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Cognitive Screening in Older Patients May Help Optimize Outcomes

Xane Peters, MD, Mark Katlic, MD, FACS, Thomas N. Robinson, MD, FACS, and Sevdenur Cizginer, MD, MPH

September 11, 2023

Cognitive Screening in Older Patients May Help Optimize Outcomes

Among older surgical patients, cognitive impairment prior to surgery is prevalent. It is detected in up to 37% of noncardiac elective surgery patients and in 50% of emergent surgery patients 60 years of age or older.1 

Preoperative cognitive impairment substantially increases the risk of costly and serious postoperative complications and further cognitive decline, underscoring the importance of comprehensive risk assessment prior to surgery. This neurocognitive dysfunction introduces crucial factors into the surgical decision-making process and perioperative care planning, which has a wide-ranging impact on surgeons, patients, caregivers, and other members of the healthcare team. 

What Is Cognitive Impairment?

Cognitive impairment is characterized by dysfunction in cognitive abilities, including memory, attention, language, problem-solving, and decision-making skills. It encompasses a range of neurocognitive disorders that significantly impact a considerable portion of older adults and potentially an even larger proportion of surgical patients. 

Mild cognitive impairment represents an intermediate state between normal cognitive function and dementia, and it is characterized by cognitive deficits that do not impede patients’ independence in daily activities.  

Dementia, on the other hand, is a severe form of cognitive impairment that hampers the patient’s social and/or occupational function. Alzheimer disease is the most prevalent form of dementia, with other forms including vascular dementia and Lewy body dementia. 

Currently, around 50 million people worldwide live with dementia, and this number is projected to surpass 150 million by 2050.2 Dementia predominantly affects older adults, a growing population that undergoes a disproportionate number of operations annually.3 As a result, the surgical community needs to improve its understanding of the unique clinical needs of patients with dementia undergoing major operations. 

Implications for Patients, Surgeons, and Healthcare Systems

Cognitive impairment and dementia substantially increase the risk of postoperative adverse events both during the hospital stay and after discharge. This includes a higher risk of surgical site infection, pneumonia, intensive care unit admission, prolonged length of stay, nonhome discharge and long-term functional decline.4,5 

Preoperative cognitive impairment is the preoperative risk factor most closely associated with the development of postoperative delirium, an acute decline in cognitive function that can lead to prolonged hospitalization, functional decline, long-term cognitive decline, and development of dementia. These adverse outcomes may be attributed, in part, to challenges encountered by patients with cognitive impairment in effectively communicating and participating in preoperative care, postoperative rehabilitation, and recovery activities such as wound care, pulmonary exercise, and ambulation.5 These factors underscore the critical need for risk assessment, risk mitigation strategies, and effective navigation of goals-of-care discussions for patients with preoperative cognitive impairment.

Patients with preoperative cognitive impairment may have difficulty comprehending instructions and actively engaging in perioperative care. Undetected cognitive impairment prior to surgery can lead to ineffective communication with the patient, potentially resulting in avoidable serious complications and unsafe care transition planning. 

In cases of severe cognitive impairment like advanced dementia, the patient’s capacity to engage in the decision-making process before and after surgery may be affected. This can create a complex communication dynamic among surgeons, patients, and families/caregivers throughout their surgical care journey.  

Preoperative cognitive impairment necessitates through planning and allocation of additional resources to ensure the coordination of safe postoperative care and discharge planning for these patients. This reality places additional considerations and burdens on healthcare providers, families, and healthcare systems. 

Preoperative Questions a Surgeon Should Consider

What additional resources may be necessary for a safe discharge for the patient?

Does the patient/family understand their role in preventing delirium?

What strategies can prevent associated adverse outcomes?

Does this surgical procedure align with the patient’s overall health goals?

Are the patient and family informed about the associated adverse outcomes?

Should we include a family member or friend to assist the patient with decision-making, perioperative care, and discharge planning?

Validated Screening Tools for Preoperative Cognitive Impairment

Surgeons may wonder how cognition screening fits into the scope and workflow of their practice and how cognitive impairment may go undiagnosed before the preoperative visit. 

