February 15, 2011

Neurocognitive Screening for POCD via the iPad

Sarah Waring and Emily WhitakerAdvised by: Dr. James L. Blair, VUMC Anesthesiology Dept.

Project Advisor

James L. Blair, ODAssistant Professor, VUMC Department of AnesthesiologyLooking to develop pre-op screening for brain function using imaging and neurocognitive tests

February 15, 2011

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:

http://www.cs.dartmouth.edu/farid/illusions/stroop.html

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 function2. Compared to pre-op, there will be significant changes in functional neuroimaging3. 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

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 pointsOur program will provide the data for the neurocognitive tests to compare to imaging dataBoth 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

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Why an iPad?

More portable than a laptop• Lightweight• Don’t have to open/close

Longer battery lifeTouch screen• Easy to use, especially for the

elderlyInstant start-up

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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 versionsResearch into POCDResearch into iPad programming

February 15, 2011

Current Work

Initial program codingResearch into relevant neurocognitive tests• Searching for computerized versions of Stroop

test, “finger tapping,” JLO, and HVLTResearch into licensing of tests

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Future Work

Continue to meet with Dr. Blair to discuss our role in projectDetermine appropriate scoring method for Stroop testFinish program codingBegin testingAdminister 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

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Long Term Implications

Decrease number of cases of post-operative cognitive dysfunctionDecrease lawsuits associated with POCDGain more knowledge of POCD/how surgery and anesthesia affect the brain

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What changes might occur if we have valid information?

Better understanding of relationship between cognitive and neurophysical changes due to anesthesia and surgeryAid in creating rank-order of toxicity of anesthetic agents and develop better anesthetic practices to decrease anesthetic risk in the elderly

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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

February 15, 2011

References

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