Reliability In Neurocognitive Telemedicine Screening (RING)

Perioperative neurocognitive disorders (PND) are common and associated with significant morbidity and economic costs. One of the dominant risk factors for PND is pre-existing cognitive impairment (CI). The importance of detecting CI pre-operatively to facilitate patient selection for optimisation pathways and informed risk assessments is stressed in recent joint guidelines by the American College of Surgeons and the American Geriatrics Society.

Despite these recommendations, screening for pre-operative CI is inconsistently performed. One systematic barrier to CI screening is telemedicine, the use of which has recently seen an inflection point partly precipitated by the Coronavirus pandemic. Telemedicine enables the delivery of tertiary level patient-centred care over expanding geographical catchments, and is likely here to stay.

To date, no brief CI screening tool has been validated for perioperative use via telemedicine.

The Mini-Cog is a brief CI screening tool that is uniquely familiar to perioperative healthcare providers. It is validated in preoperative patients and performs favourably compared to other screening tools in the detection of CI. A Mini-Cog result consistent with CI is strongly associated with postoperative delirium, and is widely used as a trigger for geriatric optimization referral.

Validation of the Mini-Cog delivered via telemedicine is an important step towards improving patient access to CI screening.

Although video pre-operative assessments have been shown to promote high levels of patient and anesthesiologist satisfaction6, it is our local experience that video call technology is less frequently available to older patients, can pose operational challenges for either participant, and reduces workflow flexibility.

Clock Drawing Test (CDT) is an integral part of the Mini-Cog, testing multiple domains of executive function and motor skills, and functioning as a 'distractor' between the registration and recall of three items.

A modified Mini-Cog has been used with illiterate patients unable to use an analogue clock. The CDT was replaced with a serial subtraction task (SST) as an alternate distractor. One study found the modified Mini-Cog correlates with a proxy-rated CI screening tool similarly to the standard Mini-Cog.

Whilst it not feasible to perform a Mini-Cog assessment during a telephone interview, the modified Mini-Cog is an attractive alternative. We therefore aim to validate the modified Mini-Cog assessment for use over the telephone.

Our study involves comparing the validated Mini-Cog with the modified Mini-Cog. Patients awaiting surgery performed the Modified-Mini-Cog with telemedicine and on a later date subsequently performed the validated standard Mini-Cog. We plan to analyse the concordance of the results.

Inclusion criteria

• Patients with age >65 at time of listing for pre-operative assessment.
• Patients with a conversational understanding of English language.
• Patients scheduled for in-person consult with an anaesthesiologist.
• Patients awaiting surgery at Vancouver General Hospital or University of British Columbia Hospital.

Exclusion criteria

• Patients with known cognitive impairment.