Catherine Price, PhD, ABPP, Associate Professor, Clinical and Health Psychology/Anesthesiology Co-Director, Perioperative Cognitive Anesthesia Network at the University of Florida talks about PeCAN.
Interview conducted by Ivanhoe Broadcast News in July 2018.
Can you tell me a little bit about PeCAN?
Catherine: PeCAN stands for Perioperative Cognitive Anesthesia Network. This is a program strategically designed to identify and intervene for older adults who are at risk for cognitive change after surgery. This program has been in development since approximately 2004 and it’s based off of years of NIH funded research showing that older adults are at greater risk for cognitive change after surgeries with anesthesia. For example, in 1955 P.D. Bedford published in the Lancet that of 4,250 patients of whom 1193 had had some operation with anesthesia,, a third of the individuals (410) had family members alleging memory or thinking changed. . We now know that the integrity of aperson’s brain prior to surgery can predict if they will be at risk for later cognitive change . The clinic part of PeCAN identifies patients with reduced cognition or frailty prior to surgery and provides them with a baseline of cognitive functioning. We flag the patient as a risk and communicate with the anesthesia and surgical team about the patients’ cognitive strengths, weaknesses. We inform the team if a post-operative geriatric consult should be considered. Our goal is to pay attention to cognition and prevention. It takes a network to implement change.. Thus the Perioperative Cognitive Anesthesia Network.
So you do that for basically every patient over 65 that’s going under anesthesia through the hospital?
Catherine: No. We see patients who fail a basic cognitive screener completed by the nursing and anesthesia medical staff during their preoperative visit. If a patient fails a simple memory and attention screener, then the PeCAN clinical team members will complete a more thorough evaluation, write a note for the medical team, and provide feedback to the patient. There are all First of all, just let me tell you that as we get older, our brain changes. The brain will get smaller as we get older, unfortunately. The bumps will get thinner, and we know that in certain areas of the brain that anesthesia responds with, if they’re getting a little bit smaller, the concern is that it’s going to be a little bit more vulnerable to anesthetic effects and the stress of surgery. In our clinic, there’s a set of approximately 10 to 15 nurses and residents and attendants who run what’s called a pre-surgical center and they screen individuals who meet certain criteria. They are checking to see if there is anything they can do to prevent having complications after a surgical procedure and they try to make the whole procedure more efficient and helpful for the patient. What they do now is, in addition to accessing all the vitals, blood pressure, lungs, etc, is now access cognition with a couple little simple tests. These are tests that our neuropsychology team introduced into the clinic. If the patient, specifically a person the age of 65 or older, performs poorly on those measures, then the resident or the staff members comes to us. They say, this is a person who is having some vulnerabilities we’d really like you to check on him or her. In particular, because we are concerned about people age 65 and older because they’re at an age group where they’re more vulnerable to having memory and thinking changes after surgery. So we pay attention to people of that age. We also pay attention to people who have a history of delirium, having confusion after surgery, because we know that one of the biggest predictors of delirium is having cognitive impairment prior to surgery, particularly memory or thinking issues. We also pay attention to frailty, which is also a risk factor, and the number of anticholinergics -medication that can disrupt acetylcholine in the brain which is an important memory and attention neurotransmitter. So like I said, it’s a whole team effort.
Give me an example of some of those tests that you perform on the patients.
Catherine: The staff members give a classic test called a clock drawing test. A neurologist and neuropsychologist created it many, many years ago. There’s a classic approach where you describe a clock at a certain hand setting and patients are asked to draw it from memory. The examiner saysI want you to draw the face of a clock with all the numbers and set the hands to a certain time period. After a patient does this then he or she is asked to copy the clock. It’s a classic test and we’re actually doing it with a digital pen that records information. It gives you time in seconds and that tells us a lot about subtle behaviors that we know now are predicting changes after surgery. Once the patient completes a clock drawing, then the nurses asks the patient to complete a three word memory test. Nurses also complete a grip strength and frailty measures, and they check for education. The nursing staff records all of this information as well as the other important vital signs.
What does your team do after that if they perform badly on one of those tests?
Catherine: Let’s say a person who is age 65 or older comes in and they’re going to have a cardiac surgery and they don’t do well on one of the screening measures (the clock drawing or three word memory). Then the resident or the nurse will come get us and we’ll go in and talk to them. We tell the patient that we are about prevention.Ee want to understand how you are doing and we want to get a good baseline on how your brain is right now. So we tell we want to check their memory more thoroughly and we explain why. First of all, there are things we can tweak to help people feel a little bit more optimized prior to surgery. Second, we explain the need for a baseline… We also want to use the information about how a person is beforehand so that we can alert the anesthesiologist, the surgery team, and the geriatric nutritionist so they can optimize the person’s care and see what they can do that’s a little bit different for those patients who might have some issues. These baselines help if a person later experiences cognitive changes. After we explain this, we then ask if we can meet with the patient and family for about thirty minutes and we do some of those memory and thinking tests. We check for comprehension, we check for reading ability—a person’s ability to read tells us a lot about where their brain was when they were younger. We also check memory ability. We do different memory measures, checking attention, working memory, some planning, and some prospective memory. For example, I’ll say that the next time I show you this I want you take the top off and give me back a pill. Thirty minutes later we check to see if they could do that. We hide objects around the room to do some special memory tests. So we do all different things. And then after about thirty minutes we meet with them, give them feedback, and talk to them about ways that we can optimize.
