Beyond Cognitive Screening: Establishing an Interprofessional Perioperative Brain Health Initiative

Abstract

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.

Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team

“…12,34 Ideally this would be done as part of a comprehensive review with a "care of the older person" physician and pharmacist. 42 The management and treatment of delirium is discussed in detail in the guidelines and best practice documents, 30e33, 35 and should encompass immediate exclusion of lifethreatening causes, such as hypoxia, hypotension, hypoglycaemia, and sepsis. Non-pharmacologic strategies are the most effective for preventing and decreasing the duration of delirium.…”

“…16,18 Incorporation of routine simple baseline screening into preoperative assessment is feasible and can be done without additional resources. 41,42 Routine cognitive screening raises awareness amongst the perioperative team and can result in some simple changes in behaviour such as reduced use of benzodiazepines. 42…”

“…41,42 Routine cognitive screening raises awareness amongst the perioperative team and can result in some simple changes in behaviour such as reduced use of benzodiazepines. 42…”

Preoperative cognitive screening and brain health initiatives

“…The test is supported by the American College of Surgeons and the American Geriatric Society 38. Moreover, routine MiniCog testing in a busy clinic was easily implemented, irrespective of experience with previous cognition screening tools 36 Animal Verbal Fluency Test is a brief cognitive assessment that involves a patient naming as many animals as possible within a short, fixed time period (usually 60 s).…”

Preoperative Frailty and Cognitive Dysfunction Assessment

“…Institutions will need to develop interprofessional relationships with geriatricians and practical care pathways for patients who have a positive screen for a high risk of perioperative complications. 9 Further, the aging research community will have to identify modifiable risk factors and demonstrate interventions that can improve perioperative outcomes of the geriatric patient that are generalizable. Institutions will need to invest in pathways to deploy preoperative optimization strategies to modify conditions identified through screening.…”