SPMSQ for risk stratification of older patients in the emergency departmentSPMSQ zur Risikostratifizierung älterer Patienten in der Notaufnahme: An exploratory prospective cohort studyEine explorative prospektive Kohortenstudie

Abstract

Background
Risk stratification of older patients in the emergency department (ED) is seen as a promising and efficient solution for handling the increase in demand for geriatric emergency medicine. Previously, the predictive validity of commonly used tools for risk stratification, such as the identification of seniors at risk (ISAR), have found only limited evidence in German geriatric patient samples. Given that the adverse outcomes in question, such as rehospitalization, nursing home admission and mortality, are substantially associated with cognitive impairment, the potential of the short portable mental status questionnaire (SPMSQ) as a tool for risk stratification of older ED patients was investigated.

Objective
To estimate the predictive validity of the SPMSQ for a composite endpoint of adverse events (e.g. rehospitalization, nursing home admission and mortality).

Method
This was a prospective cohort study with 260 patients aged 70 years and above, recruited in a cardiology ED. Patients with a likely life-expectancy below 24 h were excluded. Follow-up examinations were conducted at 1, 3, 6 and 12 month(s) after recruitment.

Results
The SPMSQ was found to be a significant predictor of adverse outcomes not at 1 month (area under the curve, AUC 0.55, 95% confidence interval, CI 0.46–0.63) but at 3 months (AUC 0.61, 95% CI 0.54–0.68), 6 months (AUC 0.63, 95% CI 0.56–0.70) and 12 months (AUC 0.63, 95% CI 0.56–0.70) after initial contact.

Conclusion
For longer periods of observation the SPMSQ can be a predictor of a composite endpoint of adverse outcomes even when controlled for a range of confounders. Its characteristics, specifically the low sensitivity, make it unsuitable as an accurate risk stratification tool on its own.

Full text

Gerontologie+Geriatrie
Zeitschrift für
Themenschwerpunkt
Z Gerontol Geriat
https://doi.org/10.1007/s00391-019-01626-z
Received: 1 July 2019
Accepted: 11 September 2019
© The Author(s) 2019
A. Schönstein1· H.-W. Wahl1·H.A.Katus
2· A. Bahrmann1,2
1Network Aging Research, HeidelbergUniversity, Heidelberg, Germany
2Heidelberg University Hospital, Heidelberg, Germany
SPMSQ for risk stratification of
older patients in the emergency
department
An exploratory prospective cohort study
Electronic supplementary
material
Theonlineversionofthisarticle(https://doi.
org/10.1007/s00391-019-01626-z)contains
supplementary material, which is available to
authorized users.
For many older patients the emer-
gency department (ED) is an entry
point into the healthcare system.
Geriatric emergency medicine is a re-
source intensive process and with
ongoing demographic aging the al-
ready high demand is expected to
rise even further [1]. At present, spe-
cial needs of geriatric patients are
likely to be overlooked in the ED [26].
To face this challenge and improve
pathways towards optimal geriatric
healthcare, the geriatric medical
concept of the state government of
Baden-Württemberg recommends
screening older patients for those
at high risk for adverse outcomes at
the very beginning of the medical
treatment, which is often in the ED of
acute care hospitals [32].
Introduction
Fundamentally, risk stratification is in-
tended to be part of a two-step process:
first, a screening tool is used for the
brief risk stratification of all presenting
older patients. Second, those patients
that screen positive undergo a multi-
modal geriatricassessment or some other
elaborate diagnostic procedure, which
then in consequence enables the clin-
ician to reliably identify the needs of
geriatric patients [4,22]. Risk stratifi-
cation of older patients in the ED there-
fore strives to enable the healthcare sys-
tem to manage its resources as efficiently
as possible. Additionally, the goal is to
provide the identified high-risk patients
with a more thorough diagnostic process
than exerted in usual ED care; however,
despite a growing body of relevant lit-
erature, implementing risk stratification
processes targeted at older patients in
German EDs seems to fall short [35].
e reasons for this situation include the
complex characteristics of the ED setting,
ambiguous results about the validity of
the potentially useful instruments, as well
as the questionable clinical utility.
