Protocol for the Pre-Operative Cognitive and

Frailty Assessment of Surgical Patients > 65 Years

Old
Protocol for the Pre-Operative Cognitive and Frailty Assessment of Surgical Patients > 65 Years Old

Abstract

Frailty and pre-operative cognitive impairment represent two important risk factors for
the development of post-operative complications, such as post-operative delirium. For
that reason, several Anesthesiology and Surgery societies recommend that these are
assessed in elderly patients, in order to allow the health care providers to take
measures to reduce possible complications resulting from the identified risks and
optimize the patients’ pre-operative process.

In the present project, we aim to study the feasibility of applying a pre-operative frailty
and cognitive assessment protocol in a clinical context, as a part of the pre-operative
anesthesiology assessment. We will also report the incidence of frailty and mild
cognitive impairment in our specific population.

Sumário

Frailty, ou fragilidade, e declínio cognitivo no pré-operatório representam dois

importantes fatores de risco para o desenvolvimento de complicações no pós-
operatório, como o delirium pós-operatório. Por essa razão, várias sociedades de
Anestesiologia e Cirurgia recomendam que estas questões sejam avaliadas em
pacientes mais idosos, para permitir que os profissionais de saúde possam tomar
medidas para reduzir possíveis complicações resultantes dos riscos identificados, bem
como para otimizar o processo pré-operatório dos doentes.

No presente projeto, pretendemos estudar a viabilidade da aplicação de um protocolo

pré-operatório de avaliação de frailty e declínio cognitivo em contexto clínico, como
parte integrante da avaliação pré-anestésica. Pretendemos, ainda, reportar a
incidência de frailty e declínio cognitivo ligeiro na nossa população específica.

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Protocol for the Pre-Operative Cognitive and Frailty Assessment of Surgical Patients > 65 Years Old

Index

1. Introduction

2. Aims

3. Methods

- Participants

- Instruments

- Procedure

4. Ethical Considerations

5. Team

6. References

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Protocol for the Pre-Operative Cognitive and Frailty Assessment of Surgical Patients > 65 Years Old

1. Introduction

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Protocol for the Pre-Operative Cognitive and Frailty Assessment of Surgical Patients > 65 Years Old

2. Aims

Aim #1. To study the feasibility of applying a frailty and cognitive assessment protocol
in the pre-operative context of the anesthesiology assessment prior to an elective
surgery, in patients over 65 years old.

Aim #2. To report the incidence of frailty and mild cognitive impairment in our specific
population.

3. Methods

3.1. Participants
Our participants will be older adults (≥ 65 years old) undergoing elective
surgery at the Champalimaud Clinical Centre.

The exclusion criteria include:

- Native language other than Portuguese;

- Illiteracy;
- Inability to understand the instructions of one or more instruments.

3.2. Instruments
The assessment protocol comprises two frailty instruments, four cognitive
instruments and one affective scale.

3.2.1 Frailty Instruments

a) Tilburg Frailty Indicator (TFI) (Gobbens et al., 2010; Coelho et al., 2015):
self-report frailty screening questionnaire with a total of 25 questions,
assessing the determinants and domains (physical, psychological, and
social) of frailty.
b) FRAIL Screening Tool (Morley et al., 2012): frailty screening scale with a
total of five questions, assessing fatigue, resistance, ambulation,
illnesses, and involuntary weight loss.

3.2.2 Cognitive Instruments

a) Semantic Fluency Test – Animals (Cavaco et al., 2013): the individuals

are asked to vocally generate, in one minute, as many different animal
names as possible.

