The Preoperative Phases of the Perioperative Cognitive Anesthesia Network for Older Adults Electing Surgery: Results From an Observational Cohort.

Abstract

Background: Individuals with neurodegenerative disorders are often provided the same perioperative care as unaffected peers, even though unidentified diminished preoperative "brain health" worsens surgical outcomes. We summarize the implementation and standardized data from a phased preoperative cognitive assessment consisting of screening tests administered by clinic staff and, on a failed screening, an immediate neuropsychological assessment from licensed neuropsychologists.

Methods: The present observational study used deidentified patient data provided via an honest broker over 2 years. The data included patients aged 65 or older at the time of treatment who were triaged for an in-person preoperative clinic visit, excluding those patients who were scheduled for orthopedic surgery. The cognitive screening assessed education, frailty, clock-drawing-test to command and copy conditions, and 3-word registration and recall. The neuropsychological evaluation involved 90-minute assessments with interviews, cognitive testing, interpretation, and recommendations to the perioperative care team. Standardized data from general cognition, attention, and memory metrics are shown for this current report.

Results: Of the 14,795 patients eligible for cognitive screening, 83.1% underwent screening, identifying 22.7% with atypical cognitive performance. Patients successfully screened were more often white (87.8% vs 78.4%; P < .0001), married (61.2% vs 57.9%; P < .0001), and less frail (nonfrail: 45.6% vs 20.5%; P < .0001). Of the 2790 patients referred for the comprehensive assessment, 48.9% completed the neuropsychological evaluation. Referred patients were older (74.6 ± 6.5 vs 72.9 ± 5.7 yrs; P < .0001), less educated (13.2 ± 2.9 vs 14.1 ± 2.9 yrs; P < .0001), less likely married (58.1% vs 62.8%; P < .0002), more frail (frail: 24.6% vs 16.5%; P < .0001), more likely to live in socioeconomically-deprived geographic regions (52.0% vs 47.7%; P < .0001), and had a 50% greater 1-year mortality than nonreferred patients (P < .0001). Patients who showed no impairment or had only memory impairment on the neuropsychological examination were less frail (nonfrail: 45.5% vs 30.6%; P < .0001) and only half as likely to have a canceled surgery than those who exhibited attention or combined attention and memory impairment (P = .0002).

Conclusions: Findings highlight how preoperative anesthesiology and neuropsychology teams can provide cognitive screening with referrals to brain health exams, and underscore the severity of unmet cognitive health care needs in older patients electing surgery.