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 agefriendly 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.
Coronary heart disease (CHD) is prevalent and often related to an unhealthy diet and hyperlipidemia. The diagnosis of hyperlipidemia should be carefully made, using more than one measurement in the manner described. An assessment of risks allows one to decide whom to treat. Patients with CHD should be treated aggressively but it is less clear how aggressive to be with patients without CHD. Diet and exercise recommendations are appropriate for almost all patients. For those for whom the benefit is greater than the potential risks, statins are first-line drug therapy and they appear to have beneficial effects aside from their lipid-lowering properties.
The most common postoperative complication for older adults is perioperative neurocognitive disorder (PNCD). Its greatest risk factor is preoperative cognitive impairment. Cognitive impairment also predicts higher likelihood of postoperative complications. While the cause of disparity in outcomes is likely multifactorial, the ability to correctly follow perioperative instructions may be one modifiable component. The purpose of this study was to determine whether cognitive impairment led to reduced preoperative instruction compliance and if so, identify barriers and enact a tailored care-plan to close the gap. Our preoperative clinic implemented routine Mini-Cog screening to identify older (age ≥ 65) surgical patients at increased risk. All patients received the same instructions and, on day of surgery, were surveyed to determine correct execution of nil per os guidelines, chlorhexidine wipe use and medication management. Data was stratified by cognitive status to evaluate whether impairment predicted instruction execution. Feedback from patients and families were compiled. Of those who screened negative for impairment, 68% correctly followed instructions, while 84.2% of those impaired struggled with ≥1 instruction(s); impaired patients were more likely to incorrectly follow instructions (OR = 10.5, p-value = 0.001). Areas for change were identified and team-based solutions were enacted with additional support for those with impairment. We found a clear difference in correct execution with respect to cognitive status. By improving instructions as an institution and adding additional support for those with impairment, the compliance gap was significantly reduced. Targeting perioperative instructions and tailoring care in this population may be one modifiable component in the outcome disparity they face.
We are in the midst of an opioid crisis, but have more patients in pain than ever before. Seniors have painful conditions such as chronic back pain, arthritis, neuropathy and fibromyalgia. As many as 50% of older Americans have pain daily from more advanced disease. CDC guidelines mandate that we use opioids less and adjuvant medications more. But using adjuvants in this patient population adds an extra layer of complexity. Some are not well tolerated contributing to cognitive decline, some have to be dose adjusted for declining kidney or liver function. Some medications are safe but underutilized by this patient population. Strategies for safe opioid use will be discussed from both provider and patient perspectives. A review of adjuvant medication will be provided focusing on safe medication use in seniors. Prescription and over-the-counter and alternative medications will be reviewed.
Opioid use is at a crisis level. According to the CDC, an estimated 20 % of patients presenting to physician offices with non-cancer pain receive an opioid prescription (1). According to the Administration on Aging and Substance Abuse and Mental Health Services Administration, the population of older adults who misuse opioids is expected to double by 2020. Today’s mandate to reduce opioid use and to manage patients safely with adjuvant medications comes with many challenges in geriatrics. Many patients have comorbidities which limit the use of adjuvant pain medications. A careful balance must be achieved, in order to provide good pain management and improve quality of life in this patient population. This symposium will explore multidisciplinary approaches to managing pain in geriatrics to reduce opioid use and manage safe opioid use where necessary. Pharmacological strategies for adjusting dosing and managing compliance will be discussed. Cooperative education to improve prescribing practices along with patient education to improve safe use, are important elements. Adjunct use of physical therapy and integrative medicine are also discussed as viable and effective adjuncts or alternatives to traditional pain management. You will learn how to use medications safely, utilize physical therapy to its maximum potential and learn more about innovative integrative medicine techniques, all of which decrease pain and improve function and most importantly quality of life. (1) Daubresse M, Chang HY, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 200-2010. Med Care 2013; 51:870-8
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