David A Scott Lis Evered. Department of Anaesthesia and Acute Pain Medicine St Vincent s Hospital, Melbourne University of Melbourne

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1 David A Scott Lis Evered Department of Anaesthesia and Acute Pain Medicine St Vincent s Hospital, Melbourne University of Melbourne

2 This talk will include live polling so please be sure to have the meeting app downloaded! Android: iphone: Access code: PeriSIG18

3 Aims: Understand the new terminology and definitions for perioperative neurocognitive disorders (PND) Differentiate between delayed neurocognitive disorder (dncr) and Postoperative Delirium (POD) Identify risk factors for PND Understand simple screening tools for cognition and delirium screening Learn the basics of scoring screening tools and how to interpret the results

4 POCD is a research diagnosis Neuropsychological battery Rey AVLT Trails A&B Pegboard CERAD COWAT DSST POCD = sd on 2 tests or cumulative z-score sd

5 Recommended terminology for the cognitive impairment associated with anaesthesia and surgery which is consistent with other medical disciplines including neurology, psychiatry and gerontology

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7 2013 DSM-5: Neurocognitive Disorders (NCD) Disorders where the primary clinical deficit is in cognitive function Mild NCD NIA-AA: MCI Objective decline in cognition (1-2 SD below controls/norms) Preserved ADLs Cognitive concern Not delirium nor otherwise explained Major NCD Objective decline in cognition ( 2 SD below controls/norms) Decline in ADLs Cognitive concern NIA-AA: Dementia Not delirium nor otherwise explained

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9 Postoperative Cognitive Dysfunction (POCD) PerioperativeNeurocognitive Disorders (PND) Subtle change in cognition Defined on a battery of cognitive tests Decrease in a test of 1.96 SD (controls) Decrease in 2 tests out of battery (5-10) Measured at time intervals after surgery Occurs following cardiac surgery, noncardiac surgery and sedation Only known predictors are age, IQ and subtle baseline cognitive impairment Subtle change in cognition Defined on at least one cognitive test Decrease in a test of 1-2 (mild); 2 SD (major) (controls/norms) Decrease in one domain Measured over the lifespan Occurs in population 65y or more Only known predictors are age, IQ and subtle baseline cognitive impairment Subjective deficit required IADL assessment (function)

10 Aims: understand the new terminology and definitions for perioperative neurocognitive disorders (PND) Differentiate between delayed neurocognitive disorder (dncr) and Postoperative Delirium (POD) Identify risk factors for PND Understand simple screening tools for cognition and delirium screening Learn the basics of scoring screening tools and how to interpret the results

11 Pre-op Cognition Anaesthesia/Surgery EMERGENCE Perioperative Neurocognitive Disorders Uneventful recovery days weeks months years Delirium or not POCD Early dncr POCD Late Postoperative NCD Dementia NCD Elderly 5 60% 10 50% 10-15%

12 Cognitive function Perioperative Neurocognitive Disorders POCD/NCD 0 Preoperative Perioperative period: Delirium Cognitive nadir day 30-90

13 Time-course of Cognitive change Early POCD/dNCR and Delirium Delirium in Elderly patients 30 65% Orthopaedic arthroplasty 5-14% Orthopaedic # NOF 35 65% Cardiac & Vascular Surgery 37 52% ICU 19 82% 7d 4w 6w 3m 12 m 5y 7.5y Shaw 1987 Newman 2001 Van-Dijk 2002 Liu 2009 Rodriguez 2010 Royse 2011 Evered 2016 DECS 2014 Colak 2014 Shaw 1987 non ISPOCD 1998 non Steinmetz 2010 non Evered 2011 non Ballard 2012 non Radtke 2013 non Chan 2013 non Silbert 2014 Scott 2014 non

14 Perioperative Cognitive Disorders What s the difference between POCD/dNCR and Delirium? Features / characteristics Risk Factors

15 Early postoperative neurocognitive signs and symptoms POCD / dncr Emergence excitation Delirium? Confusion Fluctuating conscious state Disorganised thinking Fluctuating conscious state Memory problems Forgetfulness Acute onset Executive functions Concentration Acute onset Planning / high level thinking Agitation on ward Inattention Acute onset Agitation on ward

