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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 and Figures

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.
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Zeitschrift für
Z Gerontol Geriat
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
An exploratory prospective cohort study
Electronic supplementary
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].
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
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-
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
ability to strengthen the effective use of
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-
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.
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
fied as similar to comparable studies in
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
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
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
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).
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
© The Author(s) 2019
SPMSQ for risk stratificationof older patients in the emergency department. An exploratory
prospective cohort study
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
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
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
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.
Cognition · Geriatrics · Screening · Adverse
outcomes · Mor tality
SPMSQ zur Risikostratifizierung älterer Patienten in der Notaufnahme. Eine explorative prospektive
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
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.
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
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
Zeitschrift für Gerontologie und Geriatrie
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)
Age (years) 79.31 (5.97) 78.40 (5.65) 82.31 (6.07) <0.001
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
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
nPatients with
adverse outcome
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).
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
4e suggested 3errorscut-o
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
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
Zeitschrift für Gerontologie und Geriatrie
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
1 - Specicity
Area Under the Curve = 0.6318
0.00 0.25 0.50 0.75 1.00
1 - Specicity
Area Under the Curve = 0.6330
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
Survival Probability
2: SPMSQ with less than 3 errors1: SPMSQ with 3 or more errors
60 55 53 52 0
200 192 183 180 0
0 100 200 300 400
Survival Probability
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
Zeitschrift für Gerontologie und Geriatrie
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
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
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.
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-
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
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.
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
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
Corresponding address
A. Schönstein, MSc
Network Aging Research,
Heidelberg University
Heidelberg, Germany
Funding . This study was funded by the Robert
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
Compliance with ethical
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 (
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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... There are other limitations to be mentioned. First, we did not have data available about many important factors such as frailty and functional impairment [7,23], socio-economical status [36], palliative care, cognitive impairment [37], use of medications or whether patients were admitted from or discharged to nursing homes, rehabilitation facilities or their own homes. The possibility for interpretation in a causal framework [38] is therefore limited, and the focus of the current study is limited to identification of predictors. ...
... Such data, possibly combined with biomarkers [41] and other screening systems [37] could be used to select groups of patients where targeted interventions could be evaluated [41]. High risk patient groups could be offered timely follow up face to face at home or in an outpatient clinic [42], a longer hospital admission, or discharge to rehabilitation facilities with frequent follow-up. ...
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Background The mortality of older patients after early discharge from hospitals is sparsely described. Information on factors associated with mortality can help identify high-risk patients who may benefit from preventive interventions. The aim of this study was to examine whether demographic factors, comorbidity and admission diagnoses are predictors of 30-day mortality among acutely admitted older patients discharged within 24 h after admission. Methods All medical patients aged ≥65 years admitted acutely to Danish hospitals between 1 January 2013 and 30 June 2014 surviving a hospital stay of ≤24 h were included. Demographic factors, comorbidity, discharge diagnoses and mortality within 30 days were described using data from the Danish National Patient Registry and the Civil Registration System. Cox regression was used to estimate adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for all-cause mortality. Results A total of 93,295 patients (49.4% men) with a median age of 75 years (interquartile range: 69–82 years), were included. Out of these, 2775 patients (3.0%; 95% CI 2.9–3.1%) died within 30 days after discharge. The 30-day mortality was increased in patients with age 76–85 years (aHR 1.59; 1.45–1.75) and 86+ years (aHR 3.35; 3.04–3.70), male gender (aHR 1.22; 1.11–1.33), a Charlson Comorbidity Index of 1–2 (aHR 2.15; 1.92–2.40) and 3+ (aHR 4.07; 3.65–4.54), and unmarried status (aHR 1.17; 1.08–1.27). Discharge diagnoses associated with 30-day mortality were heart failure (aHR 1.52; 1.17–1.95), respiratory failure (aHR 3.18; 2.46–4.11), dehydration (aHR 2.87; 2.51–3.29), constipation (aHR 1.31; 1.02–1.67), anemia (aHR 1.45; 1.27–1.66), pneumonia (aHR 2.24; 1.94–2.59), urinary tract infection (aHR 1.33; 1.14–1.55), dyspnea (aHR 1.57; 1.32–1.87) and suspicion of malignancy (aHR 2.06; 1.64–2.59). Conclusions Three percent had died within 30 days. High age, male gender, the comorbidity burden, unmarried status and several primary discharge diagnoses were identified as independent prognostic factors of 30-day all-cause mortality.
