Frailty and Cognitive Screening for the Elderly: Should it Be a Routine Practice?

Educational Objectives

The goal of this program is to improve preoperative screening of elderly patients for cognitive dysfunction and frailty. After hearing and assimilating this program, the clinician will be better able to:

1. Identify risk factors for frailty and preoperative and postoperative cognitive dysfunction.
2. Employ recommendations for screening for cognitive dysfunction and frailty.

Summary

Preoperative cognitive dysfunction: cognition consists of the mental processes involved in gaining knowledge and understanding, including perception, memory, attention, reasoning, problem solving, and decision-making; preoperative dysfunction in these processes predicts postoperative dysfunction; risk factors include, eg, age >65 yr, presence of a functional or sensory handicap, extremes of body mass index, hypertension, diabetes mellitus, coronary artery disease, chronic renal insufficiency

Frailty: a decrease in physiologic reserve across several organ systems, resulting in a lack of resistance to stressors; frailty is often marked by weakness (assessed through grip strength), slower motor movements (eg, walking speed), decreased physical activity, increased fatigue and exhaustion, and unintentional weight loss; patients often struggle to complete their activities of daily living, have decreased mobility, higher risk for cognitive impairment, and are much less likely to return to baseline function after a major stressor (eg, operation); 10% of adults ≥65 yr of age have complete frailty; 45% of adults ≥65 yr of age show signs of frailty; ≈33% aged ≥80 yr have complete frailty; frailty is more common among women and among patients requiring surgical procedures

Consequences: preoperative cognitive dysfunction and frailty are associated with increased morbidity, mortality, and postoperative complications (eg, pneumonia, ventilator dependence, urinary tract infection, acute renal disease), need for post-discharge institutionalization, and increased risks for postoperative delirium and postoperative cognitive dysfunction (POCD); delirium and POCD are the 2 most common complications among patients >65 yr of age; some estimates suggest that 30% to 80% of patients have some degree of delirium after major surgery, 30% to 40% experience early POCD (defined as cognitive dysfunction manifesting prior to hospital discharge), and 10% to 15% develop late POCD (3 mo after surgery); delirium and POCD are associated with increased length of stay, morbidity, mortality, costs, and use of health care resources

Screening: recommendations — the American Society of Anesthesiologists (ASA), American Geriatric Society, and American College of Surgeons recommend screening for patients who are >65 yr of age or at high risk for preoperative cognitive dysfunction and frailty; despite recommendations, screening is not widely implemented; the ASA formed the Brain Health Initiative to educate others and promote provision of better perioperative cognitive care for patients >65 yr of age; per Berger et al (2018), “Baseline cognition should be objectively evaluated with a brief screening tool during preoperative evaluation in all patients >65 yr of age and in any patient with risk factors for preexisting cognitive impairment”; benefits — screening improves physician ability to provide informed consent and may lead to a new diagnosis, prompting additional neurocognitive evaluation; Partridge et al (2014) demonstrated that ≈66% of patients ≥60 yr of age presenting for vascular surgery have baseline cognitive dysfunction or dementia (previously unrecognized in ≈90% of patients); screening aids in risk stratification, improves patient ability to time important decisions, improves diagnosis of postoperative neurocognitive disorders, and improves planning of perioperative care

Anesthesia-specific measures: for patients with preoperative cognitive dysfunction, use age-adjusted maximum anesthesia concentration for volatile anesthetics, reduce or avoid the use of medications that can worsen postoperative cognitive function (eg, antihistamines, anticholinergics, benzodiazepines, metoclopramide, meperidine, corticosteroids), and adopt a multimodal analgesic approach to pain management (including attempting to reduce opioid use when possible); evidence suggests it is more important to prevent uncontrolled pain by providing adequate analgesia than to avoid opioids; though recent research has explored the use of intraoperative raw electroencephalography monitoring to avoid excessively deep anesthesia and prevent POCD, the results of these studies have been inconsistent, and the efficacy of this approach in preventing POCD remains uncertain; avoid hypoxia and hypotension to maintain cerebral perfusion; evidence does not suggest an association between the type of anesthesia and risk for POCD

System-specific measures: positive preoperative screening can result in preoperative referrals for neuropsychiatric evaluation, cognitive training, and prehabilitation; a multidisciplinary team can care for high-risk patients; education programs are beneficial; screening for delirium facilitates early detection; encourage early mobilization, frequent reorientation techniques, return of sensory and cognitive aids, facilitation of normal sleep-wake cycles, presence of family and friends, reduction of unnecessary transfers of care, and minimization of noise

Barriers to implementation: include lack of education, lack of a defined standard for preoperative screening, low institutional support, and time and economic pressures

Screening settings: large institutions with ample resources can develop formal education at the institution level for various health care professionals and establish standardized screening processes that are conducted well before the day of surgery (ideally during preoperative clinic visits); a multidisciplinary team is involved throughout the entire perioperative process (ie, preoperative optimization, day-of-surgery care, postoperative management, discharge planning); it may be challenging to implement screening processes in private practices or small institutions

Screening tools: the most commonly recommended screening tool for preoperative cognitive screening is the Mini-Cog tool, which involves patients memorizing a list of 3 objects (step 1), drawing a clock with a specific time (step 2), and recalling the original list of 3 objects (step 3); the most common tool to screen for frailty is the FRAIL questionnaire, which involves asking patients questions regarding their daily activities; both screening tools can be completed in <5 min total; when use of screening tools is impractical, judge patient fitness for surgery based on the initial clinical impression; evidence suggests an experienced provider’s assessment correlates well with the risk for developing POCD and delirium

Readings

Allison R 2nd, Assadzandi S, Adelman M. Frailty: evaluation and management. Am Fam Physician. 2021;103(4):219-226; Berger M, Schenning KJ, Brown CH 4th, et al. Best practices for postoperative brain health: recommendations from the fifth International Perioperative Neurotoxicity Working Group. Anesth Analg. 2018;127(6):1406-1413. doi:10.1213/ANE.0000000000003841; Brodier EA, Cibelli M. Postoperative cognitive dysfunction in clinical practice. BJA Educ. 2021;21(2):75-82. doi:10.1016/j.bjae.2020.10.004; Charipova K, Urits I, Viswanath O, et al. Preoperative assessment and optimization of cognitive dysfunction and frailty in the ambulatory surgical patient. Curr Opin Anaesthesiol. 2020;33(6):732-739. doi:10.1097/ACO.0000000000000901; Gregory SH, King CR, Ben Abdallah A, et al. Abnormal preoperative cognitive screening in aged surgical patients: a retrospective cohort analysis. Br J Anaesth. 2021;126(1):230-237. doi:10.1016/j.bja.2020.08.026; Partridge JS, Dhesi JK, Cross JD, et al. The prevalence and impact of undiagnosed cognitive impairment in older vascular surgical patients. J Vasc Surg. 2014;60(4):1002-11.e3. doi:10.1016/j.jvs.2014.04.041; Seitz DP, Chan CC, Newton HT, et al. Mini-Cog for the detection of dementia within a primary care setting. Cochrane Database Syst Rev. 2021;7(7):CD011415. doi:10.1002/14651858.CD011415.pub3.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Starling was recorded at Texas Society of Anesthesiologists 2024 Annual Meeting, held September 5-8, 2024, in San Antonio, TX, and presented by the Texas Society of Anesthesiologists. For information on upcoming CME activities from this presenter, please visit tsa.org. Audio Digest thanks the speakers and Texas Society of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

AN664703

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.