Author: Michael Vlessides
Protecting the brain health of elderly patients who work their way through the perioperative process is a lofty, but attainable, goal, according to the work of a multidisciplinary team of clinicians at Keck School of Medicine of USC.
Yet, as they reported at the 2019 annual meeting of the American Society of Anesthesiologists (ASA), the key to successful development of the program lies in abtaining buy-in from a broad range of medical specialties with a common goal in mind.
“As our population ages and surgical techniques advance, more older adults are having elective surgeries,” said Justyne Decker, MD, an assistant professor of anesthesiology at Keck, in Los Angeles. “With that, the most common postoperative complication they face is the development of perioperative neurocognitive disorder.
“These cognitive changes can be life-altering to our patients and their families alike,” Dr. Decker continued. “Therefore, as perioperative clinicians, we need to provide information about this risk and work together with our patients and colleagues to do something about it.”
The Problem Is Significant
For Dr. Decker—who worked alongside Carol Peden, MD, the clinical director of anesthesiology at USC and vice chair for Performance Improvement of the Perioperative Brian Health Initiative (Figure)—the first step in the development of the program was determining the nature of the problem.
“We know the greatest risk factor for perioperative neurocognitive disorder is the presence of preoperative cognitive impairment,” Dr. Decker said in an interview with Anesthesiology News. “If you don’t establish what your problem is—the incidence of preoperative cognitive impairment—you can’t really build an initiative to combat perioperative neurocognitive disorder among patients at increased risk.”
As such, she implemented routine cognitive screening at her institution’s preoperative clinic, an effort that was well founded: 25.4% of elderly patients were identified with preoperative cognitive impairment. Dr. Decker and her colleagues used this incidence rate to drive the establishment of a multidisciplinary initiative to expand awareness and implement perioperative neurocognitive disorder risk mitigation and prevention strategies.
“From there, the next step was to build the team,” Dr. Decker explained. She and her anesthesiology colleagues reached out to their peers from a variety of departments at the institution, including family medicine (geriatrics), pharmacy, occupational therapy, internal medicine, nursing and surgery. They also recruited data analysts, information technology and hospital volunteer services.
At the 2019 annual meeting of the ASA (abstract F2074), Dr. Decker said that the execution stage of the initiative began with brief weekly meetings with members of the multidisciplinary team where they discussed the goals of the program.
The researchers then pooled their expertise and developed a perioperative care pathway built around evidence-based recommendations endorsed by the ASA, American Geriatrics Society and the American College of Surgeons. As part of this pathway, older patients routinely underwent neurocognitive screening followed by brief baseline cognitive assessments, which allowed the clinicians to appropriately stratify them according to their likelihood of developing postoperative cognitive complications.
Patients identified as high risk were then offered enrollment in the perioperative care pathway, and resources were allocated as necessary. The process, Dr. Decker noted, is similar to that used for individuals at increased risk for cardiopulmonary complications.
Nursing Plays a Key Role
Although the program is still under development, the investigators anticipate that clinicians will be given a fair degree of clinical latitude with respect to the intraoperative care of cognitively impaired patients. “We’re telling anesthesiologists and surgeons that the patient is cognitively impaired, and allowing them to guide their clinical decision making from there,” she said. “Then at least they have all the information and can do what they think is best.”
Postoperatively, the brain health initiative makes use of what Dr. Decker called “nursing champions” who ensure that older patients with cognitive impairment receive the tailored care they need after surgery. Their varied responsibilities include returning sensory aids to patients as soon as possible; advocating for placement in rooms with windows and/or near the nurses’ station; and encouraging sleep hygiene and regular daytime visitors. Nursing champions also are empowered to maximize nonpharmacologic interventions and administer lower risk medications.
“These are all aimed at helping prevent delirium events during their hospitalization and also provide the education, risk mitigation strategies, and resources for patients and families after discharge,” she explained.
Looking forward, the researchers hope to evaluate the effects of the multidisciplinary perioperative care pathway on perioperative neurocognitive disorder rates at the institution. Despite the lack of robust outcomes data, Dr. Decker nevertheless urged her colleagues to consider similar initiatives at their institutions.
“I think all institutions and practitioners have the ability to implement something into their practice,” she said. “This may range from just starting to screen older surgical patients through developing a tailored perioperative care pathway.”
Dr. Decker also recognized that local resource limitations will change the face of each program. “Everyone’s team is going to look a little different, and that’s OK. My advice is to establish your institutional problem, find your partners, and start by doing what you can with what you have. You’ll be surprised by how many other individuals within your institution have a similar passion and want to be a part of a collaborative effort.”
Perhaps the best part of the initiative is that it makes use of existing resources, which should prevent additional costs to an institution’s bottom line. “The few key things that we started with are all best practice, low cost, and easy to implement,” she added.
Role of Delirium Needs Study
As Daniel I. McIsaac, MD, MPH, an assistant professor of anesthesiology and pain medicine at the University of Ottawa, in Ontario, told Anesthesiology News, the work represents an important early step in helping to tackle issues of postoperative neurocognitive decline and delirium in older people undergoing surgery. “The team at USC has demonstrated that they can routinely conduct neurocognitive screening before surgery and engage a multidisciplinary team. These aspects are very important, as preoperative cognitive deficits are among the strongest predictors of postoperative delirium and clinically important cognitive decline after surgery. As such, multidisciplinary care at an institutional level will likely be a key component in trying to decrease these adverse outcomes.”
Yet as Dr. McIsaac discussed, substantial knowledge gaps remain. “We still don’t fully understand the causal pathway between delirium and subsequent cognitive decline,” he said. “Is delirium an important component or just a marker of preexisting issues? Will decreasing the incidence of delirium lead to better long-term cognitive outcomes?”
Answering such questions will require cognitive function to be assessed before surgery in all older people, Dr. McIsaac added, and managed by a multidisciplinary team.