Characteristics of the ED setting
and risk stratification with
identification of seniors at risk
(ISAR)
e key to any systematic screening in the
ED is feasibility as ED settings provide
limited time and room as well as oen
noisy and busy surroundings. Not only
are multimodal geriatric assessments not
suited for this environment, some of the
screening methods designed specifically
for the risk stratification of older adults
are likely too long and effortful for effi-
cient use in EDs [14,36]. In a consensus
statement for the identification of geri-
atric patients in the ED setting in Ger-
many, the German Geriatric Society as
well as the German Society of Gerontol-
ogy and Geriatrics mentioned a number
of potential tools for the risk stratifica-
tion of older adults in the ED setting
[6,16,21]. Specifically, the use of the
identification of seniors at risk screen-
ing (ISAR) tool was recommended for
settings where no other instruments or
geriatric expertise are available, mainly
because of the ISAR’s simple adminis-
tration and its existing extensive body
of international literature [35]; however,
while positive and negative results on
the predictive validity of the ISAR have
been reported in the international liter-
ature [9,29], meta-analyses found it to
have either insufficient or only modest
predictive accuracy [5,13]. In light of
negative results, Hwang and Carpenter
argued that w hile more accurate tools are
being developed the ISAR should con-
tinuetobeusedtoensureawarenessand
understanding of geriatric patients be-
yond the acute problem [17]. e only
study that examined the predictive va-
lidity of the ISAR in a German sample of
ED patients found it to have “acceptable”
predictive validity [30]. ere are two
major aspects that complicate the inte-
gration of the ISAR tool into the clinical
routine: first, with the risk of adverse
events (e.g. rehospitalization, nursing
home admission and mortality) it mea-
sures a construct of general risk, which is
difficult to grasp and unspecific regard-
ing its medical indications. Second, in
the studies conducted using German ED
samples, the ISAR classified more than
80% of patients as high-risk patients [30,
37], thus questioning its specificity and
Zeitschrift für Gerontologie und Geriatrie

Themenschwerpunkt
ability to strengthen the effective use of
resources.
Addressing the previously mentioned
concerns and the suggestion made in the
literature to explore alternative variables
for the risk stratification of older ED pa-
tients[5], the objectiveof this studywas to
examinethe predictive validityof thecog-
nitive screening tool short portable men-
tal status questionnaire(SPM SQ [25]) for
adverse events aer an ED hospital stay.
e SPMSQ is an established short cogni-
tivetestthathasalreadyfoundapplication
in the ED setting [28]; it has also been
shown to predict adverse events in older
patients [21,31]. Furthermore, cogni-
tive impairment is common but oen
remains undetected or clinically unused
in older ED patients [15]. According to
the recommendations of the Society for
Academic Emergency Medicine cogni-
tive screening can even be seen as one of
the major quality indicators in geriatric
emergency medicine [34]. To the best of
our knowledge, there is no study that has
examined the predictive validity of the
SPMSQ for adverse events in a sample
of German ED patients across a con-
siderable observational period. Conse-
quently, due to the need for risk strat-
ification and cognitive screening in the
ED and the existing strong relationships
between cognitive impairment and un-
desired outcomes, this study examined
the suitability ofcognitive screening with
the SPMSQ as a to ol for risk stratification
up to a 1-year interval.
Methods
Study design and participants
is was a single center, exploratory and
prospective cohort study with 260 con-
secutivelyrecruitedEDpatients. edata
on the predictive validity of the SPMSQ
were drawn from the usual care group of
an ongoing intervention study. e study
was approved by the ethics committee at
the medical faculty of Heidelberg Uni-
versity (S-455/2016). Since the study was
based on the usual care group of an ongo -
ing intervention study, no specific power
calculation was conducted; however, the
overallsamplesizeof260canbequali-
fied as similar to comparable studies in
theexistingliterature(e.g.[3,29]).
