscular Weakness

ICU stays are typically associated with muscle weakness which can last for months to years following hospitalization and is associated with disability, prolonged recovery time, and neuropsychiatric dysfunction.19,20 Muscle atrophy occurs early and rapidly for the critically ill patient, with up to 30% decrease in muscle mass and 40% decrease in strength within the 1st 10 days of hospitalization.14,21,22 Immobility may result in 1.3-3.0% loss in muscle strength per day in healthy individuals.23 Neuromuscular dysfunction illustrated by generalized weakness and difficulty weaning from the ventilator can occur in the absence of pre-existing disability.23 This dysfunction is thought to be due to illness and also may present as a side effect of treatment.23 Neuromuscular weakness may persist for up to 5 years in over 90% of patients.24

ICU-Aquired Weakness (ICU-AW) 25

ICU-AW is a clinically detectable weakness in the form of critical illness polyneuropathy (CIP), myopathy (CIM), or a combination.11,21,26 ICU-AW is seen in approximately 25-58% of adult ICU patients who require prolonged ventilation and is correlated to delayed vent weaning, and increased mortality.18,21,23,27 

Critical Illness Polyneuropathy (CIP): Disease of peripheral nerves and contributor to persistent disability. 

  • Present with limb weakness/atrophy and decreased spontaneous movement. Cranial nerves and muscle stretch reflexes are generally intact. But there is a loss of peripheral sensation to light and sharp touch

  • Most likely require mechanical ventilation with difficulty weaning

  • Recovery from mild to moderate injury can take weeks to months. With some residual nerve dysfunction noted several years post-onset

Critical Illness Myopathy (CIM): Disease of limb & respiratory muscles. Can be associated with complete recovery. 

  • Present with flaccid quadriparesis affecting proximal more than distal muscles; facial weakness can also result. Muscle stretch reflexes are absent, but sensation remains intact.

  • Demonstrate difficulty weaning from the vent

  • Can be associated with complete recovery

 

Effects of Bed Rest

Traditionally, bed rest is prescribed for patients in the ICU and is thought to be helpful in preventing complications, conserving energy, and patient comfort.19,20 However, prolonged bed rest can actually delay recovery and have harmful effects on all body systems including muscular, skeletal, respiratory, cognition, and the skin.8,19,21,28 Following as little as five days of bed rest, patients can experience postural hypotension, tachycardia, decreased stroke volume, and decreased cardiac output.12 Other effects that patients might experience include: weakness, contractures, exercise/activity intolerance, hypoventilation, atelectasis, increased risk for pneumonia, decreased metabolic rate, pressure ulcers, systemic infection, confusion, sensory deprivation, depression, anxiety, constipation, reflux, and urinary retention.37

Cognitive and Psychological System

ICU Psychosis & Delirium

Delirium, an acute change in mental state resulting in confused thinking, restlessness, and incoherent thoughts and speech, is a significant and frequent problem for patients in the ICU. Incidence is as high as 45-87% in mechanically vented and 20-56% in non-vented elderly patients.16,29 Risk factors for delirium include: preexisting cognitive impairment, advanced age, mechanical ventilation, untreated pain, sedative medications, sleep deprivation, multisystem illness, and prolonged immobilization.27 Many critically ill patients require some form of sedative medication while in the ICU which is shown to increase delirium.16 A cohort study of 542 patients showed that duration of delirium directly impacts survival with an 11% increase in mortality for every 48 hours that delirium persists.30 Furthermore, it has been estimated that a majority of cases are preventable with use of environmental aids (hearing aids and glasses), appropriate day/night rhythm, and participation in early mobility and rehabilitation.29,31 ICU patients who participated in an OT-specific treatment protocol to address delirium showed improved cognition, function, and delirium.29

Cognitive and Psychological Morbidity

There is a high prevalence of cognitive impairments and mental health problems, including depression, post-traumatic stress disorder, and anxiety in ICU survivors.10,32-35 This high prevalence is thought to be due to a psychological reaction or sequelae of brain injury, with medications, physiologic changes, pain, and unfamiliar environment listed as potential contributing factors.10 It was found that cognitive impairments occurred in 73% of acute respiratory distress syndrome (ARDS) survivors at hospital discharge, 46% at one year, and 47% at two years.35 ICU survivors report moderate to severe depression and anxiety persisting up to two years post-discharge.35,36 Of note, approximately one-fourth of patients ventilated for seven or more days report severe depression following hospital discharge with depressive symptoms correlated with functional dependence.36 Overall, ICU survivors have a higher rate of depression when compared to the general population.36 Often, cognitive impairments are underrecognized and frequently missed by both the medical and rehabilitation providers. Education on cognitive impairments may be warranted to increase therapy referrals.35

References

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