16 MMSE? Mini-mental State Examination Orientation, instructions, language, attention Max 30, impairment < 24 [7-8 min] ceiling effect decreases sensitivity for MCI easier to use in more impaired patients Sensitivity Specificity MMSE 66% 97% NOT = POCD / dncr / POD

17 Delirium - DSM 5 Criteria 4 3

18 Delirium screening & diagnosis 4AT 3D-CAM CAM CAM-ICU Marcantonio E, Inouye S. Ann Intern Med. 2014;161:

19 Delirium The extent of the problem Affects > 50% of hospitalised elderly patients It is NOT a transient inconvenience Adverse outcomes Acute & Long term Costs average of US$26,000 per patient est. US$164 Billion (2011) Delayed discharge Complications Dependency Dementia Death Preventable in up to 40% of inpatients Inouye, Marcantonio 2016 Alzheimer s & Dementia epub

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21 Impact: POCD/NCD Increased mortality at 1y and 7.5 y (Monk et al; Evered et al) Delayed discharge (Silbert et al) Decreased return to work (Steinmetz et al) Decreased quality of life at 5y (Newman et al)? Increased risk of MCI / dementia? Anaesthesia associated with AD pathology

22 Long-term consequences of POCD 701 patients followed up for median 8.5 years Cognition assessed at Baseline, 1 week, 3 months post operative No 3 Mo No 1 week 3 Mo 1 week Survival OR 1.63 [ ] Labour market disengagement OR 2.26 [ ] Denmark: Steinmetz J et al ISPOCD Group Anesthesiology 2009; 110:548 55

23 Delirium, Cognition and Dementia Non-cardiac surgery SAGES 70y n=560 Cardiac surgery 70y n=225 Baseline adjusted Delirium 46% Risk lower baseline MMSE 24% Baseline actual 24% Inouye, S Alz and Dementia 2016; 12(7): Saczynski et al N Engl J Med 2012; 367(1): 30-39

24 Aims: Understand the new terminology and definitions for perioperative neurocognitive disorders (PND) Differentiate between delayed neurocognitive disorder (dncr) and Postoperative Delirium (POD) Identify risk factors for PND (POCD / dncr / POD / NCD) Understand simple screening tools for cognition and delirium screening Learn the basics of scoring screening tools and how to interpret the results

25 POCD and Delirium Risk Factors POCD / dncr POD Increasing age Lower education / IQ Preoperative cognitive impairment Increasing age Cognitive Impairment Comorbidities Drugs Frailty Polypharmacy / Alcohol / Benzodiazepines Functional impairment / Lack of mobilisation Sensory deficits / lack of orientation Visual / Auditory Prior events Bladder catheter Complications Type of surgery Pain Sleep disruption

26 Aims: factors for PND Understand simple screening tools for cognition and delirium screening earn the basics of scoring screening tools and how to interpret the results Learn the basics of scoring screening tools and how to interpret the results

27 Screening versus diagnosis Population screening versus selective screening Not diagnostic Ideally Easy to administer / do Inexpensive High negative predictive value Caution with use of result false positive effect Should lead to further and more specific testing

28 Baseline Clinical Evaluation Routine clinical interview Diagnosis of Pre-dementia, MCI, Dementia Risk for pre-existing cognitive impairment Vascular disease Family history Genetic (ApoE) if known Prior head injury Age Cognitive risk Any memory problems Level of education Partner / informant information

29 Neuropsychological Testing MCI/Dementia Informant Memory Orientation Judgement /Problem solving Community affairs Home/hobbies Personal care Subject Memory Orientation Judgement/problem solving Subjective complaint or concern patient / family / clinician Functional assessment ADLs / IADLs