Recruitment was done by the first au-
thor and took place 7 days a week dur-
ing the day shis in a cardiological ED
(chest pain unit) affiliated with a uni-
versity hospital, with 12 beds in the ED
and a total of 114 beds in the associated
cardiology department. e first patient
was recruited in July 2017 and the last
patient in May 2018. Patients aged 70
years or above were included. Exclusion
criteria were missing informed consent
or a likely life expectancy of less than
24 h. Due to procedural reasons, patients
that had to undergo isolated care were
also not included in the study. Patients
were asked to participate in the study af-
ter the initial medical examination. On
agreement, a respective informed con-
sent document to participate in all data
waves was signed. Follow-ups were con-
ducted 1, 3, 6 and 12 months aer initial
contact via telephone interviews. e
data were combined with hospital files,
online death recording via obituaries and
registry office information.
Measures and outcomes
In addition to several demographic char-
acteristics, the patient’s cognitive perfor-
mance was assessed by use of the SPMSQ
tool, which can be retrieved from the
original publication [25] or other avail-
able resources [12,18]. e SPM SQ score
is derived from the amount of errors
based on a 10-item list by coding errors
as “1” and correct answers as “0”. Items
include tasks on orientation (“Whatis the
date today?”), memory (“What was your
mother’s maiden name?”) and attention
(“Subtract3from20andkeepsubtract-
ing 3 from each new number, all the
way down”). us, individual cognitive
scores ranged from 0 to 10 errors, with
lower values indicating better cognitive
performance.
As outcomes unplanned rehospital-
izations (ED and general) were recorded
as well as nursing home admissions and
all-cause mortality. For the primary anal-
ysis all outcomes were combined into
a binary coded composite adverse out-
come variable, meaning at least oneof the
eventshadoccurredwithin1monthaer
initial contact, if the composite outcome
was coded as positive for the first follow-
up. is composite outcome was exam-
ined for primarily 1 month, but further
also for 3, 6 and 12 months aer initial
contact. For a secondary analysis the all-
cause mortality within 1 year aer initial
contact was also examined.
Statistical methods
Descriptive statistics of the sample were
calculated using means and standard
deviations for continuous normally
distributed variables, median and in-
terquartile range for continuous/discrete
but not normally distributed variables
and absolute and relative frequencies for
categorical variables. Group differences
across these variables were calculated for
cognitively impaired and unimpaired
patients (SPMSQ error score ≥3and
<3). Given the binary coding of the
primary outcome, logistic regression
models were used to test for the rela-
tionship between the SPMSQ score and
the primary outcome. In these analyses,
pairwise deletion was used for missing
data. Receiver operating characteristic
(ROC) curves were used to illustrate
the discriminatory performance of the
cognitive risk screening. For the sec-
ondary outcome, a survival analysis was
conducted with Kaplan-Meier estimates.
Statistical analyses were performed us-
ing SAS Version 9.4 (SAS Institute Inc.,
Cary, NC, USA).
Results
Descriptive statistics for the 260 included
patients can be found in .Table 1.Pa-
tients were mostly male 163/260 (63%).
e mean age was 79 years (SD =5.97
years), 37/260 (14%) of the patients
had no education beyond the basic
school level, 156/260 (60%) completed
an apprenticeship, 48/260 (19%) fin-
ished a university degree and 19/260
(7%) held a PhD. As also displayed
in .Table 1, using the SPMSQ cut-off
of ≥3 errors, patients identified by the
SPMSQ as cognitively impaired (60/260
or 23%) were older (MDiff =3.91 years;
t(91) = 4.44; p<0.001) and less educated
(U= 4264.00; p<0.001; r= –0.24) than
Zeitschrift für Gerontologie und Geriatrie

Abstract · Zusammenfassung
Z Gerontol Geriat https://doi.org/10.1007/s00391-019-01626-z
© The Author(s) 2019
A.Schönstein·H.-W.Wahl·H.A.Katus·A.Bahrmann
SPMSQ for risk stratificationof older patients in the emergency department. An exploratory
prospective cohort study
Abstract
Background. Risk stratification of older
patients in the emergency department (ED)
is seen as a promising and efficient solution
for handling the increase in demand for
geriatric eme rgency medicine. Previously, the
predictive validi ty of commonly used tools for
risk stratification, such as the identification of
seniors at risk (ISAR), have found only limited
evidence in German geriatric patient samples.
