“When you see patients who seem completely normal and tell them to draw a clock and they draw a car or an apple, you have no choice but to then take action.”
By Sandra Gordon for ASA
Arash Motamed, MD, Clinical Associate Professor of Anesthesiology and Medical Director of Keck Hospital Anesthesia Inpatient Service offers advice on how to begin assessing preoperative cognitive health with the Mini-Cog screening tool in older surgical patients.
When Arash Motamed, MD began assessing the preoperative brain health of older surgical patients in 2018 with the Mini-Cog screening tool as part of Keck Hospital’s brain health initiative, which was brand new at the time, he met a patient in his 90s who taught him a valuable lesson. “When I interviewed this gentleman in the preoperative clinic, he seemed as sharp as a tack to the point where I jokingly told him, ‘I want to be like you when I’m your age because you’re so sharp,’” Motamed says. After the interview, the nurse did the Mini-Cog test, which required the patient to draw a clock with the hands at a particular time, such as 10 past 10. Surprisingly, the patient failed the test.
“That’s when I realized that what I think is going on with a patient’s brain is very different than what may actually be going on. It was my ‘ah ha’ moment,” Motamed says.
Implementing Preoperative Neurocognitive Testing
Motamed and his team did a subsequent internal study to see how well their preop clinic could tell if patients had a neurocognitive disorder just from the patient interview. “After the provider spent 15 minutes with a patient, we asked them: ‘Do you think this patient would fail or pass the Mini-Cog?” When patients’ Mini-Cog results were revealed, providers were correct only 50% of the time. “It was a coin toss. The study confirmed that as clinicians, we’re just not good at picking up neurocognitive decline during short interactions and patients are good at talking around things. They may not even be aware themselves that their brain isn’t working the way it used to,” Motamed says.
Many older surgical patients don’t undergo screening for neurocognitive decline preoperatively. If cognitive impairment isn’t listed on their chart, it may be because it’s either not being screened for or no one has paid attention. But a simple presurgical screening tool, such as the Mini-Cog, a three-minute screening tests that consists of two components: a three-item recall test for memory and a simply scored clock drawing test, can get the ball rolling. “My general recommendation for any institution or hospital that wants to begin preoperative neurocognitive testing would be to just start with the Mini-Cog. It’s cheap, doesn’t take any time and the results are so powerful,” Motamed says.
Presenting Mini-Cog Data
Motamed recommends having surgical patients age 65 and older do the Mini-Cog during their pre-op appointment. While taking the patient’s preoperative vitals, a medical assistant could administer the Mini-Cog by asking patients to remember three words and handing them a sheet of paper to draw a clock face with 10 past 10.
“Collect the data on your own patients,” he says. Studies report an incidence of 25% in patients 80 to 84; 37. Still, it pays to collect the data on your own patients because the information is more compelling, Motamed says. Keck’s data for patient over age 65 is 24% based on over 3,000 screens.
Once you have several weeks of Mini-Cog data, present it to hospital administration by making a visual impact. “Put up a picture of what we consider to be a normal patient and a picture of their Mini-Cog clock draw,” Motamed says. “Most people will be able to relate to it. Many hospital administrators in management positions are either in that age range in which they’re personally concerned or have parents and other family members in that age range who are potentially dealing with these issues,” Motamed says. “They need to see the data because when they don’t see it, they don’t know it exists.”
“That’s what happened with us. The data was so compelling that it was an easy sell to hospital administrators,” Motamed says. “When you see patients who appear cognitively intact and then tell them to draw a clock and they draw a car, or an apple, you have no choice but to then take action. Our hospital administrators and surgeons were very supportive.”
Changing Clinical Practice
The Mini-Cog is changing clinical practice at Keck Hospital. If patients fail the Mini-Cog, an occupational therapist will conduct more extensive testing with the patient. Providers may also spend extra time with patients when giving preoperative and postoperative instructions. One elderly patient did so poorly on his Mini-Cog that allowing him to drive himself home was a safety risk. The staff contacted the patient’s son to pick him up. There was no indication of cognitive decline on his medical record.
Motamed and his team have also provided educational sessions to the anesthesia providers on the meaning of Mini-Cog scores, such as 5/5 = normal, ≤2/5 = fail. They also routinely note patients’ Mini-Cog scores in their preop clinic note, such as “Mini-Cog 2/5,” which is visible to anyone opening the patient’s EMR. For patients with poor Mini-Cog scores, anesthesiologists have stopped giving benozdiazepenes. They altered the management of patients just from seeing patients’ Mini-Cog scores in the patients’ EMR, Motamed says. It all goes back to getting the data and putting it out there to create change.
“We’re pretty good at caring for patients with cardiac, lung, and kidney issues, but the brain is the next area we need to focus on,” Motamed says. “The Mini-Cog is one tool that can help guide you in a way that results in a better outcome for the patient. All you need is to give the patients three words to remember and a sheet of paper for drawing a clock.”
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