February 15, 2011 Neurocognitive Screening for POCD via the iPad Sarah Waring and Emily Whitaker Advised by: Dr. James L. Blair, VUMC Anesthesiology Dept.

Project Advisor James L. Blair, OD Assistant Professor, VUMC Department of Anesthesiology Looking to develop pre-op screening for brain function using imaging and neurocognitive tests February 15, 2011

Overview of POCD Cognitive Dysfunction  impairment of vital mental processes After surgery with anesthesia  post operative cognitive dysfunction (POCD) Most common in elderly patients Affects perception, memory, and information processing Problems can persist for several months Impedes activities of daily living (ADL)

February 15, 2011 Overview of Neurocognitive Tests Stroop test Assesses concept shifting ability and executive function Name ink color, not the word Example: Easy to read  ink = word Trickier  ink ≠ word

February 15, 2011 The Problem “Comprehensive” pre-operative screening neglects brain All other major organs are tested Elderly patients often end up with some degree of POCD Causes need for assistance with ADL Causes increased mortality risk for next year

February 15, 2011 Current “Solutions” Neurocognitive testing (NCT) after surgery to assess mental functions One week and three months post-surgery These tests determine presence of POCD Accuracy without a pre-op baseline?

February 15, 2011 Group Purpose A pre-operative test of mental function is needed MRI/DTI/fMRI Neurocognitive testing (NCT) Values can be obtained for baseline Physiological Neurocognitive abilities Can NCT be a screening tool for high risk of POCD? Dr. Blair’s upcoming study will compare NCT results to physiological changes

Dr. Blair’s Hypothesis 1. Serial MRI scans pre- & post-op will show anatomic changes to structures associated with memory and executive function 2. Compared to pre-op, there will be significant changes in functional neuroimaging 3. NCT changes will correlate highly with alterations in functional and neuroanatomic substrates for memory and executive function as noted in 1 & 2 February 15, 2011

Group Objective Create an iPad program that will be used to administer a battery of neurocognitive tests as part of the pre-op screening process Must be: user friendly, in touch screen format, easy to administer, and take approx. 10 min. Develop accurate scoring methods for program Stroop test to start; other tests added later

How does our project fit in? Dr. Blair’s study aims to determine if MRI can demonstrate changes in the central nervous system pre-op vs. post-op, and how these changes relate to neurocognitive tests given at the same time points Our program will provide the data for the neurocognitive tests to compare to imaging data Both sets of data will be used to determine if there is a correlation between CNS changes (both structural and functional) and anesthesia and surgery February 15, 2011

How does our project fit in? The iPad program will provide an easier and more efficient method to administer and score the neurocognitive testing portion of the study February 15, 2011

Why an iPad? More portable than a laptop Lightweight Don’t have to open/close Longer battery life Touch screen Easy to use, especially for the elderly Instant start-up February 15, 2011

Completed Work Met with Dr. Blair to discuss overall project objectives Received project protocol Decided to focus initially on Stroop test Research into Stroop test, both paper- and computer-based versions Research into POCD Research into iPad programming

February 15, 2011 Current Work Initial program coding Research into relevant neurocognitive tests Searching for computerized versions of Stroop test, “finger tapping,” JLO, and HVLT Research into licensing of tests

February 15, 2011 Future Work Continue to meet with Dr. Blair to discuss our role in project Determine appropriate scoring method for Stroop test Finish program coding Begin testing Administer to patients and test program performance

Long Term Implications iPad format: Combination of multiple tests into one program cuts costs Easy transfer of data for analysis Scoring algorithm: Results calculated quickly Data all in the same format Trained proctor not necessary February 15, 2011

Long Term Implications Decrease number of cases of post-operative cognitive dysfunction Decrease lawsuits associated with POCD Gain more knowledge of POCD/how surgery and anesthesia affect the brain February 15, 2011

What changes might occur if we have valid information? Better understanding of relationship between cognitive and neurophysical changes due to anesthesia and surgery Aid in creating rank-order of toxicity of anesthetic agents and develop better anesthetic practices to decrease anesthetic risk in the elderly February 15, 2011

Cost-Benefit Analysis Costs iPad Our time – for production and coding No actual $ costs associated with developing the program  Free to register as an Apple Developer  iOS Developer Program – needed to test application and distribute via App Store February 15, 2011

Cost-Benefit Analysis Benefits Most important benefit – knowledge of anesthesia’s effect on the brain Once tested, will be able to share with other hospitals to reduce POCD cases Reduced lawsuits and legal fees Potential for sale in the App Store February 15, 2011

References Hanning CD. Postoperative cognitive dysfunction. Br J of Anaesth. Jan 2005;95(1):82-87 Monk TG, Weldon BC, Garvan CW, et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology. Jan 2008;108(1):18-30 Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg. Jan 2005;100(1):4-10