Given that the adverse outcomes in question,
such as rehospitalization, nursing home
admission and mortality, are substantially
associated with cognitive impairment, the
potential of the short portable mental
status questionnaire (SPMSQ) as a tool for
risk stratification of older ED patients was
investigated.
Objective. To estimate the predictive validity
of the SPMSQ for a composite endpoint of
adverse events (e.g. rehospitalizat ion, nursing
home admission and mortality).
Method. This was a prospective cohort study
with 260 patients aged 70 years and above,
recruited in a cardiology ED. Patients with
a likely life-expectancy below 24 h were
excluded. Follow-up examinations were
conductedat1,3,6and12month(s)after
recruitment.
Results. The SPMSQ was found to be
a significant predictor of adverse outcomes
not at 1 month (area under the curve, AUC
0.55, 95% confidence interval, CI 0.46–0.63)
but at 3 months (AUC 0.61, 95% CI 0.54–0.68),
6 months (AUC 0.63, 95% CI 0.56–0.70) and
12 months (AUC 0.63, 95% CI 0.56–0.70) after
initial contact.
Conclusion. For longer periods of observation
theSPMSQcanbeapredictorofacomposite
endpoint of adverse outcomes even when
controlled for a range of confounders. Its
characteristics, specifically the low sensitivity,
make it unsuitable as an accurate risk
stratification tool on its own.
Keywords
Cognition · Geriatrics · Screening · Adverse
outcomes · Mor tality
SPMSQ zur Risikostratifizierung älterer Patienten in der Notaufnahme. Eine explorative prospektive
Kohortenstudie
Zusammenfassung
Hintergrund. Die Risikostratifizierung von
älteren Patienten in der Notaufnahme gilt als
vielversprechender und effizienter Lösungs-
ansatz, um die steigende Nachfrage nach
geriatrischer Notfallmedizin zu bewältigen.
Bisher zeigte sich die prädiktive Validität des
am häufigsten e ingesetztenInstruments, dem
Identification of Seniors at Risk (ISAR), für
deutsche Stichproben jedoch als begrenzt.
Da die interessierenden Outcomes, wie
Rehospitalisierung, Pflegeheimübersiedlung
und Mortalität deutlich mit kognitiver
Beeinträchtigung zusammenhängen, war es
unser Ziel, das Potenzial des Short Portable
Mental Status Questionnaire (SPMSQ) als
Instrument zur R isikostratifizierung von
älteren Notaufnahmepatientenzu überprüfen.
Fragestellung. Schätzung der prädiktiven
Validität des SPMSQ für einen kombinierten
Endpunkt adverser Outcomes (Rehospi-
talisierung, Pflegeheimübersiedlung und
Mortalität).
Daten und Methode. Es handelte sich um
eine prospektive Kohortenstudie mit 260
Patienten im Alter von mindestens 70 Jahren,
die in einer kardiologischen Notaufnahme
rekrutier t worden waren. Patienten mit einer
Lebenserwartung von unter 24 h wurden
exkludiert. Follow-ups fanden nach 1, 3, 6,
und 12 Monaten statt.
Ergebnisse. SPMSQ war signifikanter Prädiktor
für den kombinierten Endpunkt adverser
Outcomes zwar nicht für 1 Monat (AUC: 0,55;
95 % KI 0,46–0,63), aber für 3 Monate (AUC:
0,61; 95 % KI 0,54–0,68), 6 Monate (AUC: 0,63;
95 % KI 0,56–0,70) und 12 Monate (AUC: 0,63;
95 % KI 0,56–0,70) nach Erstkontakt.
