Background:

By 2080, 1 in 7 of the European population will be over the age of 80 years. The elderly have greater comorbidities and require more frequent hospital admissions. There is a consequent responsibility for medical professionals to ‘get it right’ for this cohort. Any rise in avoidable hospital complications and length of stay therefore has potentially huge implications for quality and safety of care and greatly increased financial cost.
Pre-existing cognitive impairment in the elderly strongly predicts post-operative delirium. This is associated with longer hospital stays, increased peri-operative mortality and post-operative functional decline. Cognitive impairment should be routinely screened for and delirium risk factors aggressively minimised in the elderly. We performed a snapshot study of elderly patients admitted to 2 general surgical and 1 orthopaedic wards to investigate this issue.

Methods:
All patients over 75 years old (in total 37) admitted over 3 weeks were screened for delirium risk factors and their cognitive function was assessed daily using the Mini-Cog tool. A score of 0-2 indicated impairment and a drop in daily score was also noted. Drug charts and patient notes were also reviewed to identify patients that were taking cognition-affecting (‘Beer’s criteria’ positive) medications and whether peri-operative screening for cognitive impairment had occurred.

Results and Discussion:
100% of our patients had 2 or more delirium risk factors. Notably, none had any documented pre-operative cognitive screening in hospital.
35% of patients had a Mini-Cog score of 2 or less during their admission. Over 1 in 5 of patients dropped scores at least once and of these 3 were taking Beer’s positive drugs. Interestingly, 1 patient had scores that dropped over 3 days - in retrospect this clearly heralded clinical deterioration and subsequent admission to ITU.
More than 40% (16 patients) of the patients were on 1 medication with cognition-altering effects, 12% were on 2 such drugs. Of these, 6 patient’s drugs were started in hospital.

Conclusion:
Despite the clear risks posed by cognitive impairment and peri-operative delirium in our elderly patients, these remain poorly recognised.
Screening at any time throughout admission appears scant. Single point assessment can be misleading as it doesn’t identify all those with peri-operative delirium. Assessment should occur more frequently in ‘at-risk’ elderly patients.

Getting it wrong: avoidable perioperative delirium in our elderly?