**6. Discussion**

Brain function will be impairment if there is not preventive intervention in ICU. Patients will get impairment cognitive, physical functional, delirium, impairment hormone in the brain. The brain will release oxidative stress, the body compensates by reducing oxidative metabolism in the brain. As a result, brain dysfunction occurs which causes delirium symptoms. This condition also triggers the formation of reactive oxygen and nitrogen which worsens the damage to brain tissue. This damage is permanent and causes complications in the form of permanent cognitive decline. Disturbance in Critically ill patients will also create an imbalance of neurotransmitters, especially acetylcholine and dopamine. Acetylcholine levels were found to be decreased in delirium patients in the ICU. These levels return to normal after the patient is no longer delirium. Additionally, anticholinergic drugs (acetylcholine blockers) have been shown to cause delirium. Dopamine and acetylcholine have a reciprocal (opposite) relationship. There is an increase in dopamine levels in delirium. The administration of dopamine blockers can also reduce symptoms of delirium. Serotonin is increased in hepatic encephalopathy and septic delirium. Serotonin agonists (hallucinogenic drugs) can also cause delirium. In critically ill patients with delirium, changes in gamma-aminobutyric acid (GABA) and histamine levels occur. Changes can be either increasing or decreasing, depending on the cause of the delirium. Neuroendocrine disorders can also occur where this hormone is associated with increased proinflammatory cytokines in the brain and neuronal damage. The neuroendocrine hypothesis also explains the development of delirium in patients receiving exogenous glucocorticoids. Circadian cycle disruption can affect sleep quality and physiology. Lack of sleep can lead to delirium, memory deficits, and psychosis. Melatonin is a hormone that regulates the circadian cycle. One study shows a link between low melatonin levels and the incidence of delirium. Another study says that administering exogenous melatonin to hospitalized patients reduces the incidence of delirium.

Physical Cognitive Therapy significantly affects physical function in critically ill patients in the ICU. The subjects of the study intervention group increased physical function after intervention with a mean difference of the increase in the intervention group of 3.2, whereas in the control group decreased physical function with a mean of 0.2. The intervention group increased physical function because of physical exercise that is done properly and regularly. Physical exercise at each joint can increase the activity of mechanisms neuromuscular Critically ill patients during bed rest. Physical activity done regularly prevents apoptosis activity. The control group decreased physical function due to a decrease in neuromuscular muscle-debilitating up until the occurrence of cell apoptosis. Improved physical function occurs along with increased functionality and functional use of aid mobilization, step, shoulder strength, and the strength of the knee. Physical-cognitive therapy is expected to be physiologically capable of activating mechanical neuromuscular patients, it is supported by the theory that in principle, the physical exercises to stimulate muscle

nerves to recognize that when the patient bed rest does not happen mechanical unloading and decreased neuromuscular activity. The results of research supported by the theories Margaret that moment activity neuromuscular becomes better, it will inhibit the complex adaptation response (protein synthesis), protein degradation, and apoptosis of muscle cells [1, 2, 6, 7–13, 15, 21, 30, 31, 45–56]. Mechanisms that occur are the main contributor muscle atrophy, loss of muscle strength in critically ill patients during bed rest. Physical-cognitive therapy is expected to increase muscle metabolism which further increases the formation of protein to energy solution for patient immobilization or bed rest. Physical-Cognitive therapy can improve physical function declined over the patient in the ICU, it was supported by the results of research Thomsen stated that ambulation and early mobilization in critically ill patients in the ICU were able to improve the patient's physical function and also decrease the use of sedation [57]. Critically ill patients in ICU should be done as soon as possible physical mobility exercises to improve muscle metabolism and does not activate a response or apoptosis mechanism. The results of research supported by Elliott in the prevention of damage to physical function after discharge from the ICU who stated that early mobility can mitigate the negative impact of critical illness and improved its physical function [20].

Physical-cognitive therapy significantly impacts on improving the cognitive functions of Critically ill patients in ICU. These results correspond with the results of a study that critically ill patients in the ICU can experience mental health disorders such as anxiety and they have cognitive impairment and poor sleep quality.5 Improved cognitive function was not affected by the characteristics of the study subjects from the intervention group. The decline in cognitive function is influenced also by gender by the statistical results and strengthened by the results of cognitive function decline Wreksoatmojo is motivated by a variety of risk factors that cannot be avoided such as age and gender, as well as some physical conditions and diseases [58]. The decline in cognitive function can slow recovery in patients. The research subjects in the control group were restless anxiety and pain scale settled on the first day to the third day.

