By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Dr. Ghetti reports no financial relationships relevant to this field of study.
Mild cognitive impairment and early dementia are prevalent in women seeking care for pelvic floor disorders.
Kunkle CM, Abernethy MG, Van Tongeren LR, et al. Prevalence of cognitive impairment in older women with pelvic floor disorders. Int Urogynecol J 2017;28:1645-1650.
Kunkle et al conducted this study to determine the overall prevalence of mild cognitive impairment (MCI) and early dementia in women who sought care for pelvic floor disorders (PFDs) and to identify associations between cognitive impairment and condition-specific quality of life (QoL). This was a cross-sectional study of women 55 years of age or older. They excluded women who had existing diagnoses of dementia. The primary outcome was the prevalence of MCI and early dementia as measured by Short Test of Mental Status (STMS), a validated screening tool used in dementia assessment. The authors defined MCI having an STMS score of ≤ 31 and early dementia as having a score ≤ 29. Other outcome measures included pelvic organ prolapse measured by the Pelvic Organ Prolapse Quantification (POP-Q), urinary incontinence severity measured by the Sandvik Severity Index (SSI), and depression assessed by the Patient Health Questionnaire (PHQ-9). PHQ-9 scores of 10 to 14 correspond to moderate depressive symptoms, scores of 15 to 19 correspond to moderately severe depressive symptoms, and scores of 20 to 27 correspond to severe depressive symptoms. Condition-specific QoL was assessed with the Pelvic Floor Distress Inventory Short Form (PFDI-20) and the Pelvic Floor Impact Questionnaire Short Form (PFIQ-7). Higher scores on these measures indicated greater symptom severity and effect on condition-specific QoL.
Two hundred eleven women were eligible for the study. The baseline prevalence of MCI and early dementia were 15% (95% confidence interval [CI], 10.9-20.6; n = 32) and 17% (95% CI, 11.9-22.1; n = 36), respectively. Upon univariate analysis when patients with MCI and early dementia were compared to those with normal cognition, those with impaired cognition were older, had lower educational levels, had lower rates of alcohol use, and were less likely to have had prior PFD treatment. Patients with abnormal cognition also had higher depressive symptom scores. POP-Q stage, PFDI-20, and SSI scores were similar between groups; however, patients with cognitive impairments had higher PFIQ-7 scores. The authors reported results of a multivariate linear regression, with PFIQ-7 score as the main outcome and cognitive impairment (MCI plus early dementia) as the main exposure of interest. The final model only included variables that most significantly affected the cognitive impairment/PFIQ-7 association, which included education, prior treatment for PFDs, alcohol use, and depression. In this model, only prior treatment for PFDs and depression were independently associated with higher PFIQ-7 scores. However, in a second model excluding depression, cognitive impairment was independently associated with higher PFIQ-7 scores.
COMMENTARY
PFDs are known to affect many women, and the proportion of women who report at least one PFD increases with age.1 Mild cognitive impairment affects 22% of the general population older than 55 years of age. The U.S. Census Bureau has estimated that by 2030, one-fifth of women will be 65 years of age or older. As the population of older women increases, the burden related to PFDs and cognitive impairment will increase.
Although this study had several limitations, it is only the second study of which I am aware that investigated cognitive impairment and pelvic floor disorders. Erekson et al studied the occurrence of frailty, cognitive impairment, and functional disability in older women seeking treatment for PFD and found that 16% of women 65 years or older seeking care for a PFD met the criteria for frailty and that 21.3% of women screened positive for dementia, using the Saint Louis University Mental Status score.2 One-third of women reported functional difficulty or dependence in performing at least one activity of daily living. Together these studies highlight the unique needs of our older gynecologic patients.
Cognitive impairment is difficult to diagnose from one screening tool. In addition, there are very complex relationships between depression and cognitive impairment. Depression is common in patients with cognitive impairment or dementia, and cognitive decline seems to affect older patients with depression frequently.3 The interrelationship of cognitive impairment and depression needs to be explored more fully, as does the complex relationship of these factors with condition-specific QoL. These are limitations of this study.
