An exploration of intensive care unit patents’ experiences of the Addenbrooke’s Cognitive Examination (ACE-III) as a screening tool for cognitive functioning at different points in recovery from critical illness

Abstract

Being critically ill can result in cognitive change. Cognitive functioning should be screened at different points in the care pathway, and it is important to understand patient’s experience of this process. A service evaluation examined fifteen in-patients’ and eleven outpatients’ experiences of completing the Addenbrookes Cognitive Examination-III (ACE-III) using thematic analysis. Four themes emerged: (1) willingness & acceptability (2) strengths and weaknesses (3) factors affecting performance and (4) improving delivery. Generally, patients accepted the ACE-III and valued cognitive screening. Consideration is given to areas for development.

Introduction

Intensive Care Unit (ICU) survivors can experience neurocognitive problems ¹ including: language, decision making, memory, executive functioning and motivation.^{2 –5} Cognitive assessments across the care pathway could identify difficulties.^6,7 The Addenbrookes Cognitive Examination-III (ACE-III), assesses the domains of: attention, memory, fluency, language and visuospatial skills. ⁸ Developed as a cognitive screen for dementia, the ACE-III is used with wider clinical populations,^{9 –11} detects mild cognitive impairment, is superior to other cognitive screens^12,13; providing domain-related information for differential diagnosis ⁸ and treatment planning. ¹⁴ The ACE-III is freely available in multiple versions for repeat testing and multiple languages.

Patients’ views are essential for achieving high-quality care^15,16 including cognitive screening. ¹⁷ A service evaluation, approved by the Audit Team, was conducted in a UK adult general and neurological ICU exploring patients’ experience of ACE-III screening at different points in the care pathway.

Method

The research team (all female) included a trainee clinical psychologist (HC) and five psychology assistants (AH, LBS, KK, AB and HS). Participants were convenience selected and approached in person. Inclusion criteria were: ICU-stay greater than 48 h, 18+, able to read and write. Exclusion criteria were: neurological injuries/illnesses, palliative pathway. An interview schedule was developed.

The ACE-III was completed bedside by a Psychology Assistant with 58 inpatients following step-down from ICU. Outpatient participants were sought via critical care psychology, with the ACE-III completed in-person or online. Patients were given an information sheet explaining the study purpose, consent, support, and researchers’ details, and time to consider.

Consent was sought prior to the interview. Interviews were completed bedside with inpatients, in-person or online with outpatients, by a Psychology Assistant not involved with screening. Interviews were 10–30 min. All data were recorded, anonymised and transcribed.

Inductive thematic analysis was undertaken. ¹⁸ Transcription and re-reading allowed data familiarisation. Two researchers (HC and AH) not involved in screening, carried out first and second level coding, highlighting key concepts, for inpatient and outpatient data respectively, creating separate coding schemes, which were then jointly cross examined. Anomalies were discussed and coding discussion and emergent themes shared with the research and Expert group.

Results

Fifteen inpatients (ages 26–79; 9 males, 6 females; length of ICU stay 2–51 days) and eleven outpatients (ages 32–81; 5 males, 6 females; average time since ICU discharge 11 months) participated. Records do not indicate why potential participants did not take part.

Four superordinate themes emerged. Names are pseudonyms.

Theme 1: Acceptance and willingness

All were willing to undertake ACE-III screening. There was awareness of cognitive changes: ‘I know that my brain, everything is a knot (Walter)’. Some found the screening reassuring, whilst others found it stimulating; ‘It’s just stretching the brain (Yolande);’ ‘It’s always beneficial whether it’s positive or negative because you can always build on areas for improvement (Lawrence)’.

Theme 2: Strengths and weaknesses

Participants reflected on cognitive strengths and weakness: ‘The remembering one was hard. . . I’ve got a short memory span (Sachin)’, some linked this to previous functioning: ‘I am normally quite forgetful (Tim)’. Outpatient participants gave richer descriptions of difficulties: ‘I’m tending to have to write things down like lists. . .whereas before [critical illness] I could keep that all in my head (Nicola)’.

Theme 3: Factors affecting performance

Some inpatients described the ward environment affecting their performance: ‘It’s like being in an amusement arcade (John)’. Tiredness, medication, surgery and medical investigations were mentioned, as was the emotional impact of cognitive change: ‘I’m upset that [being unwell] is happening and now my brain isn’t working properly (Jo).’ Other environmental challenges included wearing a mask, wards and feeling unprepared. Outpatients felt prepared and acknowledged the emotional impact: ‘I think I was getting angry, a bit agitated. . .because I knew I couldn’t do it (Annie).’

Theme 4: Improving delivery

Some inpatients preferred screening when feeling cognitively alert: ‘I’m just a bit brighter in the mornings (Stuart);’ and more prepared: ‘I think five minutes warning would have helped (Jennifer)’, with a suggestion of providing more information: ‘You could put it on a sheet and not use too difficult language (Jo)’. Outpatients discussed online: ‘I’ve got quite used to this virtual stuff (Sally)’ and in-person screening: ‘I would prefer to be in the room with someone (Lawrence)’.

Discussion

Patients are willing to undertake an ACE-III, recognise changes in cognitive functioning, identified factors impacting performance and suggested improvements, such as a quiet environment, clear information, and advance notice. Impairments in attention and stamina should be considered. ¹⁹ An information leaflet will be developed. The ACE-III used across the care pathway may help track cognitive profiles across recovery journeys, build the evidence base for critical illness related cognitive change and develop the identification of appropriate interventions.