What are some of those ways they can optimize?
Catherine: There are lots of things you could do. One thing that’s really important is to talk to them about their sleep. How many hours of sleep, are they using a CPAP machine, are they compliant with some of the sleep recommendations that they have. Are they taking any medications over the counter that they might not have known could disrupt acetylcholine or other neurotransmitters in the brain? For example, some people take Benadryl and antihistamines to help them sleep and many people think that that’s an okay thing to do. It’s okay, occasionally, but if you take it every day, particularly every day for twenty five years, that can be a problem. That can create a lot of issues, so we talk to them about that. We talk to them about the other medications that could be anticholinergic. We go through what’s called an anticholinergic risk scale and we review those medications. Then if we see some issues, we alert the primary leader of the team and the anesthesiologist so that they know they’re taking all these anticholinergics. We also talk to them about their dietary habits, bodily inflammation—a lot of things that we eat can create inflammation so we want to talk to them about general well being and health habits. Other aspects we talk about are brain activities, we give them different tips, we talk about stopping smoking because many people that come in smoke. Sometimes we find people who can’t read or read at a very low level and they’re still going through these procedures and having some difficulty. We want to make sure that the attendants and everybody know that they’re having some reading difficulties. Many times the medical professionals don’t know. If we have individuals who come in who are really demonstrating signs of Alzheimer’s disease whom have not been diagnosed before, or we have people who have small vessel vascular disease whom haven’t been diagnosed before, then our biggest issue is to make sure that they get assistance. Perhaps it won’t happen before the surgery, but at least as soon as it can after the surgery. So we will talk to them about how they’re doing, talk to them about their strengths and weaknesses, and talk about some strategies after the surgery that they need to be aware of. They need to be aware of the possibility of delirium, we talk about confusion, we talk about hyperactive aspects where a person can be agitated and pull out lines and things and then there’s also hypoactive where a person could be less attentive or engaged. And those are things that they need to watch as a family so we try to educate a lot. A lot of times we find that the family members, particularly of people who might have Alzheimer’s disease or small vessel vascular dementia or other types of dementias, are concerned that their loved one has signs and could have more cognitive issues after a surgery. When we discuss this, it basically identifies the big elephant in the room. We then talk about this.We also want to make sure that they know that they can get in touch with geriatric physicians. So we contact some of our wonderful colleagues in geriatric medicine and we have them check in with them after the surgery. That’s great because in PeCAN clinic we do a pre-surgery delirium screen. This is based off research by Sharon Inouyeand her team. . Then the geriatricians our preoperative assessment for their own post-op assessment. So that’s really nice. For individuals who may have Alzheimer’s disease or small vessel vascular dementia or any other types, the biggest thing is to also make sure that they get continuity of care. We set them up with other follow up appointments if needed and if they want to, either here at the University of Florida or other places near where they live.
Once you do the prescreening, you give them the strategies and they go through surgery. Do you follow them afterwards to see their progress so far?
Catherine: No. But just like you go in to have an audiology check for your hearing, we are a specialist for an individual who might have some concerns or vulnerability prior to surgery. We see them pre-surgery, and we can see them after but we don’t follow everybody. Now we do have prospective research that’s part of our program, and for those individuals who agree to be in our research investigations we do follow them longitudinally over time up to a year. For example, we just finished a study where we’ve been following individuals who elected to have total knee replacement surgery. For that study, we looked at individuals who were electing the surgery with general anesthesia, had the same surgery with the same surgeon and the same anesthetic protocol and we did a pre-surgery brain scan to understand how their brain was prior to surgery. Then they did paper and pencil testing, something similar to what we do here in the clinic. Then we follow them through the surgery, we monitor them with a monitor on their frontal lobes and we monitor their oxygenation level. We looked at how many emboli bubbles and bone fragments might travel up through into their brain. We just monitored them throughout the whole time and then we also did a post-surgery MRI scan to see how brain changes were. And then we followed them out to three weeks, three months, and one year after the surgery. So we just finished that one. Findings that are published right now show that there are brain changes acutely after surgery. The functional communication between the frontal and the parietal areas of the brain, particularly right in the middle of the brain, changes after surgery. It changes the most for individuals who are performing lower on their memory and thinking scores prior to surgery and for people who have more brain disease. So people who have smaller areas of the brain that are associated with memory and people who have more vascular disease in the brain are the individuals who also seem to be changing functionally after surgery. At least on this MRI scan. Now from a longitudinal standpoint, are those individuals experiencing any greater changes? We don’t know yet. We’re still finishing those analyses, but those are the type of studies that have been going on that we’ve been pushing for a long time that really pushed toward the need for these types of clinics actually. To help identify patients and give them some other resources because the research out there is very large without the numbers about how much brain integrity, cognition, and frailty pre-surgery is a risk factor for post-surgery outcome. So there’s a lot of research on that and that’s why the clinic is here and the research understanding the mechanisms of why that occurs needs to be done now. That’s what we’re building in this clinic. Some people will elect to be in prospective studies, so that’s what we’re doing.
