Preoperative Cognitive Evaluations

Most surgeons would not perform an elective surgery, especially one requiring admission, without a preoperative assessment of cardiac risk—for good reason. At the time of Dr. Lee Goldman's first publication recommending a cardiac risk stratification index, the mortality rate of patients with coronary artery disease undergoing non-cardiac surgery was 22.3%.1 A preoperative cardiac risk assessment quickly became standard practice to preserve cardiac function and reduce morbidity, mortality, and dependency after surgery. Recognizing the value of a preoperative cardiac risk assessment, there are now similar practices for preoperative assessments of other organs: Creatinine measurements for the kidneys, pulmonary function tests for the lungs, and blood tests for coagulation. What about the brain? Older adults (age 65 and above) commonly have some degree of cognitive impairment, which we define as poor performance in at least 1 cognitive domain that is beyond what is expected for normal aging. Older adults currently comprise approximately 50% of surgical patients in the United States and studies suggest the prevalence of cognitive impairment in older adults pursuing elective surgery is 25%–45%.2,3 As the population ages, surgeons will see an increasing number of older adults, many of whom will have cognitive impairment. A preoperative assessment of the brain's cognitive capacity to withstand a surgical procedure would help patients, caregivers, and surgical teams with decision making and management in the perioperative period. It is time for a preoperative cognitive assessment to become standard practice. Evidence of impaired cognition is often subtle, but may greatly impact a patient's postoperative outcomes. Cognitive impairment in older surgical patients is associated with higher rates of acute renal failure, pneumonia, septicemia, stoke, falls, urinary tract infections, delirium, and cognitive and functional changes that can persist for months after discharge.2 These complications contribute to additional medical complexity, healthcare utilization, healthcare spending (delirium alone costs the US health care system $164 billion each year), and increases dependency after surgery.4 Early identification of cognitive impairment in older adults undergoing surgery with a planned admission is paramount for improving outcomes. Recognizing the importance of cognition, new guidelines from the American College of Surgery recommend preoperative cognitive assessments for older adults; however, this practice has no widely accepted standard approach.4 There are many modalities to evaluate cognition ranging from very quick assessments for dementia (eg, Clock Drawing test or the Mini-Cog); to more sensitive tests such as the Mini Mental Status Exam or Montreal Cognitive Assessment (6–10 minutes); to self-administered testing.5 But if no cognitive assessment is done, then patients will not have the opportunity to benefit from interventions available in the pre-, intra-, and postoperative periods that help preserve cognition and independence after surgery (Fig. 1).FIGURE 1: Perioperative interventions available to help preserve cognition and independence in older surgical patients with cognitive impairment.The goals of a preoperative cognitive evaluation parallel many of the goals of the preoperative evaluation of other organ systems. For example, in patients with cardiovascular disease, the preoperative cardiac assessment allows for cardiac optimization, assists with decision making, and influences perioperative management. In some patients, the cardiac assessment presents an opportunity for interventions such as improving blood pressure, additional diuresis for heart failure, or in rare cases, coronary revascularization. In many instances, however, chronic diseases in older adults—like coronary artery disease or chronic obstructive pulmonary disease—cannot be further optimized. In such cases, information from the preoperative evaluation assists surgeons and patients when weighing the potential for harm against the clinical benefits of a proposed surgery. It also helps in guiding medical management in the intra- and postoperative periods. Detection of underlying cognitive impairment could help in the same ways: to provide opportunities to optimize cognition, better inform the decision to pursue surgery, and promote intra and post-op management strategies that minimize injury to a vulnerable brain. In the preoperative period, early identification of cognitive impairment may first influence the decision to undergo surgery. This includes whether to proceed versus reconsidering medical management or a different surgical approach; or, if there are concerns about a patient's ability to provide informed consent or follow postoperative instructions. It could also facilitate deprescribing or dose reductions of centrally-acting medications such as anticholinergics, benzodiazapines, and opiates. These medications are associated with cognitive impairment and also increase the odds of developing of postoperative delirium.6 Referrals