Faculty Bibliography

Dementia is under-recognized in primary care settings. Benefits of early detection of dementia, proactive care, and patient-centered management are recognized in several studies (Borson 2013). Centers for Medicare & Medicaid Services introduced the AWV in 2011 to incentivize preventive care for older adults. In 2017, Montefiore Medical Center, Bronx NY implemented cognitive screening, as a required component of the AWV, and we describe its performance.
Method(s): The Montefiore Medical Group (MMG) provides primary care to over 40,000 older adults in underserved neighbor-hoods. A template for the AWV was built into our electronic health record, EPIC. All patients that present for their AWV are asked a cognitive screening question about "difficulty with memory or confusion." Patients answering affirmatively undergo testing with the Picture Based Memory Impairment Screen (PMIS) for cognitive impairment (Verghese, 2012; Malik, 2018). The AWV cognitive screening question was piloted by licensed practical nurses in 5 MMG sites. The charts of patients with an abnormal PMIS were reviewed for demographics; new neurological and psychiatric diagnosis; and refer-rals to subspecialists and community-based organizations (CBOs).
Result(s): 5,870 AWV were completed from July 2017-Oct 2018. Clinical staff performed the PMIS on 442 who had a positive response to the cognitive screen question. Cognitive impairment was identified in 32% (142/442) with PMIS < $sup$5$/sup$. Mean age of those with abnormal PMIS 80 + 9 years, 76 % female. New neurological and psychiat-ric diagnosis included: Dementia 52% (63/142); MCI 4% (5/142); memory loss 19% (23/142), and depression 3% (4/142). Referral to subspecialists: 11% (13/142) Geriatrics; 49% (60/142) Neurology and 39% (47/142) were referred to CBOs.
Discussion(s): Implementation of the AWV in a large primary care network was successful in identifying older adults with memory impairment. The PMIS was readily integrated into the workflow of the AWV. There was a 2.4% (142/5870) prevalence of an abnormal screening test in this population. Implementation of the AWV resulted in newly diagnosed dementia patients and new referrals to specialists and CBOs

Cerebral oximetry is a simple method of measuring regional cerebral oxygen saturation (rSO(2)). One promising application is its use during carotid endarterectomy (CEA) to help minimize the risk of perioperative stroke. The authors used the INVOS-4100 cerebral oximeter at several steps during CEA to measure the effect of carotid clamping and shunting on rSO(2). The authors prospectively evaluated 42 consecutive CEAs in 40 patients. All had CEA under general anesthesia with the routine use of a Javid shunt. The INVOS-4100 oximeter was used to measure rSO(2) before clamping (t1), after clamping but before shunting (t2), 5 minutes after shunt insertion (t3), and after patch closure with reestablished flow (t4). The Wilcoxon signed-rank and rank-sum tests were used for analysis. Clamping of the internal carotid artery (t1 vs t2) resulted in a drop of ipsilateral rSO(2) by -12.3% (p < 0.001). Shunt insertion (t2 vs t3) increased rSO(2) by 10.9% (p < 0.001). Contralateral rSO(2) for the same time periods was insignificant. Patients with preoperative neurologic symptoms had a greater decrease in rSO(2) after clamping (-18.4%) compared with a decrease of -10.4% in asymptomatic patients (p = 0.037). Cerebral oximetry monitoring is simple and inexpensive. The study showed statistically significant changes in rSO(2) as a result of clamping and shunting of the carotid artery. Symptomatic patients had a greater drop in rSO(2).