Early Mobilization May Reduce Cognitive Risk in Critical Care

Heidi Splete

March 03, 2023

Critical care patients on mechanical ventilation who received early physical and occupational therapy showed significantly lower rates of cognitive impairment 1 year after hospital discharge compared with patients who did not receive the mobilization intervention based on data from 200 individuals.

Mechanical ventilation in the ICU setting is associated with an increased risk for post-discharge long-term cognitive impairment, wrote Bhakti K. Patel, MD, of the University of Chicago, Illinois, and colleagues.

Previous studies of early mobilization in the ICU have focused on physical and functional outcomes, but limited data suggest a potential cognitive benefit as well, they said.

In a study published in The Lancet Respiratory Medicine, the researchers randomly assigned 100 adults aged 18 years or older who required mechanical ventilation in the ICU to early mobilization and 100 to usual care. Baseline characteristics were not significantly different between the groups; slightly more than half of the participants were men, slightly more than two thirds were African American.

Participants were functionally independent at baseline and mechanically ventilated for less than 96 hours but expected to continue on mechanical ventilation for at least 24 hours. One patient withdrew from each group, leaving 99 in each group for the intent-to-treat analysis.

Patients in the mobilization group received physical and occupational therapy after interruption of sedation, beginning with range of motion activities and progressing to bed mobility and upright activities. Patients in the usual-care group began mobilization as directed by the primary care team or on extubation. Each therapy session lasted from 25 to 30 minutes.

The median time from intervention to the first therapy session was 1.1 days in the intervention group and 4.7 days in the usual-care group. A total of 93 patients in the intervention group began therapy within 96 hours of mechanical ventilation.

The primary outcome was cognitive impairment at 1 year, defined as a score < 26 on the Montreal Cognitive Assessment, a 30-point screening tool used to assess multiple cognitive domains.

At 1 year, 70 patients in the intervention group and 74 in the usual-care group were alive. Of these, 24 intervention patients and 43 usual-care patients met the criteria for cognitive impairment (24% vs 43%; P = .0043).

The findings were limited by several factors including the small sample size, low mobilization among controls, and the use of a screening tool for cognitive function assessment, the researchers noted.

However, the study is the first randomized, controlled trial to connect early mobilization in the ICU with specific improvement in long-term cognition as well as physical outcomes, they said. "The early intervention and multidisciplinary nature (ie, physical and occupational therapy teams working together at the same time) of this study are another aspect of its novelty," they noted.

Early Mobilization Enhances Many ICU Outcomes

"These results add to a growing body of evidence showing that mobilization as early as possible, when coupled with light sedation, avoidance of benzodiazepines, and other delirium risk factors, improves outcomes for patients treated in the ICU," wrote Timothy D. Girard, MD, of the University of Pittsburgh, Pennsylvania, and Pratik P. Pandharipande, MD, of the University of Pittsburgh and Vanderbilt University, Nashville, Tennessee, in an accompanying editorial.

More studies are needed to explore the mechanism by which early mobilization improves cognition, the editorialists wrote. Occupational therapy aims to promote neurologic recovery by restoring damaged pathways, strengthening existing pathways, or developing new pathways, they said.

"Additional research is needed to understand the biological benefits of early occupational therapy during critical illness," and studies using more robust outcome measures are needed, but the current study offers guidance on how to use early mobilization in the ICU and presents directions for additional research, the editorialists concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose. Girard disclosed research funding from Ceribell, consulting fees from Haisco Pharmaceutical Group, and membership of the advisory board for Lungpacer Medical.

Lancet Respir Med. January 21, 2023. Source

Lancet Respir Med. January 25, 2023. Source

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