You’re still looking into it, but explain the science behind anesthesia.
Catherine: I know anesthesia is fascinating, it really is. I’m not an anesthesiologist; I’m a neuropsychologist so my understanding is the brain and brain behavior. I would never say I’m an anesthesiologist. But with regards to anesthesia, what we know is it interacts with the frontal cortex and it interacts with an area in the middle of your brain, your thalamus and those two areas are communicating. They change and then there’s also a shift in the electrical activity between the front and the back of the brain. So the research on how the anesthesia works we don’t really know. It’s fascinating, but there is an interaction that goes with how a baseline status is and how it responds to the anesthetic. Anesthesiologists are very much trying to optimize it based on the patient so it’s always different per patient.
For this particular program, is this the first of its kind around the country or are there similar programs around the country?
Catherine: This is the first program of its kind that I know of, but it’s been pushed by lots of anesthesiology groups across the country. Now there is a really wonderful group that’s at Duke University and it’s led by geriatric physicians. It’s called Posh and they have been around for quite a while. They have targeted optimization and following patients prior to surgery, particularly cardiac surgery and that’s based on some of the research that they did around cardiac surgery in the late 1990s and early 2000s. So that’s a group. Our group is different in that we really push the cognitive component too. We’re neuropsychologists, Duke’s group is largely geriatricians, and we’re both saying that you have to do some pre-habilitation. Our clinic is unique only in the fact that I think we are really linked to the pre-surgery anesthesia. We see a lot of patients who are coming to the hospital. We typically see between five to twelve people a day who get referred to us, so we can see up to forty people a week. That may not sound like a lot, but for a neuropsychologist that’s a lot. And typically, they’re about 100 to 150 people age 65 and older who are coming through for surgical procedures throughout the hospital here for the pre-surgical center. Since august 7, one year ago, we have seen over a thousand patients prior to their surgery. People are getting older and dementia rates are increasing. Unfortunately, there was a study that shows that at least 23% of individuals in the community have undiagnosed early forms of some sort of disorder, possibly what’s called mild neurocognitive disorder. Our clinic is unique because we’re linked to the pre-surgery anesthesia center and also because of where we’ve pushed the cognitive component of care.
You said that Duke’s group was called Posh?
Catherine: Yep.
So what implications would this type of program have in the medical field?
Catherine: There’s a clinic and then there’s a research component and then there’s a training component. So right now, the implications I think are pretty promising. From a clinical perspective, there’s awareness of cognition and brain and awareness of how a person’s cognitive status can interact with elements. From a research standpoint, it provides us with an avenue so that we can begin to understand mechanisms more. It brings people together since it’s a network, so we can start to work as a larger team to tackle this important problem and issue. Then from a training perspective, it’s fabulous because now we bring people of different disciplines together. Anesthesiologists are really focused, perhaps on the pharmaceutical aspects of medication and the biochemistry, but they don’t understand the behavior aspects. Neuropsychologists work on the behavior, but they’re not really focused on the pharmaceutical aspect. Now, you push them together and we can start some synergy, pulling in your neuroscience, pulling in geriatric medicine, and pulling in biomedical engineering to improve the elements of monitoring pre and post-surgery. So it really opens up a lot of doors and improves communication.
Five years down the road, where do you see this program going? What goals do you hope to accomplish?
Catherine: Well, I hope this program will be in other hospitals. We get excellent feedback from patients and physicians, particularly primary care physicians. I do think that we need more programs like this in the country. I also believe that it will lead to more synergy for improved patient care and improved research, targeting the aspects of brain, anesthesia, surgical stress, and inflammation interactions. I really hope that it will lead to more general awareness about brain health. We pay a lot of attention to everything neck down and I get a lot of questions like, how does having a knee surgery have anything to do with my brain? Or, why would a bladder surgery make any difference to my brain? It’s all connected, it is not separate. So I really hope that it will push that bigger message of okay, it’s just another vital sign, checking your brain status. Just a couple of memory and attention measures and we’ll be able to check cognitive vital signs.
So most of the time, are you dealing with the caregivers for the patient?
Catherine: We work with the patients and we work with the caregivers. It can be very empowering to talk to the caregiver and give them some tools on what they can do postoperatively if the patient experiences delirium. Debbie, for example, was not one of our patients but was one of the inspirations. Her experience inspired us and really pushed us to move this clinic forward.
Anything else you would like to add?
Catherine: No.
END OF INTERVIEW
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