Presentation
What Medical Interventions Create the most Risk for Cognitive Impairment?
DescriptionCognitive impairment is a significant patient safety issue. Early identification of cognitive impairment followed by timely medical intervention will increase the quality of life and prevent patient safety incidents. Using serious games to assess cognitive impairment has shown benefit in practice. There is an opportunity identify cognitive impairment in practice using cognitive serious games. Psychometric validation of such cognitive serious games in clinical settings, and wise-practices to support the adoption and implementation of cognitive assessment games, are needed.
The World Health Organization (WHO) has proposed that functioning, rather than the presence or absence of a given disease or condition, be the most important marker of healthy aging, which it defines as “the process of developing and maintaining the functional ability that enables well-being in older age” (Clegg et al., 2013). Developing and implementing successful interventions to maintain cognitive function during aging will require concerted efforts from a range of stakeholders (Coley et al., 2022).
Healthcare can combat rising levels of cognitive impairment, as people get older, by ensuring that brain health is not harmed unnecessarily by medical interventions. In this presentation we will review some key medical interventions that have been found to create risk of cognitive impairment. We will then identify insufficient monitoring of cognitive status as an impediment to better management of cognitive status in patients as they receive treatments, and we will propose a way forward with cognitive assessment games.
Many research studies have identified chemotherapy used in cancer treatment as a source of cognitive impairment. Schagen et al. (2022) state that “Chemotherapy-induced cognitive impairment is multifactorial: different molecular mechanisms result in blood–brain barrier disruption, inflammation, accelerated cellular senescence and neuronal stem cell abnormalities, all of which lead to cognitive impairment.” Schagen et al. then went on to say: “neuropsychological monitoring is not yet standard practice in most cancer centres, clinicians frequently learn of potential cognitive dysfunction through patient self-reports in clinics or on questionnaires.” Clearly a system that relies on delayed patient self-reports is not monitoring cognitive status adequately.
Radiotherapy used to treat brain cancers has also been implicated as a source of cognitive impairment. Neurological side effects of cranial irradiation have been reported to occur in 50–90% of adult patients (Greene-Schloesser and Robbins, 2012).
Cognitive impairment after surgery is sufficiently prevalent that there is a special term for it, i.e., postoperative cognitive dysfunction (POCD). Li et al. (2022) stated that: “[POCD] is a common neurological complication following surgery and general anesthesia, especially in elderly patients.” Elevated risk of cognitive impairment has also been found to occur with kidney dialysis, and with a variety of medications including anticholinergics, sedatives, opioids, and antipsychotics.
One motivation for more use of cognitive assessment in healthcare is to avoid loss of cognitive status due to medical interventions. Another motivation is to use cognitive assessments to diagnose and monitor various neurological and psychiatric conditions, including dementia, delirium, and traumatic brain injuries. Commonly used tests in the clinical setting include the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) and the Confusion Assessment Method (CAM).
Existing clinical tests are typically paper-based and require a trained administrator. They tend to have limited repeatability (with only one, or a few questionnaire forms), and they tend to be uninteresting for the participant. Since the administration of clinical tests is relatively costly, they are used less frequently than they should be. In addition, most tests are designed to make a major categorical decision (e.g., does the patient have mild cognitive impairment, or does the patient have dementia, or delirium?) and are not well suited to tracking more subtle, but still important, changes in cognitive status.
Delirium is an important target for improved cognitive assessment because recognition of delirium in the Emergency Department (ED) using clinician gestalt is poor, with rates between 16% and 35% (Lewis et al., 1995). Patients discharged with unrecognized delirium have greatly increased risk of near-term mortality compared to non-delirious patients (Kakuma et al., 2003). In a meta-analysis carried out by Goldberg et al. (2020), delirium was found to be significantly associated with long-term cognitive decline in both surgical and nonsurgical patients. Delirium is also quite prevalent in hospitals and long-term care homes. For instance, delirium affects 7% to 10% of older Emergency Department patients (Lee et al., 2019). In their study, Lee et al. found that 14/16 older ED patients with delirium were able to use their serious game for cognitive assessment, with the game showing potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium.
Many cognitive assessment games have been developed in recent years (e.g., Lumsden et al., 2016), but they often fail to utilize psychometric methods such as convergent validation with standard psychological tasks requiring specific cognitive abilities (Zhang and Chignell, 2020).
In our proposed conference presentation we show that loss of cognitive status is a pain point in healthcare and that existing methods of cognitive assessment need to be supplemented with cognitive assessment games that can provide more efficient, and sensitive, testing. Challenges may exist with the implementation of cognitive assessment games in healthcare where, as an example, there are incumbent methods and relatively low levels of current interest in changing the paradigm when it comes to cognitive assessment. We will conclude our presentation with a suggested roadmap for validating and implementing cognitive assessment games in healthcare contexts.