Schlussfolgerung. Für längere Beobach-
tungszeiträume scheint der SPMSQ, auch
unter Kontrolle potenziell konfundierender
Variablen, ein Prädiktor für adverse Outcomes
zu sein. Seine Eigenschaften, insbesondere
die niedrige Sensitivität, machen ihn jedoch
für den Einsatz als alleiniges Screening-
Instrument wenig tauglich.
Schlüsselwörter
Kognition · Geriatrie · Screening · Adverse
Outcomes · M ortalität
those with a negative SPMSQ result
(200/260 or 77%).
Results for logistic regression re-
garding the composite outcome and
related patient attrition are reported
in .Table 2. e composite endpoint
occurred in 64/250 (26%) at 1 month,
117/249 (47%) at 3 months, 145/245
(59%) at 6 months and 165/245 (67%)
at 12 months aer initial contact. us,
until 12 months aer initial contact
15/260 (6%) patients or indirect follow-
ups provided insufficient information
on the outcomes for the cases to be in-
cluded in the analysis. In the univariate
logistic regression model SPMSQ was
a statistically significant predictor of the
compositeendpointat3months(odds
ratio, OR: 1.34, 95% confidence interval,
CI 1.12–1.60), at 6 months (OR: 1.47,
95% CI 1.20–1.80) and at 12 months
(OR: 1.54, 95% CI 1.22–1.93) but not at
1 month (OR: 1.13, 95%CI 0.94–1.36)
aer initial contact. Statistical signif-
icance was retained, when controlling
for a range of possible confounders (e.g.
age, sex, education, body mass index,
and comorbidity).
.Fig. 1displays the exact discrimi-
natory performance of the SPMSQ score
(continuous) for those time points where
it was found to be a significant predictor
of the composite outcome, hence the 3,
6, and 12-month intervals. Associated
areas under the curve (AUC )foralltime
points were 0.55 (95% CI 0.46–0.63) for
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Themenschwerpunkt
Tab le 1 Descriptive statistics of thetotal sample and groupdifferences between patientsclas-
sified as normal or impaired by the SPMSQ
Characteristic Tot a l
(N= 260)
SPMSQ normal (<3)
(N= 200)
SPMSQ impaired (≥3)
(N= 60)
p-value
Age (years) 79.31 (5.97) 78.40 (5.65) 82.31 (6.07) <0.001
Sex
Male 163 (63%) 130 (65%) 33 (55%) 0.16
Fema le 97 (37%) 70 (35%) 27 (45%)
BMI 26.84 (4.74) 27.06 (4.49) 26.08 (5.47) 0.21
CACI 5 (4–7) 5 (4–7) 6 (5–7.5) 0.12
Education
None 37 (14%) 21 (11%) 16 (27%) <0.001
Apprenticeship 156 (60%) 118 (59%) 38 (63%)
University degree 48 (19%) 45 (23%) 3(5%)
PhD or similar 19 (7%) 16 (8%) 3(5%)
Data are number (% of group total), mean (SD), or median (interquartile range)
pvalues for group dierences from Welch’s t-test (age, BMI), Mann-Whitney test (CACI, education)
and from χ2-test (sex); signicant p-values in bold
BMI body mass index, CACI Charlson age-comorbidity index
Tab le 2 Univariate and multivariate odds ratios (OR) and 95% confidence intervals (CI) for the
composite adverse ou tcome variable predicted by SPMSQ errors at initial contact
Time after
initial
contact
nPatients with
adverse outcome
(n,%)
Univariate Multivariate/adjusteda
OR 95% CI OR 95% CI
1month 250 64 (26%) 1.13 0.94–1.36 1.09 0.90–1.32
3months 249 117 (47%) 1.34** 1.12–1.60 1.31** 1.09–1.57
6months 245 145 (59%) 1.47*** 1.20–1.80 1.45*** 1.18–1.79
12 months 245 165 (67%) 1.54*** 1.22–1.93 1.53*** 1.20–1.94
aThis multivariate model was adjusted for patient sex, education and body mass index (BMI) at
initial contact. Age and comorbidity at initial contact were also controlled by using the score of the
Charlson age-comorbidity index
**p< 0.01, ***p< 0.001
1 month, 0.61 (95% CI 0.54–0.68) for
3 months, 0.63 (95% CI 0.56–0.70) for
6 months and 0.63 (95% CI 0.56–0.70)
for 12 months aer initial contact. Sensi-
tivities and specificities of the SPMSQ for
the prediction of the composite outcome
across different possible cut-off values
can be found in the Supplementary ma-
terial Table 1. For the time points where
SPMSQ was a significant predictor of ad-
verse outcomes, the associated sensitivi-
ties and specificities using the ≥3errors
cut-off were as following: 34% sensitiv-
ity and 88% specificity (3 months), 30%
sensitiv ity and 91% sp ecificity (6 m onths)
and 29% sensitivity and 94% specificity
(12 months).
