COGNITIVE ASSESSMENT IN THE

ELDERLY PATIENT

Jennifer Breznay, MD, MPHDivision of Geriatrics

Department of MedicineMaimonides Medical Center

November 2, 2009

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

1960 1970 1980 1990 2000 2010 2020 2030 2040 20500

10

20

30

40

50

60

70

80

90

16.620

25.6

31.134.7

39.4

53.2

69.4

75.278.9

0.9 1.4 2.2 3 4.3 5.7 6.58.5

13.6

18.2

ElderlyOldest Old

US Bureau of the Census

DEMOGRAPHICS

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Population: 1960 to 2050 (in millions)

WHY ARE THE ELDERLYAN IMPORTANT POPULATION?

• 20th century:<65-year-olds tripled>65-year-olds increased 11

• 35% of surgeries

• 20 million surgeries/year

• Present later for care

• More comorbidities

• Tend to need more emergent care

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30-DAY SURGICAL MORTALITY

1.22.2

2.9

6

8.4

0123456789

10

30 Day Percent mortality

All ages

60 -69y

70-79y

>80y

>90 y

Emergency abdominal surgery > 80 years: 10%Major procedure mortality over 90 years: 20%

Jin & Chung. Br J Anaesth. 2001; 87:604-624.Slide 4

CORTICAL FUNCTIONS

• Level of consciousness• Orientation/perceptual ability• Memory• Attention/concentration• Language• Motor functions/praxis • Visuospatial skills• Executive function• Judgment/abstraction

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WHAT IS DEMENTIA?

• Acquired syndrome of decline in 2 or more cognitive functions

• Decline in function from baseline

• Different from normal cognitive lapses; not due to delirium, psychiatric illness, or other medical diagnoses

• Not an inherent aspect of aging 1 in 10 persons aged 65+ have dementia 1 in 2 persons aged 85+ have dementia

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CONSENSUS STATEMENT

First International Workshop on Anesthetics and Alzheimer’s Disease

• University of Pennsylvania, University of California at San Francisco, Harvard University, University of Wisconsin, University of Virginia, Columbia University, Mount Sinai School of Medicine

• May, 2008

• Interest in onset of Alzheimer’s and exposure to anesthetics

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SCREENING FORCOGNITIVE DECLINE

• Mini-Cog 3-item recall

Clock drawing test

• MMSE

• Animal naming

• Digit span

• Orientation questions

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DELIRIUM VS. DEMENTIA

• Delirium and dementia often occur together in older hospitalized patients

• The distinguishing signs of delirium are: Acute onset Cognitive fluctuations over hours or days Impaired consciousness and attention Altered sleep cycles

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MORTALITY OF DELIRIUM

In medical units at YaleNew Haven Hospital:• Mortality of in-hospital delirium: 25%33%• Unrecognized by physicians in 30%50% of cases

Inouye et al. Am J Med. May 1999.Slide 10

POST-OP DELIRIUM (1 of 2)

• Incidence 10%15% after age 65

• Increases risk of mortality and longer hospital stay

• Numerous risk factors besides advanced age: Dementia Depression Anemia Alcohol and drug withdrawal Metabolic derangement Acute MI Infection Emergency surgery

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POST-OP DELIRIUM (2 of 2)

Often due to:

• Medications

• Hypoxia

• Pain

• Infection

• Sleep deprivation

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EVALUATION: CAM(CONFUSION ASSESSMENT METHOD)

DELIRIUM

Acute onset &

fluctuating courseAND Inattention

plus either

Disorganized

thinkingAltered LOC

Inouye et al. Ann Intern Med. 1990;113:941-948. Reprinted with permission. Slide 13

AVOID INPATIENT DELIRIUM!

• Orientation strategies

• Maintain day/night schedule

• Avoid restraints

• Avoid sedative/hypnotics

• Ensure assistive devices are working (eyes

and ears)

• Avoid immobility

• Avoid dehydration

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Slide 15

ACKNOWLEDGMENTS

• Sheila R Barnett, MD, Assistant Professor of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School

• Barbara Paris, MD, Chief of Geriatrics, Maimonides Medical Center

• Kalpana Tyagaraj, MD, Program Director, Department of Anesthesiology, Maimonides Medical Center

• Dennis Feierman, MD, PhD, Vice Chairman, Department of Anesthesiology, Maimonides Medical Center

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Visit us at:

Facebook.com/AmericanGeriatricsSociety

Twitter.com/AmerGeriatrics

www.americangeriatrics.org

THANK YOU FOR YOUR TIME!

linkedin.com/company/american-geriatrics-society

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