May 17, 2019
by Sandra Gordon for ASA
In response to the AARP/ASA Call to Action, which encourages organizations to promote brain health before, during and after surgery to patients, hospitals, regulatory agencies and funders, a team at Keck Medical Center of the University of Southern California (USC) recently launched the Brain Health Initiative at USC, a multidisciplinary quality improvement initiative for older surgical patients at risk for cognitive impairment.
The initiative began in 2018 with just one component: the Mini-Cog, a brief screening tool to help detect cognitive impairment in older adults. “We started by screening all surgical patients over 65 whose primary language was English or Spanish, so we could administer the test in their native language,” says Justyne Decker, M.D., Brain Health Initiative faculty lead and Assistant Professor of Anesthesiology specializing in Perioperative Medicine. The goal of the program is to ensure best practices for the perioperative period for patients identified at increased risk of developing postoperative delirium and perioperative neurocognitive disorders.
Keck Medical Center of USC has a comparatively high case mix index. “Our patients are some of the sickest in the country,” says Carol J. Peden, M.D., M.P.H., Professor of Anesthesiology and Executive Director of Health Systems Innovation Center, who also serves as Vice Chair for performance improvement on the ASA’s Ad Hoc Committee on Brain Health. Currently, one-quarter of Keck Medical Center’s surgical patients over age 65 screen positive on the Mini-Cog assessment as part of their preoperative evaluation, which is consistent with the national average.
That meant that one-quarter of Keck Medical Center’s older surgical patients were at increased risk for a delirium event and/or more prolonged and persistent neurocognitive disorders after surgery, which leads to increased length of stay, morbidity and cost. “It was shocking to see the incidence of positive screens in our patient population,” Decker says. After analyzing the Mini-Cog data, the significant incidence was used to prompt routine consideration of cognitive status in clinical management and to drive forward the idea of developing a multidisciplinary Brain Health Initiative team.
Passion Project
“As anesthesiologists, Dr. Peden and I looked from within the ranks of our institution for strategic partners for our team,” Decker says. The Brain Health Initiative is a collaborative team with lead representation from the departments of anesthesiology, geriatrics/family medicine, pharmacy, occupational therapy, surgery, nursing and analytics. They began meeting weekly to develop a complete perioperative care pathway, which includes preoperative education and risk mitigation as well as postoperative and postdischarge follow-up for older surgical patients marked at increased neurocognitive risk. “We put in effort on our own time because we’re all passionate about this. That’s what has helped us move forward very quickly,” says Peden.
The brain health care pathway systematizes a work flow for patients and providers (pptx), which includes these components:
1. Preoperative Anesthesia Assessment including the Mini-Cog
When surgical patients 65 years and older present for their preoperative assessment and evaluation at the Keck Medical Center’s anesthesiology-run perioperative clinic, an anesthesiologist, nurse practitioner or CRNA preoperative care team member screen them with the Mini-Cog.
Older surgical patients who screen positive will meet with one of our occupational therapists, Phuong Nguyen, OTD, OTR/L, Assistant Director of Occupational Therapy and Associate Professor of Occupational Therapy, Jess Holguin, OTD, OT/L, Associate Professor of Occupational Therapy or John Margetis, OTD, OTR/L, Assistant Professor of Occupational Therapy, for an assessment of baseline physical and mental function, using the Stroop Color and Word Test (SCWT) and Symbol Digit Modalities Test (SDMT) to assess their true cognitive baseline. “We’re interested in neurocognitive function, issues of delirium and postoperative neurocognitive delay and recovery from a functional perspective,” Nguyen says. To implement improvements as quickly as possible, Nguyen and her team may recommend that patients increase their activity levels and other functional best practices to optimize patient outcomes.
Patients and their families will also be given an educational handout on perioperative brain health (pdf) and what they can do before and after surgery to reduce their risk of cognitive complications. Before surgery, the anesthesiologists and surgeons will be notified of the patient’s Mini-Cog score in the preoperative evaluation.
