cognitive assessment in the elderly patient jennifer breznay, md, mph division of geriatrics...
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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
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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)
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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
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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
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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
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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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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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