1. Neurocognitive Screening for POCD via the iPad
Sarah Waring and Emily Whitaker
Advised by: Dr. James L. Blair, VUMC Anesthesiology Dept.
November 14, 2018

2. 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
November 14, 2018

3. 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)
References:
CD  required for activities of daily living (ADL) - #3
Increased risk of mortality - #3, #102
Problems – Hanning 2005
November 14, 2018

4. 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
November 14, 2018

5. 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
November 14, 2018

6. 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?
November 14, 2018

7. 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
November 14, 2018

8. 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
November 14, 2018

9. 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
November 14, 2018

10. 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
November 14, 2018

11. 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
November 14, 2018

12. Why an iPad? More portable than a laptop Longer battery life
Lightweight
Don’t have to open/close
Longer battery life
Touch screen
Easy to use, especially for the elderly
Instant start-up
November 14, 2018

13. 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 and POCD+depression
Research into iPad programming
Completion of first test program
Resources include Apple iOS Developer site and Stanford University CS193P lectures
November 14, 2018

14. Xcode and SDK
November 14, 2018

15. Test Program
November 14, 2018

16. Test Program
November 14, 2018

17. Current Work Design of viewer interface
Lessons in Objective-C and MVC coding
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
November 14, 2018

18. Basic Design Layout of Program
Using Xcode and SDK
Patient ID entry, patient instructions, actual test, end of test, score report + export capability
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25. Future Work
Continue to meet with Dr. Blair to discuss our role in project
Determine appropriate scoring method for Stroop test
Finish program coding
Finalize look and feel of program
Begin testing
Administer to patients and test program performance
November 14, 2018

26. 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
November 14, 2018

27. 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
November 14, 2018

28. 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
November 14, 2018

29. 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
November 14, 2018

30. 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
November 14, 2018

31. References POCD and Anesthesia POCD and Depression
Hanning, C.D. Postoperative cognitive dysfunction. British Journal of Anaesthesia 95(1): 82-87
Monk, T.G., et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology 108(1):18-30.
Monk, T.G., et al. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 100(1):4-10.
POCD and Depression
Ancelin, M. et al. "Exposure to Anesthetic Agents, Cognitive Functioning and Depressive Symptomology in the Elderly." British Journal of Psychiatry 178(2001):
Johnson, Tim, et al. "Postoperative Cognitive Dysfunction in Middle-aged Patients." Anesthesiology 96.6(2002):
November 14, 2018