Beyond the Mini-Cog: Developing a Perioperative Brain Health Initiative at Keck Hospital

“Developing our PBHI with minimal funding took passion and knowledgeable willing parties, whom we call champions.”

December, 2020
By Sandra Gordon for ASA

Carolyn Kaloostian, MD, MPH, a clinical associate professor of family and geriatric medicine at Keck Medicine of USC discusses the patient-centered approach her hospital has made to manage older surgical patients who fail the Mini-Cog screening in the preop clinic.

After the PBHI team at USC initially began screening older surgical patients with the Mini-Cog screening tool in the preop clinic in 2018, it quickly became apparent a next step was necessary for patients who failed the screening test, with a score of two or three. But what? It was then that Carolyn Kaloostian, MD, MPH, a family and geriatric medicine physician at Keck Medicine of USC championed for the hospital’s perioperative brain health initiative led by Justyne Decker, MD, clinical assistant professor of anesthesiology and Carol Peden, MD, clinical professor of anesthesiology, at the Keck School of Medicine at USC.

Implementing a Mini GAP Program
Kaloostian, a geriatrician who directed the HRSA GWEP Geriatric Assessment Program (GAP) for patients showing signs of advanced cognitive impairment, created a “mini GAP” for older surgical patients who failed their Mini-Cog at their preop visit. “We suspected patients who scored poorly were at higher risk of surgical complications and we hoped to reduce this risk,” Kaloostian says. “The PBHI was a great opportunity to develop a management plan for a patient with an abnormal cognitive test.”

Kaloostian recruited a pharmacist who was equally passionate about geriatric brain health. Together, they began conducting 5 p.m. video chats with patients to review their medications. “Patients typically think: ‘I failed the Mini-Cog. I must have dementia or Alzheimer’s,’ but that’s the farthest from reality,” Kaloostian says. “Many issues could cause an abnormal Mini-Cog score.”

Reasons for Failing the Mini-Cog

  • True cognitive changes
  • Taking the screening test without eyeglasses or hearing aid
  • Unmanaged pain
  • Thyroid dysfunction
  • Vitamin B12 deficiency
  • Depression
  • Language barrier
  • Medication side effects

Overall, Kaloostian and her team can help reverse some impairments. “If you improve depression, patients Mini-Cog scores improve. If you improve vitamin deficiencies, their scores get better,” Kaloostian says. In some cases, Kaloostian may conduct more in-depth cognitive testing, which may include the Montreal Cognitive Assessment (MoCA). “Ideally, we’re hoping to see less post-operative complications such as delirium due to our intervention,” she says.

Continuity of Care
USC’s Perioperative Brain Health Initiative crosses over the entirety of the perioperative experience. “We developed a program identifying patients in the pre-operative evaluation, followed them through the surgical experience and ensured continuity of care with their primary care provider. For example, the surgeon and the nursing team would be alerted to the Mini-Cog score and thus change management of the case accordingly, such as perhaps avoiding benzodiazepines and anticholinergic medications,” Kaloostian says. After surgery, Kaloostian calls the patient’s primary care provider, whether or not the provider was in network, to relay the patient’s Mini-Cog score. “I would also convey any reversible causes of the abnormal test such as depression, and our recommendations for follow-up,” Kaloostian says. “The continuity of the PBHI has been impactful for patients, their families and the health care team.”

Practical Advice for Implementing a PBHI
How does a patient-centered PBHI like this come to life? Kaloostian offers these recommendations for a PBHI program that requires little funding.

Choose your champions carefully. Before initiating a PBHI, “identify a professional within your organization who has an established relationship with different specialties, a true intra-professional who has worked, for example with OT, and even knows them by name,” Kaloostian says. “I was lucky I was in the GAP clinic and knew some of the most passionate, caring pharmacists, OTs and PTs interested in brain health.” Ideally, that person is a good team player and has a background in management and health care innovation, as Kaloostian does. Continue to build your PBHI team by recruiting champions passionate about brain health across the various disciplines. “Ideally, we want innovation without overburdening the care team,” Kaloostian says.

Educate the nursing staff. Kaloostian and her team conducted in-service meetings and other presentations to educate the nursing staff about the PBHI. With a $2000 team building grant (the extent of their funding), they had brain health initiative stickers designed and printed. To build program awareness “we put brain health stickers on trays of donuts and delivered them to their nursing meetings,” Kaloostian says.

Recruit a family physician. If your health system doesn’t have a geriatrician, recruit a family physician or other geriatric-trained profession with an interest in brain health to be a champion. These providers can check for reversible causes of cognitive decline, such as depression, vitamin and thyroid deficiencies.

Overall, “we thought a program like this was going to be tedious and so much work. It did take passion and knowledgeable willing parties whom we call champions, but it wasn’t as difficult as we anticipated,” Kaloostian says.


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