It is important to recognize that patients may arrive at the surgical clinic without a prior diagnosis of cognitive impairment or dementia for various reasons. Symptoms of cognitive impairment can be misinterpreted by patients, family members, or primary care physicians as normal processes. 

Patients also may delay seeking evaluation or downplay symptoms due to concerns about the associated stigma. When assessing a patient for cognitive impairment symptoms, obtaining input from trusted family members becomes crucial to gain insights into the patient’s daily routine, mood, and behavior over time. 

Cognitive impairment in this population can be subtle enough for patients to pass the initial evaluation in the exam room often referred to as the “eyeball test,” which relies solely on clinical observation. Hence, the use of validated screening tools is essential to detect subtle yet clinically significant deficits. 

Although cognitive impairment or dementia may be commonly associated with memory decline, it is important to recognize that other cognitive domains, including visuospatial, language, executive function, problem-solving, or social cognition, can only be identified thorough comprehensive cognitive assessment.6 

In the preoperative context, there are several validated screening tools available that address multiple cognitive domains. These tools are convenient for surgeons and their supporting staff because they can be completed in 15 minutes or less. Some of the available validated tools include:

  • Montreal Cognitive Assessment (MoCA) is a widely used tool to assess cognitive function. It evaluates various cognitive domains, including short-term memory, visuospatial ability, executive function, attention, language, and orientation. The MoCA can be completed in approximately 10 minutes and is available in paper, digital, or telephone formats.7 
  • Mini-Mental State Exam (MMSE) is another frequently used cognitive screening tool that assesses orientation, memory, attention, language, and executive function. The MMSE can be administered in approximately 5 minutes.8 
  • Mini-Cog is a brief cognitive screening tool that involves a three-word recall task and a clock-drawing test that evaluates visuospatial ability. It can be administered in under 5 minutes, making it a time-efficient option to assess cognitive function.9
  • Saint Louis University Mental Status is another cognitive screening tool that is readily available and can be administered in fewer than 10 minutes.10

Although each screening tool has its own strengths and weaknesses, they all share the advantage of requiring minimal time investment while providing substantial benefits to patients, families, and care teams. However, it is important to acknowledge that patients may exhibit variable performance on these screening tests due to differences in their cultural, linguistic, and educational backgrounds. 

Implementation of a screening process requires thoughtful evaluation of available resources and careful consideration of how it can be seamlessly integrated into regular preoperative surgical practice. This integration may be achieved through the administration of a preoperative screening test in the clinic waiting room by clinic support personnel. Participation in the ACS Geriatric Surgery Verification Program provides a practice-based approach to successfully integrate cognitive screening instruments, mitigate risks, and enhance the decision-making process in the care of older surgical patients.

What Can I Do If a Patient Screens Positive?

As a surgeon, there are several steps you can take when a patient screens positive for preoperative cognitive impairment:

Communicate Effectively

Adapt your communication style to accommodate the patient’s cognitive impairment. Use clear and simple language, allow extra time for comprehension, and consider providing visual aids like pictures or videos. Encourage questions from the patient and their family members. 

Involve the Patient’s Support System

Engage family members or caregiver(s) in the decision-making process and ensure they are well-informed about the patient’s condition. These individuals can provide valuable insights and assistance in managing the patient’s care. Consider providing additional resources and shifting responsibilities to family and other support mechanisms. 

Risk Assessment and Goals-of-Care Discussion

Just like you discuss increased risk of perioperative cardiac events for patients with underlying cardiac disease, talk about increased risk of delirium, related consequences (e.g., loss of function), and other adverse postoperative outcomes associated with cognitive impairment. 

Discuss the patient’s treatment preferences and potential risks to ensure the expected outcomes of surgical intervention match your patient’s health-related goals and quality-of-life objectives. Allocate extra time and resources for in-depth discussions to facilitate informed and meaningful decision-making regarding the necessity, potential benefits, and risks of the proposed operation. 

Additionally, explore alternative pathways and treatment options, considering the individual circumstances and preferences of each patient. Established values and preferences documented before surgery can serve as a valuable reference and can guide future decision-making processes in the event that a patient develops postoperative delirium and/or loses the capacity to make decisions. 