References
Borchers, F., Spies, C.D., Feinkohl, I., Brockhaus, W.R., Kraft, A., Kozma, P., Fislage, M., Kühn, S., Ionescu, C., Speidel, S. and Hadzidiakos, D., 2021. Methodology of measuring postoperative cognitive dysfunction: a systematic review. British Journal of Anaesthesia, 126(6), pp.1119-1127.
Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., & Rockwood, K. (2013). Frailty in elderly people. The lancet, 381(9868), 752-762.
Coley, N., Giulioli, C., Aisen, P. S., Vellas, B., & Andrieu, S. (2022). Randomised controlled trials for the prevention of cognitive decline or dementia: A systematic review. Ageing Research Reviews, 101777.
Czyż-Szypenbejl, K., Mędrzycka-Dąbrowska, W., Kwiecień-Jaguś, K., & Lewandowska, K. (2019). The occurrence of postoperative cognitive dysfunction (POCD)-systematic review. Psychiatr Pol, 53(1), 145-160.
Goldberg, T.E., Chen, C., Wang, Y., Jung, E., Swanson, A., Ing, C., Garcia, P.S., Whittington, R.A. and Moitra, V., 2020. Association of delirium with long-term cognitive decline: a meta-analysis. JAMA neurology, 77(11), pp.1373-1381.
Greene-Schloesser D, Robbins ME, Peiffer AM, Shaw EG, Wheeler KT, Chan MD. 2012. Radiation-induced brain injury: a review. Front Oncol. 2:73.
Kakuma R, du Fort GG, Arsenault L, et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4):443-450.
Lee, J. S., Tong, T., Tierney, M. C., Kiss, A., & Chignell, M. (2019). Predictive ability of a serious game to identify emergency patients with unrecognized delirium. Journal of the American Geriatrics Society, 67(11), 2370-2375.
Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13(2):142-145.
Li, Z., Zhu, Y., Kang, Y., Qin, S., & Chai, J. (2022). Neuroinflammation as the underlying mechanism of postoperative cognitive dysfunction and therapeutic strategies. Frontiers in Cellular Neuroscience, 16, 843069.
Lumsden, J., Edwards, E. A., Lawrence, N. S., Coyle, D., & Munafò, M. R. (2016). Gamification of cognitive assessment and cognitive training: a systematic review of applications and efficacy. JMIR serious games, 4(2), e5888.
Zhang, B., & Chignell, M. (2020, August). A framework for using cognitive assessment games for people living with dementia. In 2020 IEEE 8th International Conference on Serious Games and Applications for Health (SeGAH) (pp. 1-8). IEEE.
The World Health Organization (WHO) has proposed that functioning, rather than the presence or absence of a given disease or condition, be the most important marker of healthy aging, which it defines as “the process of developing and maintaining the functional ability that enables well-being in older age” (Clegg et al., 2013). Developing and implementing successful interventions to maintain cognitive function during aging will require concerted efforts from a range of stakeholders (Coley et al., 2022).
Healthcare can combat rising levels of cognitive impairment, as people get older, by ensuring that brain health is not harmed unnecessarily by medical interventions. In this presentation we will review some key medical interventions that have been found to create risk of cognitive impairment. We will then identify insufficient monitoring of cognitive status as an impediment to better management of cognitive status in patients as they receive treatments, and we will propose a way forward with cognitive assessment games.
Many research studies have identified chemotherapy used in cancer treatment as a source of cognitive impairment. Schagen et al. (2022) state that “Chemotherapy-induced cognitive impairment is multifactorial: different molecular mechanisms result in blood–brain barrier disruption, inflammation, accelerated cellular senescence and neuronal stem cell abnormalities, all of which lead to cognitive impairment.” Schagen et al. then went on to say: “neuropsychological monitoring is not yet standard practice in most cancer centres, clinicians frequently learn of potential cognitive dysfunction through patient self-reports in clinics or on questionnaires.” Clearly a system that relies on delayed patient self-reports is not monitoring cognitive status adequately.
Radiotherapy used to treat brain cancers has also been implicated as a source of cognitive impairment. Neurological side effects of cranial irradiation have been reported to occur in 50–90% of adult patients (Greene-Schloesser and Robbins, 2012).
Cognitive impairment after surgery is sufficiently prevalent that there is a special term for it, i.e., postoperative cognitive dysfunction (POCD). Li et al. (2022) stated that: “[POCD] is a common neurological complication following surgery and general anesthesia, especially in elderly patients.” Elevated risk of cognitive impairment has also been found to occur with kidney dialysis, and with a variety of medications including anticholinergics, sedatives, opioids, and antipsychotics.
One motivation for more use of cognitive assessment in healthcare is to avoid loss of cognitive status due to medical interventions. Another motivation is to use cognitive assessments to diagnose and monitor various neurological and psychiatric conditions, including dementia, delirium, and traumatic brain injuries. Commonly used tests in the clinical setting include the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) and the Confusion Assessment Method (CAM).