Kaplan-Meier curves were used to an-
alyze patient survival probabilities de-
pending on positive or negative SPMSQ
results (with cut-off ≥3; see .Fig. 2). Of
the total sample (N= 260) one patient
with negative SPMSQ was lost to fol-
low-up at 6 months aer initial contact
and therefore censored. Overall, the log-
rank test showed no statistically signif-
icant differences between the resulting
two survival curves, although there was
a trend that lowered cognitive perfor-
mance was associated with higher all-
cause mortality (χ2(1) = 2.92, p= 0.087).
Discussion
Tothebestofourknowledgethisisthe
first study that examined the predictive
validity of the cognitive screening tool
SPMSQ for the risk stratification of older
ED patients regarding adverse outcomes
(e.g. rehospitalization, nursing home ad-
mission, mortality). e key findings can
be summarized as following:
4SPMSQ seems to be a useful predictor
of adverse outcomes in older German
ED patients; however, not for brief
(e.g. 1 month) but only for longer
observation periods (e.g. 1 year).
is relationship remained stable
when controlling for a range of
confounders.
4e suggested ≥3errorscut-off
appeared to be the most useful
when predicting adverse outcomes at
different points in time.
4While the specificity is high sensitiv-
ity is low. Overall, these characteris-
tics can be regarded as insufficient for
useasascreeningtool.
4Although a tendency was observed
for a decreased 1-year survival
probability of patients with a SPMSQ
score of ≥3 errors when compared to
those with <3 errors, results were not
statistically significant.
Geriatric screening in the ED is of spe-
cial relevance, because scarcity of re-
sources and increasing demand for geri-
atric emergency medicine necessitate an
empirically tested approach for risk strat-
ification of the patients. Identified high-
risk patients can undergo a multimodal
assessment and, if suitable profit from
specialized interventions or optimized
treatment pathsforgeriatric patients[33].
e best studied instrument and there-
fore the reference standard for qualifying
our results is the ISAR. Singler et al. [30]
reported the ISAR to predic t adverse out-
comes at 28 days and at 6 months aer
initial contact in a German ED sample.
