Beyond Cognitive Screening: Establishing an Interprofessional Perioperative Brain Health Initiative

Justyne Decker; Carolyn L Kaloostian; Tatyana Gurvich; Phuong Nguyen; William Widjaja; Hugo Cardona; Veronica Pagan; Arash Motamed; Carol J Peden

doi:10.1111/jgs.16720

Beyond Cognitive Screening: Establishing an Interprofessional Perioperative Brain Health Initiative

J Am Geriatr Soc. 2020 Oct;68(10):2359-2364. doi: 10.1111/jgs.16720. Epub 2020 Aug 3.

Authors

Justyne Decker¹, Carolyn L Kaloostian², Tatyana Gurvich³, Phuong Nguyen⁴, William Widjaja¹, Hugo Cardona¹, Veronica Pagan⁵, Arash Motamed¹, Carol J Peden^{1

5}

Affiliations

¹ Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
² Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
³ Department of Pharmacy, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
⁴ Chan Division of Occupational Science and Occupational Therapy, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, USA.
⁵ Gehr Family Center for Health Systems Innovation, University of Southern California, Los Angeles, California, USA.

PMID: 32748487
DOI: 10.1111/jgs.16720

Abstract

Objective: Perioperative neurocognitive disorder (PND) is now recognized as the most common postoperative complication in older surgical patients. Current multidisciplinary guidelines recommend simple cognitive screening of older adults before surgery. Patients identified at risk should have input from an interprofessional team with expertise caring for older surgical patients. Data suggest these recommendations are infrequently met. We set out to test feasibility of routine cognitive screening in a busy preoperative assessment clinic and establish a perioperative pathway with multidisciplinary support for patients identified at risk.

Methods: We undertook a prospective quality improvement study. A cohort of 1,803 older surgical patients scheduled for preoperative evaluation was screened with the Mini-Cog© test. As the project developed, we began confirmatory neurocognitive testing by occupational therapists for those patients flagged at risk. Patients confirmed at risk were referred for further evaluation by a geriatrician and geriatric pharmacist. Alerts were developed to flag patients at risk through their in-patient journey, and a multidisciplinary team developed a comprehensive care pathway.

Results: We demonstrated that implementing routine cognitive screening can be done in a busy clinic, regardless of prior experience. The prevalence of preoperative cognitive impairment was 21% in our older patients undergoing inpatient surgery, rising to 36% in those older than 85 years. When the Mini-Cog results were not known to providers, they were unable to identify cognitive impairment in half of the patients, supporting the use of a validated screening test. We established an interprofessional team and pooled relevant recommendations into an age-friendly perioperative care pathway for patients at increased cognitive risk.

Conclusion: Cognitive screening must be done to reliably identify older surgical patients at risk of PND. Demonstrating the prevalence of cognitive impairment in older surgical patients can provide impetus to develop a multidisciplinary team and care pathway with the aim of reducing the incidence of PNDs. J Am Geriatr Soc 68:2359-2364, 2020.

Keywords: perioperative brain health; perioperative neurocognitive disorder; surgery and aging.

Publication types

Evaluation Study
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Aged, 80 and over
Cognitive Dysfunction / diagnosis*
Cognitive Dysfunction / epidemiology
Feasibility Studies
Female
Geriatric Assessment / methods*
Health Plan Implementation
Humans
Male
Mental Status and Dementia Tests
Neuropsychological Tests
Patient Care Team*
Perioperative Care / methods*
Postoperative Cognitive Complications / etiology
Preoperative Care / methods*
Preoperative Period
Prevalence
Prospective Studies
Quality Improvement
Risk Assessment