The results also showed increased cognitive function occurred in all subdomains variable orientation, regression, attention-calculation, recall, and language. Research shows that physical-cognitive therapy can improve the function of any existing variables. The results of research supported by the results of studies that suggest that cognitive therapy can change the perception of self in patients with heart problems [59]. Research subjects most heart problems with a variety of conditions and consciousness and care in the ICU. The subjects of the study intervention group experienced an increase in all indicators of cognitive function. Cognitive function has several major functions in which work is recertified function, memory function, the function of thinking, and repressive function. This repressive function involves the ability to make the selection process, clarify and integrate the information provided. Researchers on the provision of physical-cognitive therapy provide the stimuli of orientation, registration, attention-calculation, recall until the language with the hope of the study subjects were able to do the selection process to integrate more complex information. The research subjects' control group decreased cognitive function have a significant relationship to independence by the results of research conducted by Balquis [60]. Subjects have been unable to carry out compliance activities of daily needs and also experience pain at a mild to moderate level. It also can affect the patient's condition, especially the condition of his illness. Based on the results that research subjects have the most control group cognitive impairment in moderate time in the ICU.

The research subjects in the control group with a decline in cognitive function may occur and demonstrate emotional response after discharge from the ICU such

**63**

**Author details**

Heru Suwardianto

Baptist Hospital Health Collage, Kediri, Indonesia

provided the original work is properly cited.

\*Address all correspondence to: herusuwardianto@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Physical and Cognitive Therapy (PCT) in Critically Ill Patient*

as anxiety, depression, fatigue, reflection, and solitude in accordance expressed by Strahan.21cognitive decline will worsen and weaken the function of other organs if not prevented in treatment in the ICU [29]. These results are also supported by another theory which states that the impact of the decline in cognitive function for patients in ICU that increase the treatment time, a decline in cognitive function, physical function (organs, muscle contractility, functional capacity and pain, vitality, fatigue), and worsening mental health (anxiety), emotional responses, depression, reflection, loneliness, inability to perform the activity and the use of instruments in everyday life. Condition of patients with worsening cognitive function for patients in ICU should be prevented to maintain the patient's quality of life and function as whole human beings with various functions in carrying out daily activities. Approach to symptom management theory indicated expected any problems can be overcome by a specific patient. Specific Nursing Interventions applied and overcome specific problems as well. The results also were able to study the possible factors that need to be improved in the provision of Interventions, to provide maximum benefit to patients on the signs and symptoms of health prob-

I would like to offer my special thanks to patients in ICU Kediri Baptist Hospital. I would like to thank dr. Jati Listiyanto Pujo, Sp. An., KIC., Erina Purwanti (intensivist), Dr. dr. Awal Prasetyo, Sp.THT-KL, M. Kes, and Ns. Reni Sulung Utami,

*DOI: http://dx.doi.org/10.5772/intechopen.94154*

lems in critically ill patients in the ICU.

S. Kep, MSc for their help in this research.

**Acknowledgements**

*Physical and Cognitive Therapy (PCT) in Critically Ill Patient DOI: http://dx.doi.org/10.5772/intechopen.94154*

as anxiety, depression, fatigue, reflection, and solitude in accordance expressed by Strahan.21cognitive decline will worsen and weaken the function of other organs if not prevented in treatment in the ICU [29]. These results are also supported by another theory which states that the impact of the decline in cognitive function for patients in ICU that increase the treatment time, a decline in cognitive function, physical function (organs, muscle contractility, functional capacity and pain, vitality, fatigue), and worsening mental health (anxiety), emotional responses, depression, reflection, loneliness, inability to perform the activity and the use of instruments in everyday life. Condition of patients with worsening cognitive function for patients in ICU should be prevented to maintain the patient's quality of life and function as whole human beings with various functions in carrying out daily activities. Approach to symptom management theory indicated expected any problems can be overcome by a specific patient. Specific Nursing Interventions applied and overcome specific problems as well. The results also were able to study the possible factors that need to be improved in the provision of Interventions, to provide maximum benefit to patients on the signs and symptoms of health problems in critically ill patients in the ICU.