Collaborate with Other Healthcare Professionals

Consult with geriatricians, neurologists, or other specialists experienced in managing cognitive impairment. Involve a case manager and social worker teams if needed. Their expertise can help guide the perioperative care plan and address specific needs or concerns. 

Optimize Perioperative Care
  • Counsel patients and families on their critical roles in prevention, identification, and management of postoperative delirium. 
  • Activate and inform perioperative care teams to implement evidence-based delirium prevention strategies to minimize the occurrence of postoperative delirium and the associated deleterious outcomes. This approach may include appropriate medication management, maintaining a familiar environment, frequent reorientation, maintenance of normal sleep wake cycles, opioid-sparing multimodal pain regimens, regular mobilization, and immediate return of sensory aids postoperatively. 
  • Inform anesthesiology team members to avoid agents with high anticholinergic burden during surgery and minimize opioids in the perioperative recovery care unit.
  • Provide instructions to surgical recovery team members about placing patients with preoperative cognitive impairment near windows and involving family members immediately after surgery to help with efficient orientation and maintenance of normal sleep wake cycles.
  • Review all home medications and decrease anticholinergic burden through dose adjustment or deprescribing with expert input. 
Coordinate Postoperative Care and Support

Collaborate with the healthcare team to ensure a smooth transition from the hospital to postoperative settings. Provide appropriate referrals for rehabilitation, social workers, home care, or cognitive support services as needed. 

Follow Up and Monitor

Schedule regular follow up appointments to assess the patient’s recovery and cognitive function. Monitor for any changes or complications that may require further intervention.

It is important to note that formal diagnosis for cognitive impairment is established through rigorous testing, including patient interviews and questionnaires, neurological examination, and neuropsychological tests—all of which lie outside the time constraints and clinical scope of a practicing surgeon. Patients with positive screens for cognitive impairment should follow-up with a geriatrician or neurologist in addition to the action items listed here. 

By taking these proactive measures, surgeons can optimize care and outcomes for patients who screened positive for cognitive impairment.

Preoperative cognitive screening is a crucial component of preoperative assessment in older surgical adults, similar to preoperative cardiac and pulmonary assessments. 

The presence of cognitive impairment prior to surgery significantly increases the risk of undesirable postoperative outcomes and impacts patients’ ability to participate in their surgical decision-making and perioperative care, necessitating careful considerations for perioperative care. Therefore, preoperative cognitive screening is essential to identify patients at high risk for adverse postoperative outcomes and those who require more comprehensive care planning, additional resources, and thoughtful discussions about the goals of care throughout both preoperative and postoperative periods. 

By identifying patients with preoperative cognitive impairment, surgery team members can implement strategies to prevent adverse outcomes associated with cognitive impairment in the surgical setting. This proactive approach enables care teams to plan for a successful recovery and ensure a safe transition of care. Overall, preoperative cognitive screening empowers the care team to take appropriate measures to optimize outcomes and provide comprehensive care tailored to the specific needs of older surgical adults with cognitive impairment. 

For more information, listen to episode 18 of the House of Surgery podcast series, “Cognitive Impairment Screening,” hosted by Dr. Xane Peters, at facs.org/houseofsurgery.

Dr. Xane Peters is a general surgery resident at Loyola University Medical Center in Maywood, IL, and currently an ACS Clinical Scholar working with the College’s Division of Research and Optimal Patient Care.


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  2. Alzheimer’s Diseases International. World Alzheimer Report 2019: Attitudes to Dementia. 2019. Available at: https://www.alzint.org/resource/world-alzheimer-report-2019. Accessed July 26, 2023.
  3. Centers for Disease Control and Prevention. Number of all-listed procedures for discharges from short stay hospitals, by procedure category and age: United States. 2010. Available at: https://www.cdc.gov/nchs/data/nhds/4procedures/2010pro4_numberprocedureage.pdf. Accessed July 26, 2023.
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  10. Tariq SH, Tumosa N, Chibnall JT, et al. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry. 2006;14(11):900-910.