Existing clinical tests are typically paper-based and require a trained administrator. They tend to have limited repeatability (with only one, or a few questionnaire forms), and they tend to be uninteresting for the participant. Since the administration of clinical tests is relatively costly, they are used less frequently than they should be. In addition, most tests are designed to make a major categorical decision (e.g., does the patient have mild cognitive impairment, or does the patient have dementia, or delirium?) and are not well suited to tracking more subtle, but still important, changes in cognitive status.
Delirium is an important target for improved cognitive assessment because recognition of delirium in the Emergency Department (ED) using clinician gestalt is poor, with rates between 16% and 35% (Lewis et al., 1995). Patients discharged with unrecognized delirium have greatly increased risk of near-term mortality compared to non-delirious patients (Kakuma et al., 2003). In a meta-analysis carried out by Goldberg et al. (2020), delirium was found to be significantly associated with long-term cognitive decline in both surgical and nonsurgical patients. Delirium is also quite prevalent in hospitals and long-term care homes. For instance, delirium affects 7% to 10% of older Emergency Department patients (Lee et al., 2019). In their study, Lee et al. found that 14/16 older ED patients with delirium were able to use their serious game for cognitive assessment, with the game showing potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium.
Many cognitive assessment games have been developed in recent years (e.g., Lumsden et al., 2016), but they often fail to utilize psychometric methods such as convergent validation with standard psychological tasks requiring specific cognitive abilities (Zhang and Chignell, 2020).
In our proposed conference presentation we show that loss of cognitive status is a pain point in healthcare and that existing methods of cognitive assessment need to be supplemented with cognitive assessment games that can provide more efficient, and sensitive, testing. Challenges may exist with the implementation of cognitive assessment games in healthcare where, as an example, there are incumbent methods and relatively low levels of current interest in changing the paradigm when it comes to cognitive assessment. We will conclude our presentation with a suggested roadmap for validating and implementing cognitive assessment games in healthcare contexts.
References
Borchers, F., Spies, C.D., Feinkohl, I., Brockhaus, W.R., Kraft, A., Kozma, P., Fislage, M., Kühn, S., Ionescu, C., Speidel, S. and Hadzidiakos, D., 2021. Methodology of measuring postoperative cognitive dysfunction: a systematic review. British Journal of Anaesthesia, 126(6), pp.1119-1127.
Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., & Rockwood, K. (2013). Frailty in elderly people. The lancet, 381(9868), 752-762.
Coley, N., Giulioli, C., Aisen, P. S., Vellas, B., & Andrieu, S. (2022). Randomised controlled trials for the prevention of cognitive decline or dementia: A systematic review. Ageing Research Reviews, 101777.
Czyż-Szypenbejl, K., Mędrzycka-Dąbrowska, W., Kwiecień-Jaguś, K., & Lewandowska, K. (2019). The occurrence of postoperative cognitive dysfunction (POCD)-systematic review. Psychiatr Pol, 53(1), 145-160.
Goldberg, T.E., Chen, C., Wang, Y., Jung, E., Swanson, A., Ing, C., Garcia, P.S., Whittington, R.A. and Moitra, V., 2020. Association of delirium with long-term cognitive decline: a meta-analysis. JAMA neurology, 77(11), pp.1373-1381.
Greene-Schloesser D, Robbins ME, Peiffer AM, Shaw EG, Wheeler KT, Chan MD. 2012. Radiation-induced brain injury: a review. Front Oncol. 2:73.
Kakuma R, du Fort GG, Arsenault L, et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4):443-450.
Lee, J. S., Tong, T., Tierney, M. C., Kiss, A., & Chignell, M. (2019). Predictive ability of a serious game to identify emergency patients with unrecognized delirium. Journal of the American Geriatrics Society, 67(11), 2370-2375.
Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13(2):142-145.
Li, Z., Zhu, Y., Kang, Y., Qin, S., & Chai, J. (2022). Neuroinflammation as the underlying mechanism of postoperative cognitive dysfunction and therapeutic strategies. Frontiers in Cellular Neuroscience, 16, 843069.
Lumsden, J., Edwards, E. A., Lawrence, N. S., Coyle, D., & Munafò, M. R. (2016). Gamification of cognitive assessment and cognitive training: a systematic review of applications and efficacy. JMIR serious games, 4(2), e5888.
Zhang, B., & Chignell, M. (2020, August). A framework for using cognitive assessment games for people living with dementia. In 2020 IEEE 8th International Conference on Serious Games and Applications for Health (SeGAH) (pp. 1-8). IEEE.
Event Type
Oral Presentations
TimeTuesday, March 269:37am - 10:00am CDT
LocationSalon A-3
Patient Safety Research and Initiatives