In a prior issue, we discussed cognitive impairment and the use of anticholinergic medications. The identification of cognitive impairment also has significant ramifications in the care of older women, and it is especially important in the perioperative period. Cognitive impairment may significantly affect the informed consent process, a patient’s decision-making ability, and a patient’s true ability to understand the risks and benefits of treatment options. Cognitive impairment and associated frailty also affect a woman’s individual risk of complications. The most common postoperative complications for older patients include falls, delirium, surgical site infections, and electrolyte imbalance.4
In a small group of healthy older women undergoing elective gynecologic pelvic floor surgery, Richter et al found no difference in postoperative QoL outcome (measured by the Short Form 36) in subjects in whom a preoperative geriatric assessment was performed.5 However, the authors cautioned that further studies are required to better understand which patients might benefit from preoperative geriatric assessment. In a study of older women undergoing surgery for pelvic organ prolapse, Oliphant et al found that most older women with baseline functional status independence undergoing pelvic organ prolapse surgery can expect to regain independence by three months postoperatively.6
According to the American College of Obstetricians and Gynecologists Guidelines for Women’s Health Care, “Evaluation of functional assessment findings, coupled with appropriate management, referrals, or both, can assist the elderly woman to live independently and maintain her health. A functional assessment also should be carried out before any medical intervention or surgery.”7 Malani advocates strongly for incorporating preoperative assessment of mobility, functional status, and cognition into preoperative care of older adults.8 However, most of us were not trained in these evaluations. In a study of physicians that included general internal medicine, family medicine, cardiology, pulmonary medicine, endocrinology, rheumatology, gynecology, and neurology, Chodosh et al found that physicians were unaware of cognitive impairment in more than 40% of their cognitively impaired patients.9 Mildly impaired patients are more difficult to identify. This begs the question, how best can we assess mobility, functional status, and cognition in a busy clinical gynecologic practice?
Several simple and efficient screening tools can be used. The Get Up and Go test is an easy way to assess mobility. Have patients wear their regular footwear and any walking aid they normally use for this test. Instruct the patients to sit back in a standard arm chair, and when given the signal go, they should stand up from the chair, walk to a line on the floor 10 feet away, turn around, and walk back to the chair and sit down. Begin recording time at the word go and stop timing after patients sit back down. Patients who take 12 seconds or longer are considered to be at significant risk for falling.10
Reviewing the difficulty or need for assistance for basic activities of daily living is an easy way to assess functional status. Activities of daily living include walking one block, walking across a room, putting on shoes and socks, bathing or showering, cutting food, getting in and out of bed, and using the toilet. Instrumental activities of daily living include being able to perform tasks such as balancing a checkbook, paying bills, and grocery shopping.
A simple test to screen for cognitive impairment is the Mini-Cog test, which takes about three minutes to administer and is composed of a three-word recall and a clock drawing exercise. Instructions for administration and scoring can be found at https://www.alz.org/documents_custom/minicog.pdf.
These tests can help providers identify underlying deficits that can affect perioperative care and discharge planning. For example, a patient with preoperative mobility issues may be at risk for falls and may benefit from perioperative physical or occupational therapy visits postoperatively. Patients requiring assistance with activities of daily living preoperatively may need postoperative rehabilitation or in-home assistance. Knowing that a patient has cognitive deficits will help the care team be on the lookout for delirium or postoperative confusion.
The number of older women undergoing gynecologic surgical procedures and surgeries for prolapse is estimated to increase. Studies using comprehensive geriatric assessments show promise in identifying elderly patients at greater risk for morbidity and mortality following elective surgery. While instituting extensive geriatric testing may be beyond the ability of our individual practices, the use of simple measures to assess mobility, functional status, and cognitive impairment in our older patients may have a significant effect on our patients’ quality of life and on our own ability to care for them.
REFERENCES
- Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311-1316.
- Erekson EA, Fried TR, Martin DK, et al. Frailty, cognitive impairment, and functional disability in older women with female pelvic floor dysfunction. Int Urogynecol J 2015;26:823-830.
- Needham MJ, Webb CE, Bryden DC. Postoperative cognitive dysfunction and dementia: What we need to know and do. Br J Anaesth 2017;119(suppl 1):i115-i125.
- Erekson EA, Ratner ES, Walke LM, Fried TR. Gynecologic surgery in the geriatric patient. Obstet Gynecol 2012;119:1262-1269.
- Richter HE, Redden DT, Duxbury AS, et al. Pelvic floor surgery in the older woman: Enhanced compared with usual preoperative assessment. Obstet Gynecol 2005;105:800-807.
- Oliphant SS, Lowder JL, Lee M, Ghetti C. Most older women recover baseline functional status following pelvic organ prolapse surgery. Int Urogynecol J 2014;25:1425-1432.
- The American College of Obstetricians and Gynecologists. Chapter: Women 65 and Older. In: Guidelines for Women’s Health Care. 4th ed. 2014.
- Malani P. Functional status assessment in the preoperative evaluation of older adults. JAMA 2009;302:1582-1583.
- Chodosh J, Petitti DB, Elliott M, et al. Physician recognition of cognitive impairment: Evaluating the need for improvement. J Am Geriatr Soc 2004;52:1051-1059.
- Centers for Disease Control and Prevention. Assessment. Timed Up & Go (TUG). Available at: https://www.cdc.gov/steadi/pdf/tug_test-a.pdf. Accessed Feb. 1, 2018.