Even though ISAR measures an abstract
risk of adverse outcomes and SPMSQ
was designed as a cognitive screening
tool, cognitive impairment has shown to
be substantially related to adverse out-
comes, such as rehospitalization, nursing
home admittance, and mortality ([11,21,
31]). For risk stratification purposes, es-
pecially the short-term development of
patients may be of interest; therefore, the
primary analysis used the same compos-
ite outcome as the study conducted by
Singleretal. [30]andsimilarlyfocusedon
the prediction of adverse events 1 month
aer initial contact but also for longer
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0.00
0.25
0.50
0.75
1.00
Sensitivity
0.00 0.25 0.50 0.75 1.00
1 - Specicity
Area Under the Curve = 0.6129
0.00
0.25
0.50
0.75
1.00
Sensitivity
0.00 0.25 0.50 0.75 1.00
1 - Specicity
Area Under the Curve = 0.6318
0.00
0.25
0.50
0.75
1.00
Sensitivity
0.00 0.25 0.50 0.75 1.00
1 - Specicity
Area Under the Curve = 0.6330
abc
Fig. 1 8Receiver operating characteristics (ROC) curves forSPMSQ scores as a continuous predictorof the composite out-
comeata3months,b6monthsandc12 monthsafter initialcontact. Areasunder thecurve (AUC)were0.61 (95% CI0.54–0.68),
0.63 (95% CI 0.56–0.70) and0.63 (95% CI 0.56–0.70), respectively
60 55 53 52 0
200 192 183 180 0
0 100 200 300 400
Days
0.0
0.2
0.4
0.6
0.8
1.0
Survival Probability
1
2
2: SPMSQ with less than 3 errors1: SPMSQ with 3 or more errors
Group
60 55 53 52 0
200 192 183 180 0
0 100 200 300 400
Days
0.0
0.2
0.4
0.6
0.8
1.0
Survival Probability
1
2
Group
Logrank p=0.0874
+ Censored
Fig. 2 9Surviva l plots for
patients classified as cog-
nitively impaired (group 1)
or unimpaired (group 2) by
the SPMSQ with cut-off ≥3.
Numbers above the x-axis
indicate the count of pa-
tients at risk in the respec-
tive groups
observational intervals. For the 1-month
observation period, SPMSQ was not an
efficient predictor of adverse outcomes;
however, for longer observation periods
(3, 6 and 12 months) SPMSQ predicted
adverse outcomes even when controlled
for a range of confounders, such as pa-
tients’ sex, age, comorbidity and body
mass index, which may be of interest
since the data were collected in a cardio-
logical ED and also education due to po-
tentially protectivecognitive reserve [27].
e overall AUC effect size at 6 months
was found to be in a comparable mag-
nitude as observed with ISAR. Conse-
quently, the performance of solely going
for the SPMSQ seems at first glance to
be similar to the ISAR. In addition, the
results are in accordance with previously
reported findings in the literature that
cognitive impairment as measured by the
SPMSQ is a predictor of adverse events.
is further underlines the usefulness of
cognitive measures for risk stratification
of older ED patients, which is already
considered in existing tools, such as the
acutely presenting older patients (APOP)
screener [7,8,20]; however, limitations
of using the SPMSQ as a risk stratifi-
cation tool in the ED geriatric patient
population must be noted as well. Re-
garding the sensitivity and specificity of
the SPMSQ for detecting risk of adverse
outcomes, compared to the results re-
ported in the study of Singler et al. [30],
the SPMSQ was found to have a higher
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Themenschwerpunkt
specificity but a much lower sensitivity
than the ISAR for predicting adverse out-
comes at 6 months aer initial contact. If
sensitivity and specificity were weighted
equally (e.g. by examining Youden’s J),
overalldiagnostic accuracyoftheSPMSQ
to predict adverse events would be com-
parable to that of the ISAR; however, the
potentialharmfromfalsenegativesde-
serves special consideration. For exam-
ple, when overlooking a patientwith high
risk because of a negative SPMSQ cate-
gorization and consequently not taking
any active measures to prevent the ad-
verse outcome, the consequences would
be far more serious than from a false pos-
itive. A false positive would only result
in extra time spent to conduct a multi-
modal assessment with a patient that was
categorized as a high-risk patient by the
ISARbutthatis,inreality,atlowrisk
of adverse outcomes. us, the SPMSQ
appears to be inferior in terms of use as
a screening instrument when compared
to the results of the ISAR as reported by
Singler et al. [30]. Finally, the associa-
tion of cognitive impairment as catego-
rized by the SPMSQ and the all-cause
mortality of the sample of older cardi-
ology ED patients was examined. e
results of current research point to cog-
nitive impairment being a clear predictor
of mortal ity [2,19,24]. Furthermore, this
may be of special relevance in cardiol-
ogy patients, since cognitive impairment
was found to not only be associated with
detrimental cardiological events[23], but
also other predictors of mortality in car-
diological patients, such as malnutrition
[10]. Surprisingly,however,norobust
relationship between the SPMSQ cut-off
and survival was found. is is seen as an
important research question for higher
powered studies in the future, with pos-
sibly longer observation periods.
