By Sandra Gordon for ASA
“Frailty is similar to pre-existing cognitive dysfunction. It’s a measure of a patient’s reserve and how robust they are.”
Katie Schenning, MD, MPH, Assistant Director of the Preoperative Medicine Clinic and Associate Professor of Anesthesiology and Perioperative Medicine at Oregon Health & Science University (OHSU) School of Medicine discusses the cognitive impairment screening efforts at her preoperative clinic, which includes frailty screening.
In addition to pre-operative cognitive impairment, a growing body of research indicates that frailty is a major risk factor for post-operative delirium. That’s why patients age 65 and older having elective surgery or a procedure with anesthesia are being screened for cognitive impairment and frailty at the OHSU Preoperative Medicine Clinic in Portland, Oregon and have been since 2017.
“Frailty is similar to pre-existing cognitive dysfunction,” says Katie Schenning, MD, MPH. “It’s a measure of the patient’s reserve and how robust they are. It makes sense that folks who don’t have as much reserve are going to have some of these post-operative complications.”
At the OHSU Preoperative Medicine Clinic, patients 65 and older undergo preoperative cognitive impairment screening with the Mini-Cog and the Edmonton Frail Scale to flag those at highest risk for post-operative delirium. The Edmonton Frail Scale has a timed “get up and go” component, in which patients start in a chair, walk a few yards, then back again. During COVID-19 virtual and phone visits, patients have been taking an animal verbal fluency test: naming as many animals as they can in 60 seconds instead of drawing a clock for the Mini-Cog, and answering a simple FRAIL Scale questionnaire to assess frailty instead of the Edmonton get up and go test.
“If patients are frail or cognitively impaired based on a screening test, one of the most important things we do is inform them and their family members and caregivers about the fact they’re at increased risk for post-operative delirium,” Schenning says. “It’s really important to have these discussions with patients and family members. It’s easier for them to deal with delirium if they know what to expect.”
Delirium prevention at OHSU Hospital
After notifying patients and their families about an older surgical patient’s risk of post-operative delirium due to a score on a Mini-Cog or Edmonton Frail Scale or FRAIL scale test, the inpatient geriatric service is alerted about an upcoming hospital admission of patients at high-risk for post-operative delirium so they can monitor those patients in the hospital. “We also notify the anesthesiology and surgical teams so everyone is on the same page. It’s a multipronged approach,” Schenning says.
To reduce the risk of post-operative delirium, Schenning and her team minimize the use of high-risk medications whenever possible intraoperatively and in the PACU, including reducing or eliminating the AGS Beers Criteria medications (updated in 2019), such as benzodiazepines, Meperidine, Metoclopramide, and other drugs with anticholinergic properties. Multimodal pain control strategies are also employed, such as regional anesthesia techniques with non-opioid medications, to minimize the use of opioids to manage post-operative pain. In itself, post-operative pain can increase the risk of post-operative delirium, Schenning says.
Schenning’s team is also working on implementing an individualized geriatric post-op order set for the PACU so medications that may promote post-operative delirium can’t be selected for any geriatric patient, not just those at the highest risk for delirium.
Post-operatively, “some of the most effective prevention and management strategies are nonpharmacologic interventions,” Schenning says. For surgical patients at risk for post-operative delirium, family members are informed of strategies including reorienting their family member to time of day and place, providing assistive devices, and aiding with mobility. “Family members can play an important role in the prevention and earlier identification of postoperative delirium. They are often at the bedside and may notice subtle changes earlier than health care providers,” Schenning says.
Instituting pre-operative screening
Implementing a comprehensive preoperative screening program for post-operative delirium such as OHSU’s takes a multidisciplinary approach. “Our team worked together with the department of anesthesiology, with various surgical services, as well as the inpatient geriatric service and our preoperative medicine clinic, which is housed within the division of hospital medicine,” Schenning says. “Multidisciplinary buy-in and participation is really important.”
IT support is also necessary to automate the preoperative screening process. Screening for cognitive impairment and frailty adds several minutes to each patient’s preoperative visit. But building the Mini-Cog and frailty screening into the EMR helps minimize the actual time spent. Patient’s answers and screening data can get pulled into the patient’s chart automatically, which can then be seen by the anesthesiologist, the surgeon, and the nursing staff. “Automation takes the guesswork out of it,” Schenning says. “Everyone knows exactly where to look for the Mini-Cog and frailty data in the clinic note. It’s in the same place every single time.”
Mini-Cog and frailty screening aren’t difficult to implement after they become routine. “Once you get buy-in and convince people it’s important, it works pretty seamlessly,” Schenning says.
Schenning tracks Mini-Cog and Edmonton Frailty scores and post-operative outcomes, such as hospital length of stay and discharge to nursing home versus home in older surgical patients. “Delirium isn’t reliably measured by various units across the entire hospital but this outcome data is easy to pull from the EMR,” she says. Presenting the evidence can be useful for future analysis and the continued support of the need for screening for cognitive impairment and frailty as can increasing the general awareness of the morbidity and mortality associated with delirium itself.
Overall, “implementing a preoperative screening program certainly involved some effort, but postoperative neurocognitive disorders have always been my passion,” Schenning says. “I started with one-on-one meetings, then presented to entire departments to get buy-in from leadership of the various groups.”
Satisfaction comes from patients and their families. “I had a recent case, a geriatric patient who had a history of post-operative delirium several times over the years and her family members were frustrated. The patient would make paranoid accusations of hospital staff and say things that didn’t make sense. Her family members were so thankful someone had finally given a name to what they had experienced with their mom so many times in the past,” Schenning says, “and that it wasn’t their mom’s fault, but a post-operative complication.”
The patient didn’t experience post-operative delirium this time. “We were careful. We avoided all the high-risk medications and made a very intentional effort to avoid post-operative delirium as much as we could. It was exciting to be able to actually make a difference,” Schenning says. “I kept in touch with the patient afterwards and she was very thankful as were her family members.”