30 What we need is.. Quick, easy to administer, reliable screening tools for Cognitive screening Delirium screening

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32

33 Clock Drawing scoring for Mini-cog 0 or 2 points Response Question 1

34 Clock Drawing scoring for Mini-cog 0 or 2 points Answer: 0 Response Question 1

35 Clock Drawing scoring for Mini-cog 0 or 2 points Response Question 2

36 Clock Drawing scoring for Mini-cog 0 or 2 points Answer: 2 Response Question 2

37 Clock Drawing scoring for Mini-cog 0 or 2 points Response Question 3

38 Clock Drawing scoring for Mini-cog 0 or 2 points Answer: 0 Response Question 3

39 Clock Drawing scoring for Mini-cog 0 or 2 points Answer: 0 2 0

40 Montreal Cognitive Assessment Screening test for MCI ( < 10 min) Max 30, impairment < 26 (or 24) [10-12 min] Multiple domains Greater sensitivity to detect MCI and mild AD than the MMSE Sensitivity Specificity MMSE 66% 97% MoCA 94% 42% Available in multiple languages Not good for change detection even over a 6- month period

41 Clock Drawing Instruction: I want you to draw the face of a clock, put in all the numbers, and set the hands to 10 past 11.

42 MoCA clock scoring Scoring: One point is allocated for each of the following three criteria: Contour (1 pt.): the clock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle); Numbers (1 pt.): all clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour; Hands (1 pt.): there must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centred within the clock face with their junction close to the clock centre. A point is not assigned for a given element if any of the above-criteria are not met.

43 Clock Drawing scoring for MoCA 3 points max Contour Numbers Hands Response Question 4

44 Clock Drawing scoring for MoCA Answer: 3 3 points max Contour Numbers Hands Contour (1 pt.): the clock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle); Numbers (1 pt.): all clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour; Response Question 4 Hands (1 pt.): there must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centred within the clock face with their junction close to the clock centre.

45 Clock Drawing scoring for MoCA 3 points max Contour Numbers Hands Response Question 5

46 Clock Drawing scoring for MoCA Answer: 1 3 points max Contour Numbers Hands Contour (1 pt.): the clock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle); Numbers (1 pt.): all clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour; Response Question 5 Hands (1 pt.): there must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centred within the clock face with their junction close to the clock centre.

47 Clock Drawing scoring for MoCA 3 points max Contour Numbers Hands Response Question 6

48 Clock Drawing scoring for MoCA Answer: 1 3 points max Contour Numbers Hands Contour (1 pt.): the clock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle); Numbers (1 pt.): all clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour; Response Question 6 Hands (1 pt.): there must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centred within the clock face with their junction close to the clock centre.

49 Clock Drawing scoring for MoCA Answer: 3 1 1

50 TICS - Telephone Interview for Cognitive Status 1. Participant s name. (2) 2-6. Orientation. (5) 7. Participant s home address. (5) 8. Counting Backward from 20 to 0. (2) 9. Word List. (10) 10. Subtracting Serial 7s. (5) Miscellaneous questions (3) Repeat phrases (2) Current Monarch and Prime Minister s name (4) 18. Finger Tapping. (2) Opposites (2) 21. Delayed recall (10) Maximum score = 50 >38 Probable subjective memory complaint Possible MCI < 19 Possible Alzheimer s Disease

51 Screening tests MMSE MiniCOG MoCA TICS Sensitivity Specificity MMSE 66% 97% MiniCOG 76% 73% MoCA 94% 42% TICS 83% 82% 4-AT 3D-CAM

52 We all know delirium when we see it don t we? Hyperactive Hypoactive Mixed Sub-syndromal Hyperactive Mixed Hypoactive Overall Cardiac + 12% 11% 77% 23.5% + BAG-RECALL substudy Whitlock A&A 2014

53 Delirium has an Acute and Fluctuating Course cardiac non-cardiac 5 0 d1 am d1 pm d2 am d2 pm d3 am d3 pm d4 am d4 pm d5 am d5 pm

54 Delirium screening & diagnosis 4AT 3D-CAM CAM CAM-ICU Marcantonio E, Inouye S. Ann Intern Med. 2014;161:

55 Sensitivity Specificity 4AT 90% 84% 3D-CAM 95% 94%

56 Summary There is a new recommended nomenclature for Perioperative Neurocognitive Disorders POD dncr Key risk factors are Age, IQ, Pre-existing cognitive impairment Screening, applied correctly, identifies at-risk individuals but is not a diagnosis Simple screening tools are available A team approach to perioperative cognitive care is needed

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