2. Geriatric Preoperative Assessment
Patients may then be referred to Carolyn Kaloostian, M.D., M.P.H., Assistant Professor of Family Medicine, for a more formalized geriatric preoperative assessment, including further cognitive testing using the Montreal Cognitive Assessment (MoCA), lab work to identify reversible causes, imaging, medication review and changes, review goals of surgery and care. “This is a great opportunity and pathway to evaluate cognitive changes not picked up earlier, treat reversible causes of cognitive impairment, and offer risk mitigation strategies to reduce poor outcomes,” says Kaloostian, who has fellowship training in Geriatric Medicine, Hospice and Palliative Medicine and transforming primary care.
3. Pharmacy Evaluation
To minimize a patient’s medication risk of cognitive impairment, Tatyana Gurvich, Pharm.D., BCGP, Assistant Professor of Clinical Pharmacy, USC School of Pharmacy and UCI Department of Geriatrics, will review a patient’s prescription medications and over-the-counter medications as well as supplements. Medications with anti-cholinergic side effects, such as urinary and GI antispasmodics, certain anti-depressants and over-the-counter antihistamines, such as Benadryl, many anxiolytics and sedative hypnotics can contribute to postoperative delirium. Patients will be screened for polypharmacy (>5 medications) at this geriatric preoperative visit. In Gurvich’s 30 years working in geriatric pharmacy, “I see a lot of ‘symptoms’ that are simply medication side effects,” she says.
Gurvich and her team developed perioperative medication recommendations (pptx) for providers based on the 2019 Beers criteria and current literature. Common offending prescriptions and over-the-counter medications to avoid before surgery are featured as pictures on the patient handout.
4. Postoperative Care & Follow-up
When patients are admitted, a decal on the patient’s chart will serve to remind the care team of the patient’s cognitive status and the need to avoid medications that increase the odds of delirium. After surgery, patients should be given all sensory aids, including eyeglasses, hearing aids and dentures as soon as possible. Nguyen or a member of the occupational therapy team will do another quick OT assessment. Postoperative nursing staff is advised to protect a patient’s sleep-wake cycle by avoiding waking them throughout the night to check vitals or do blood draws, if possible.
At Keck Medical Center, a trained volunteer service is also available postoperatively. Volunteers will visit patients, especially those with few visitors, to engage them cognitively with conversation and activities, and to help reorient them during the day.
After discharge, patients will undergo a postoperative cognitive assessment with OT the same day as their postoperative surgical appointment. Patients are referred for comprehensive evaluation in our Geriatric Assessment Program (GAP) Clinic to develop a robust plan for long-term care that patients can bring to their primary care physician.
About four to six weeks postoperatively, the team will conduct a telephone follow-up survey with patients and their family members to see if patients have returned to their subjective cognitive baseline as well as provide feedback on their experience with the pathway and resources provided.
The Keck Medical Center comprehensive team-based approach program to optimizing brain health for older surgical patients launched in April 2019; it will be part of a systematic investigation. An institutional review board (IRB) has been submitted so the program can be formally researched.
Advice to Others: “Just start”
Keck Medical Center of USC has the advantage of being a major academic medical center. Your institution may not necessarily have the same complement of resources and talent. But don’t let that stop you from developing your own version of USC’s Brain Health Initiative. “Not every team is going to look the same, but it’s worth getting everybody involved and thinking about who is going to be seeing these at-risk patients to work with the resources you do have,” Peden says. “Just start.”
Look around for providers who are passionate about optimizing cognitive health in older surgical patients. “Your team may not be the same makeup of providers as we have, but you’ll find them,” Nguyen says. There’s a lot of talent around you, so capitalize on it. “You'd be surprised how many individuals within your institution have a similar passion and have been waiting be a part of a collaborative effort such as this,” Decker says.
“Just getting going can help crystalize that conversation,” Peden says. “If you don’t start, you don’t find it.”
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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. The 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.