Limitations
Several limitations must be considered
when interpreting the results. Inter-
viewer bias may be possible because data
collection and follow-up were conducted
entirely by the first author of this study,
who was not blinded regarding the study
goal; however, fully standardized mea-
suresandobjectiveoutcomeswereused
that are not open to interpretation. Even
though this was an exploratory study,
multiplicity should also be addressed.
e results remained significant when
multiplicity was adjusted for by using the
established Bonferroni-Holm correction
of the alpha significance level. Multi-
plicity is therefore seen as a relatively
minor problem in this analysis. Another
possible source of bias is that screening
was only possible with patients where
an informed consent procedure was fea-
sible. Patients with very severe medical
problems were consequently excluded.
Since these patients are obviously high-
risk patients, they cannot be regarded as
the target group for geriatric screening;
however, the fact that patients undergo-
ing isolated care could not be included
poses a risk to the external validity
of the results presented in this article.
Additionally, due to mostly conducting
follow-ups via phone calls, it was not
possible to provide reliable incidences of
theoutcomesthatwerecombinedinto
the composite outcome separately. For
example, the outcome mortality may
have masked a previous rehospitaliza-
tion because it was difficult to retrieve
this information. Finally, it must be
emphasized that patients were recruited
from a university affiliated cardiology
ED that may not be representative of the
general ED population due to different
morbidities and due to its popularity
with private patients from different lo-
cations. is also can be seen as a risk
to the external validity.
Conclusion
In longer observation periods the cogni-
tive screening tool SPMSQ can be a pre-
dictor of adverse outcomes, even when
controlled for a range of relevant con-
founders. Its characteristics, however,
specifically the low sensitivity, make it
unsuitable as an accurate risk stratifica-
tion tool a lone. Combinations with oth er
risk screening procedures may however
be promising.
Practical conclusion
4The SPMSQ proved to be feasible for
use in the ED setting in this sample
and was a predictor of adverse
outcomes.
4The SPMSQ does not have the capac-
ity to replace risk stratification with
common geriatric screening tools like
the ISAR.
4Further research into risk strati-
fication with different cognitive
screening tools and combinations
with other risk stratification devices
may produce results with higher
sensitivity.
Corresponding address
A. Schönstein, MSc
Network Aging Research,
Heidelberg University
Heidelberg, Germany
schoenstein@
nar.uni-heidelberg.de
Funding . This study was funded by the Robert
BoschFoundationwithintheGraduateProgram
People with Dementia in Acute Care Hospitals (GP-
PDACH), located at the Network Aging Research
(NAR), University of Heidelberg,Germany. The open
access publication was suppor ted by Robert Bosch
Stiftung.
Compliance with ethical
guidelines
Conflict of interest A. Schönstein, H.-W. Wahl,
H. A. Katus and A. Bahrmann declare that theyhave
no competing interests. Thesupplement containing
this article is not sponsored by industr y.
All procedures performed in the study were in accor-
dance with the ethical standardsof the ethical board
of the Medical Facultyat Heidelberg University and
with the 1964 Helsinki de claration and its later amend-
ments or comparable ethical standards. Informed
consent was obtained from all individual participants
in the study.
Open Access.This article isdistributedunder theterms
of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/
4.0/), which permitsunrestricted use, distribution,
and reproduction in any medium, provided you give
appropriate creditto the original author(s) and the
source,provide a link to theCreative Commons license,
and indicate if changes were made.
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