to social work could facilitate completion of a medical durable power of attorney, help caregivers complete paperwork for medical leave, and start discharge planning early by identifying preferred homecare agencies and subacute facilities before the surgery. Enhanced preoperative education that focuses on the recovery process at home would also help patients and families prepare for higher dependence and need for supervision after discharge. Using a multidisciplinary approach to medically and socially optimize older adults before surgery has been associated with a reductions in length of stay and postoperative complications.7 Such interventions could help in preserving cognition and independence after surgery. Intraoperatively, knowledge of cognitive impairment may inform anesthesia's choice of medications and degree of intraoperative sedation. It may also change the medications that are given as part of the Enhanced Recovery After Surgery protocol. Steroids, haloperidol, and diphenhydramine are often used for nausea prophylaxis but are frequent precipitants of delirium, especially in older adults with cognitive impairment. Postoperatively, patients with impaired cognition can benefit from early referrals to cost-effective, evidence-based delirium prevention programs such as the Hospital Elder Life Program (HELP)—a multidisciplinary program that provides patient-centered interventions such as daily visits for cognitive engagement, early mobilization, assistance during meals, education, and care coordination. In a 2017 study of older adults undergoing abdominal surgery, enrolling older adults in HELP reduced the odds of delirium by 56% and length of stay by 2 days.8 Other studies show a reduced risk of cognitive and functional decline, falls, and length of stay for older adults enrolled in HELP. The estimated savings of HELP are $1600 to $3800 per patient in-hospital costs and $16,000 per person-year in long term care costs.8 Knowledge of cognitive impairment may also change prescribing patterns—both in limiting centrally-acting medications and by replacing PRN medications that patients may forget are available, with scheduled doses. In doing so, surgeons may notice improved control of post-op pain, nausea, insomnia, and delirium. These small changes in the pre-, intra, and postoperative periods could yield substantial benefits to older adults. Early recognition of cognitive impairment may also help surgeons utilize other team members more effectively. Patients with cognitive impairment often have difficulty understanding and therefore adhering to recommendations (eg, NPO status, early and safe mobilization, and incentive spirometer use). When made aware, bedside nurses could help reinforce postoperative recommendations, monitor for early signs of complications common to older adults, and implement delirium and fall prevention strategies. Early consults to physical therapy and occupational therapy would help with equipment recommendations to improve functional status and in determining the appropriate discharge disposition. This would provide care coordination more time to make arrangements. Nursing and care coordinators could also help arrange for caregiver involvement in postoperative education. There is a growing body of literature suggesting that increased caregiver engagement during hospitalization and may improve outcomes. Knowledge that a patient is at higher risk for postoperative complications may also serve as a motivator for caregiver involvement. In a study of patients undergoing esophageal or pancreatic resection, involving family members at the bedside increased adherence to basic care activities such as mobilization, incentive spirometer use, cognitive engagement, and oral hygiene.9 Involvement of caregivers in the discharge process has also been associated with a 25% reduction in risk of readmission at 90 days postoperatively.10 This is likely due to improved adherence to postoperative recommendations (eg, wound care, medication changes, and mobility restrictions) and earlier recognition of potential complications. Detection of cognitive impairment in the preoperative period would underscore the need for increased caregiver involvement. It would also provide caregivers with time to make arrangements to be present at bedside (in person or virtually) and at home. As the pandemic has forced us all to evaluate our work flow and elective surgeries resume, we propose that surgical teams begin to place the same emphasis on the brain as other organ systems. This may be an opportunity for surgical teams to develop their own processes for preoperative cognitive assessments; and, educate team members (including trainees) about strategies to preserve cognition and promote independence after surgery. Cognitive impairment is common, confers higher risk, and we have interventions available to help preserve cognition and independence. Although the process for cognitive assessments will vary across practices, it will likely take surgeons to lead the charge in prioritizing the brain.

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