by Sandra Gordon for ASA
What have you been working on? We asked that question of Catherine Price, PhD, Associate Professor and Paul Satz Term Professor with appointments in the Departments of Anesthesiology and Clinical and Health Psychology, and Co-Director of the Perioperative Cognitive Anesthesia Network (PeCAN) at the UF College of Public Health and Health Profession/College of Medicine in Gainesville.
Featured here are three recent research initiatives Price and her colleagues have championed to advance the perioperative cognitive care for older adults.
Patients with Cognitive Impairment May Miss Colonoscopy and Bowel Prep
Moderate to severe cognitive impairment is a risk factor for missed colonoscopy and suboptimal bowel prep in older adults, according to the results of Pilot Study: Neurocognitive Disorders and Colonoscopy in Older Adults in Anesthesia & Analgesia.
A retrospective data review, the pilot study analyzed medical record data of patients age 65 and older presenting for a preprocedural workup before their colonoscopies at the University of Florida (UF) preoperative anesthesia clinic from August 7, 2017 to December 20, 2017. Of the 47 patients who completed all aspects of their pre-procedural appointment, 38% were frail and 29% met the diagnostic criteria for mild and major neurocognitive disorder. Nine of the 47 patients missed their scheduled colonoscopy; every “nonattender” met the diagnostic criteria for major neurocognitive disorder at the time of the preprocedural evaluation.
Of the 38 patients who presented for their colonoscopy, 23 met the diagnostic criteria for mild or major neurocognitive disorder. All 38 patients presented for their colonoscopy with inadequate bowel prep.
“The results suggest that gastroenterologists may need to spend extra time one on one with older patients scheduled for colonoscopy who fail cognitive tests in their preop clinic and address how to change bowel preparation so these patients can come to their colonoscopy appointments adequately prepared,” Price says.
It’s Feasible to Provide Frailty and Cognitive Screening in the Preop Setting
Cognitive and frailty screening protocols are feasible to administer in a tertiary care medical center, despite challenges, including staff training, missing data, and additional administration time, according to Feasibility and Rational for Incorporating Frailty and Cognitive Screening Protocols in a Preoperative Anesthesia Clinic in Anesthesia & Analgesia.
In the study, medical staff were trained in two segments to administer the Preoperative Frailty-Cognitive Protocol and screened 678 adults age 65 and older for general cognition using the Mini-Cog clock drawing and three-word memory test and frailty testing. Patients qualified as frail if they exhibited or reported greater than three of the following:
- Unintended weight loss of 10 or more pounds within the last six months
- Subjective exhaustion, defined as endorsing moderate feelings that everything the patient did was an effort over the last week or moderate feelings that the patient could not “get going” in the last week
- Slow walking speed of 15 feet in 7 or more seconds for men below 68 inches and women above 63 inches; 15 feet in six or more seconds in men above 68 inches and women above 63 inches
- Grip strength below a normative cutoff defined by the Geriatrics Evaluation and Management Tools with a hand dynamometer.
- Low physical activity, defined by the Duke Activity Status Index.
Medical staff also obtained patients’ years of education. Staff members successfully administered the screening protocol to 80% of eligible patients over two months. The likelihood of cognitive impairment was 20% (1 in 5 patients), with no difference by surgery type; cognitive impairment and dementia pathology can occur in individuals with little to no frailty.
The frailty-cognitive screening protocols added 10 to 30 minutes of additional administration time per staff member per day, with an estimate for five minutes per testing protocol with two to five patients age 65 and older per day.
“It’s important clinicians weigh the likelihood of preoperative cognitive impairment with the additional assessment time against risk prevention,” Price says. Improved perioperative monitoring may lower costly complications and have a positive impact on postoperative family caregiver burden.
7 Cognitive Screening Tools Recommended for Use in Preoperative Settings
Perioperative providers are in a unique position to identify cognitive vulnerabilities that may affect perioperative outcomes. Which cognitive screening tools are appropriate for fast-paced settings with limited staffing? In Rapid in-person cognitive screening in the preoperative setting: Test considerations and recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI) in the Journal of Clinical Anesthesia, Price and her colleagues recommend choosing from among seven screening tools, which have an average administration time of one to 10 minutes. They include:
Clock drawing test and command and copy (CDT): The brief, paper-and-pencil test takes two to five minutes. The patient is asked to draw the face of a clock, put in all the numbers, and set the hands to “ten after 11.” The patient is then asked to copy of the face of a clock, which is presented to them on a piece of paper.
Mini-Cog: This screening tool includes a clock drawing task with the clock face already provided to the patient and a three-word recall. Test time is 1.5 to 5 minutes.
The mini mental status exam (MMSE) takes roughly 10 minutes to administer. It involves a series of questions, such as: What is today’s date? Month? Day of the week? Year? Orientation to place: Where are you now? What state are you in? County? City?
Months backward test (MBT) or months of the year reverse order (MOYR): During this timed one to two minute screening test, patients recite the months of the year forward and backward as quickly as possible.
Short-blessed test (SBT) and the short orientation memory concentration test (S-OMCT) takes two minutes to administer. During the test, the patient is given a five-item address, such as John, Smith, 52, West Street, Boston, and asked to recite the address later. A score of three or more recall errors is associated with dementia.
Telephone interview of cognitive status: This 11-item screening test assesses orientation, learning and memory, attention, and language and takes 10 minutes to administer.
Time & Change (T&C) test: During this test, patients are shown the face of a clock with hands at 10 past 11 (11:10) and asked to report the time. The patient’s response and time it takes to respond are recorded. The patient has two attempts to provide a correct response within 60 seconds. In the second part of the test, the patient receives three quarters, seven dimes, and seven nickels and is asked to provide $1 in change to the health care provider. The patient has two tries to respond within 120 seconds.
“Each of these tools demonstrated adequate sensitivity for detecting cognitive impairment in older adults, is appropriate for lay examiners, don’t take much time, and they’re free or low cost,” Price says.
We want to Hear from You
Did you work to improve the perioperative experience for patients at risk for delirium? Share your story by entering a few brief details into our SBAR template. We’ll contact you for more information.
ASA and the PBHI does not endorse specific hospital procedures, policies, or programs outlined in this content. All research and clinical material published in this article (above) by ASA and the PBHI is for informational purposes only. Readers are encouraged to confirm the information contained herein with other sources and consider applications within the context of their local environment. Patients and consumers should review the information carefully with their professional health care provider. This information is not intended to replace medical advice offered by physicians. ASA and PBHI will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising therefrom.