The Importance of Cognitive Assessment Before Ventricular Device Placement: A Teachable Moment

Opinion TEACHABLE MOMENT Stephanie E. Rogers, MD, MS, MPH, PA Department of Geriatrics, University of California, San Francisco. Liviu Klein, MD, MS Division of Cardiology, University of California, San Francisco. Carla Maria Perissinotto, MD, MHS Department of Geriatrics, University of California, San Francisco. Corresponding Author: Stephanie E. Rogers, MD, MS, MPH, PA, Department of Geriatrics, University of California, San Francisco, 4150 Clement St, 181G, San Francisco, CA 94121 (stephanie.rogers @ucsf.edu). LESS IS MORE The Importance of Cognitive Assessment Before Ventricular Device Placement A Teachable Moment Story From the Front Lines A 76-year-old man with systolic heart failure presented to the advanced heart failure service after optimal medi- cal management including biventricular pacing failed to improve his symptoms. A left ventricular assist device (LVAD) as destination therapy was offered to the pa- tient after he was determined not to be a transplant can- didate owing to advanced age. The risks and benefits of such a device were discussed with the patient and his family. Although the family had noticed some subtle hints of changes in his memory, such as repeating questions, word-finding difficulties, and missing appointments, these issues were not brought to the attention of the medical team, nor were they evident during multiple clinical encounters. Formal cognitive testing was not documented. The patient and his family opted to proceed with LVAD placement, which improved the patient’s heart fail- ure symptoms. However, his postoperative course was complicated by worsening behavioral outbursts, wan- dering and getting lost, locking himself in a room (re- quiring a locksmith), and, most distressing, multiple at- tempts at pulling out his heart pump driveline and disconnecting the batteries. Formal neuropsychiatric testing revealed a diagnosis of long-standing demen- tia. The family had difficulty caring for him at home, and placement in a facility was difficult owing to the reluc- tance of any facility to undertake the complex manage- ment of an LVAD, especially in a patient who was unco- operative and confused. Teachable Moment Recent studies have shown that as many as 81% of patients who meet the criteria for dementia never have a formal diagnosis. 1 Spontaneous detection by physi- cians less accurately classifies a patient with dementia than a brief, structured, cognitive assessment tool. 2 The present case illustrates an example of how failing to formally assess older adults for cognitive impairment Published Online: March 30, 2015. doi:10.1001/jamainternmed.2015.0468. Conflict of Interest Disclosures: None reported. 1. Cordell CB, Borson S, Boustani M, et al; Medicare Detection of Cognitive Impairment Workgroup. Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013;9(2):141-150. doi:10.1016/j.jalz.2012.09.011. before a procedure can lead to unintended harms or outcomes. A diagnosis of cognitive impairment or dementia can help clinicians anticipate how a patient may tolerate or adhere to the requirements of a recom- mended therapy and in turn allow patients and families a better understanding of the risks and benefits of an intervention. The American College of Surgeons and the Ameri- can Geriatrics Society recently published their Best Practices Guidelines, 3 which included a recommenda- tion to preoperatively assess for cognitive impairment in any patient older than 65 years without a known history of cognitive impairment or dementia. Demen- tia is the strongest risk factor for the development of postoperative delirium, 4 and cognitive impairment is also associated with an increased risk of perioperative mortality, worse surgical outcomes, longer hospital stays, increased risk of postoperative functional decline, 3 and increased postdischarge institution- alization. 4 In light of this, identifying individuals with cognitive impairment before an intervention is critical to allow a more comprehensive discussion of risks and benefits. As a result of this case, the formal LVAD evalua- tion at our institution now includes routine cognitive testing using the Montreal Cognitive Assessment test even in asymptomatic patients. If they score 21 or lower of a possible 30, formal neuropsychiatric testing is performed to further evaluate. During the first year of implementation of this new process, 3 previously undetected cases of considerable cognitive impair- ment (likely to interfere with the patients’ ability to properly care for and use the LVAD) were detected through routine testing, and these patients did not undergo the intervention. This formal cognitive assessment now guides the consent process, allows families and medical teams to make better-informed decisions, and may help prevent unintended harms or outcomes. 2. Borson S, Scanlan JM, Watanabe J, Tu S-P, Lessig M. Improving identification of cognitive impairment in primary care. Int J Geriatr Psychiatry. 2006;21 (4):349-355. doi:10.1002/gps.1470. Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466. doi:10.1016/j .jamcollsurg.2012.06.017. 3. Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF; American College of Surgeons National Surgical Quality Improvement Program; American Geriatrics Society. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of 4. Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg. 2009; 249(1):173-178. doi:10.1097/SLA.0b013e31818e4776. JAMA Internal Medicine June 2015 Volume 175, Number 6 (Reprinted) Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by a UCSF LIBRARY User on 06/30/2015 jamainternalmedicine.com