Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study

Abstract

Background Preexisting cognitive impairment is emerging as a predictor of poor postoperative outcomes in seniors. We hypothesized that preoperative cognitive screening can be performed in a busy preadmission evaluation center and that cognitive impairment is prevalent in elective geriatric surgical patients. Methods We approached 311 patients ≥ 65 years-old presenting for preoperative evaluation prior to elective surgery in a prospective, observational, single-center study. Forty-eight patients were ineligible and 63 declined. The remaining 200 were randomized to the Mini-Cog (N =100) or Clock-in-the-Box [CIB; N = 100)] test. Study staff administered the test in a quiet room and 2 investigators scored the tests independently. Probable cognitive impairment was defined as a Mini-Cog ≤ 2 or a CIB ≤ 5. Results The age of consenting patients was 73.7± 6.4 (mean ± SD) years. There were no significant differences between patients randomized to the Mini-Cog or CIB test in age, weight, gender, education, ASA physical status or Charlston Index. Overall, 23% of patients met criteria for probable cognitive impairment, and prevalence was virtually identical regardless of the test used; 22% screened with the Mini-Cog and 23% screened with the CIB scored as having probable cognitive impairment (P =1.0 by Chi Square analysis). Both tests had good inter-rater reliability (Krippendroff's alpha = 0.86 (0.72–0.93) for Mini-Cog and 1 (1-1) for CIB). Conclusions Preoperative cognitive screening is feasible in most geriatric elective surgical patients and reveals a substantial prevalence of probable cognitive impairment in this population.

Impact of Total Knee Arthroplasty with General Anesthesia on Brain Networks: Cognitive Efficiency and Ventricular Volume Predict Functional Connectivity Decline in Older Adults

“…We propose to the reader, however, that lower preoperative scores on declarative memory and processing speed measures are not entirely unexpected given orthopedic limitations in physical activity and pain, both of which associate with memory and processing speed abilities [89, 90]. Our participant profile also fits with growing literature showing many older adults electing surgery have preoperative cognitive impairment [91]. We also point out that as a group, the surgery participants’ scores for all included cognitive domains were in the average range relative to published norms.…”

Why Mental Status Standards are Recommended on Medical Surgical Units in Hospitals?

“…The often-usual practice not sufficient. We concur with multiple studies that have validated the adoption in practice of sound cognitive screening tools during assessments [14][15][16]. Assessments that lack utilization of standard cognitive tools are not appropriate in science based practice and therefore use of brief Ax4 measures alone are no longer enough for nurses (Appendix).…”

“…Literature, demonstrates for example, intensive care units, and preoperative areas are integrating cognitive screening, however medical surgical units lag behind in adaption [14,15]. We suggest hospitals medical surgical units adapt standard cognitive screening tools for nurse's use during assessments based on their units' standards of practice.…”

“…Literature has recently addressed such needs for clarification to improve consistent practice in mentation measurement [6,14]. In addition to factors such as degree of the illness, age, or other reference points, sound mentation measurement tools must be used, or the patient may fail to understand the questions as requested by nurses during assessments.…”

Delayed Recall and Working Memory MMSE Domains Predict Delirium following Cardiac Surgery

“…Specifically, reduced preoperative general cognition has been associated with a two to seventeen fold increase in risk [6, 9, 10, 11, 12, 13]. These findings, coupled with the prevalence of cognitive impairment in general medical and presurgical samples [14, 15], underscore the rationale of the U.S. Preventative Services Task Force’s request for clinicians to remain alert for early signs of cognitive impairment in order to provide earlier intervention options [16]. The association between preoperative cognitive impairment and delirium provides an opportunity to predict postoperative delirium with preoperative neurocognitive testing.…”