2.1 Clinical History

A 72-year-old male is accompanied by his wife to his ambulatory memory clinic appointment. He has recently been assessed by a vascular surgeon in relation to his 5.8 cm abdominal aortic aneurysm (AAA). The surgeon has planned an open repair of the aneurysm, and refers the patient to the preoperative clinic for assessment. As part of the standard preoperative clinic assessment process, the patient undergoes a frailty screen using the Frailty Assessment for Care Planning Tool (FACT),¹ which utilizes caregiver input and objective cognitive testing (three-word recall, clock-drawing task) to assess frailty across four key domains: mobility, social situation, function, and cognition (Figure 2.1). The patient’s frailty level is determined to be severe, largely driven by his cognitive and functional impairments. While there are no perioperative concerns, his nurse assessor has concerns about the patient’s frailty and cognitive status, in particular, whether he truly understands the risks and benefits of the proposed surgery; therefore, she makes an urgent referral to the memory clinic, 1 week in advance of the scheduled aneurysm repair.

Figure 2.1 FACT utilizes caregiver input and objective cognitive testing (three word recall, clock drawing task) for assessing frailty across four key domains: mobility, social situation, function, and cognition.

In the memory clinic, a more detailed cognitive history was taken to understand the trajectory and nature of the cognitive and functional deficits noted on the FACT screen. While the patient did not self-identify any memory concerns, at the memory clinic, his wife described a gradual decline in his cognition and function over the last several years. She indicated that 4 years ago he began falling behind on bill payments and occasionally forgot to take his antihypertensive medication, so she took over these tasks. Two years ago, when his driver’s license expired, she “convinced” him not to renew it, her concerns stemming from three occasions where he’d gotten lost in familiar areas when driving alone and several driving infractions she’d witnessed as his passenger. Over the last 18 months, she has taken on all of the cooking and cleaning, and in the last 8 months, has regularly needed to remind him to bathe and put on clean clothing. Sometimes he requires hands-on help to manage the mechanics of dressing. She does not have any formal homecare assistance but has disengaged from many of her own social activities due to his agitation when she is out of the home for more than an hour.

There is no history of perceptual disturbance, depression, or neurovegetative symptoms. He reads the newspaper daily, although he usually cannot recall what he has read. He enjoys visits from his grandchildren, although he infrequently refers to them by name. He has had no behavioral issues or significant personality change, although she notes him to be more irritable with the grandchildren and more reliant on a fixed daily routine. There has been no change in his gait, balance, or physical strength.

Of his upcoming surgery, the patient’s wife says, “I’m worried about what it will mean for him, but if this is what he wants to do, I’ll support him in whatever way I can.”

2.2 General History

Other than the AAA, the patient has no chronic health conditions. He has a remote history of smoking (25 pack years, quit 20 years ago) and does not consume alcohol. He achieved a grade 12 education and worked in trades as a plumber.

2.3 Family History

There is no family history of dementing illness.

2.4 Examination

General examination reveals a gentleman who is pleasant and cooperative. There are no lateralizing neurologic deficits, but there is bilateral paratonia notable in the upper extremities. His gait and balance are intact.

Consistent with the objective cognitive testing score from the FACT screen, testing with the Mini-Mental State Examination (MMSE)² reveals a score of 18/30, losing points for orientation to date, day, month, year, name of hospital, floor, 0/3 word recall, 2/5 spelling “world” backward, and incorrect intersecting pentagon diagram copying. Testing with the Frontal Assessment Battery (FAB)³ reveals a score of 6/18 losing points in all domains (abstraction, verbal fluency, praxis, conflicting instructions, inhibitory control) except environmental autonomy. He is aware that he has “a problem with [my] blood supply,” but is unable to provide any detail around the proposed surgery nor the outcomes associated with continued surveillance.

2.5 Special Studies

A CT of the head completed 2 months earlier when he sustained a fall revealed small vessel ischemic disease and mild cerebral atrophy in keeping with his age.