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Protocol for the Pre-Operative Cognitive and Frailty Assessment of Surgical Patients > 65 Years Old

b) Montreal Cognitive Assessment (MoCA) (Freitas et al., 2010; Nasreddine

et al., 2005): cognitive screening test, assessing executive functioning,
visuospatial abilities, memory, attention, working memory, language
and orientation.
c) Teste de Leitura de Palavras Irregulares (TeLPI) (Alves et al., 2012):
provides an estimate of premorbid intelectual ability through the
reading of irregular Portuguese words.
d) Telephone Interview of Cognitive Status – Modified (TICSM-PT) (Brandt
et al., 1988; Castanho et al., 2016; Welsh et al., 1993): cognitive
screening test to be applied through the telephone, assessing time and
spatial orientation, attention, calculation, memory, and language.

3.2.3 Affect Instrument

a) Geriatric Depression Scale (GDS-15) (Sheikh & Yesavage, 1986; Simões

et al., 2015): self-report screening scale with a total of 15 questions
assessing depressive symptoms.

3.3. Procedure
This assessment protocol will be applied as a part of the pre-operative
anesthesiology assessment of patients undergoing elective surgery, either before or
after their appointment, by a neuropsychology intern study team member. In the
current pandemic situation, it may also be applied on the day scheduled for the
patient’s covid-19 test.
Before applying any of the instruments, the procedure will be briefly explained
to the patient and their informed consent will be asked. Afterwards, sociodemographic
data (date of birth and educational level) will be collected.
If the patient has given their consent to participate, the instruments will be
applied in the following order:

1. Tilburg Frailty Indicator (TFI)

2. FRAIL Screening Tool
3. Semantic Fluency Test – Animals
4. Montreal Cognitive Assessment (MoCA)
5. TeLPI
6. GDS-15

Due to the current covid-19 pandemic, if the patient has their anesthesiology
appointment over the telephone and the assessment cannot be scheduled for the day
of their covid-19 test, the assessment should be done over the telephone, applying the
instruments in the following order:

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 Protocol for the Pre-Operative Cognitive and Frailty Assessment of Surgical Patients > 65 Years Old

1. Tilburg Frailty Indicator (TFI)

2. FRAIL Screening Tool
3. Semantic Fluency Test – Animals
4. Telephone Interview of Cognitive Status – Modified (TICSM-PT)
5. GDS-15

The estimated duration of the procedure is 60 minutes.

Anesthesiology Anesthesiology
appointment appointment
(in person) (over the
telephone)

Informed Consent

Sociodemographic Data
TFI + FRAIL Screening Tool TFI + FRAIL Screening Tool

If:
FVS + MoCA + TeLPI FVS + TICSM-PT
FVS (see table)

MoCA ≤ 22

TICSM-PT ≤ 13,5

GDS-15 GDS-15 ≥ 9 GDS-15

1.Suggest
Referências
to the patient referral to a more comprehensive neuropsychological
assessment and, if necessary, to a Neurology/Psychiatry appointment

Figure 1. Flow chart of the procedure

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Protocol for the Pre-Operative Cognitive and Frailty Assessment of Surgical Patients > 65 Years Old

The patients will be informed that, if they detect any cognitive alterations
during the post-operative period, they should report them to their doctor or to Dr.
Maria João Susano (contact information will be provided). In those situations, the
patients will be assessed again using MoCA (alternative version) or, in the cases
assessed over the phone, TICSM-PT.

4. Ethical Considerations
If during the assessment, in any of the instruments, a patient obtains a score
suggestive of cognitive decline, frailty or depression, a referral to a more
comprehensive neuropsychological assessment and/or a psychiatrist (in case of
depression) should be recommended to the patient. After undergoing a
comprehensive neuropsychological assessment, if deemed necessary, a referral to a
psychiatrist or a neurologist should be suggested. This can constitute both a risk and a
benefit to the participation in this study, depending on

5. Team
This project will be developed by the Neuropsychiatry Unit of the
Champalimaud
Foundation
The team members include Maria João Susano (anesthesiologist), Raquel
Lemos (neuropsychologist) and Filipa Gonçalves (neuropsychology master student and
intern).

6. References

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Protocol for the Pre-Operative Cognitive and Frailty Assessment of Surgical Patients > 65 Years Old

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