... Even when the timeframe of the current study was restrained to 1 year after initial ED visit, we found the association for biomarkers of ageing to mortality to be considerably stronger than the association of the cognitive measure to mortality. 40 Thus, incorporation of biomarkers into the risk stratification of older patients in the ED appears to be a convenient, feasible and low-cost approach, as blood collection is already implemented into the diagnostic routines. In general, the assessment of biomarkers of age can also be considered a much more objective approach than (self-) report-based measures. ...
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Objectives This study aims to estimate the association of the often, in daily clinical practice, used biological age-related biomarkers high-sensitivity troponin-T (hs-TnT), C reactive protein (CRP) and haemoglobin (Hb) with all-cause mortality for the purpose of older patient’s risk stratification in the emergency department (ED). Design Exploratory, prospective cohort study with a follow-up at 2.5 years after recruitment started. For the predictors, data from the hospital files including the routinely applied biological age-related biomarkers hs-TnT, CRP and Hb were supplemented by a questionnaire. Setting A cardiological ED, Chest Pain Unit, University Hospital Heidelberg, Germany. Participants N=256 cardiological ED patients with a minimum age of 70 years and the capability to informed consent. Primary outcome measures The primary outcome of this study was all-cause mortality which was assessed by requesting registry office information. Results Among N=256 patients 63 died over the follow-up period. Positive results in each of the three biomarkers alone as well as the combination were associated with increased all-cause mortality at follow-up. The number of positive age-related biomarkers appeared to be strongly indicative of the risk of mortality, even when controlled for major confounders (age, sex, body mass index, creatinine clearance and comorbidity). Conclusions In older ED patients, biomarkers explicitly related to biological ageing processes such as hs-TnT, CRP and Hb were to a certain degree independently of each other as well as combined associated with an increased risk of all-cause mortality. Thus, they may have the potential to be used to supplement the general risk stratification of older patients in the ED. Validation of the results in a large dataset is needed.
... COPD is a class of respiratory diseases characterized by airway airflow limitation that is irreversible and progressive [16]. High airway response can cause severe bronchospasm in COPD patients when they are exposed to adverse stimuli. ...
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Objective: This work is aimed at evaluating the efficacy and safety of general anesthesia (GA) combined with spinal anesthesia (SA) (GA+SA) in elderly patients with chronic obstructive pulmonary disease (COPD). Methods and Material. 50 elderly COPD patients were rolled randomly into a control group (simple GA) and observation group (GA+SA). The differences in operation time, postoperative recovery time (PRT), language expression time (LET), anesthetic dosage (AD), catheter extubation time (CET), respiratory circulation indicators (mean arterial pressure (MAP), heart rate (HR), SaO2, and PaO2), postoperative VRS score, pulmonary function (forced vital capacity (FVC)), forced expiratory volume in 1 s (FEV1)/FVC and forced expiratory flow (FEF 25%~75%), serum inflammatory factors (IL-6, IL-8, and TNF-α), Short Portable Mental Status Questionnaire (SPMSQ) score, and the incidence of respiratory system events were analyzed. Results: The results showed that the PRT, LET, AD, and CET of the observation group were all shorter (P < 0.05). The postoperative MAP, HR, SaO2, and PaO2 levels of patients who received GA+SA were much higher than those who received simple GA (P < 0.05). The postoperative VRS score of the observation group was better than that of the controls (P < 0.05). The postoperative pulmonary function of patients in the observation group was better compared with that in the control group (P < 0.05). The postoperative serum inflammatory factors in the observation group were lower in contrast to the patients who received simple GA (P < 0.05). The postoperative cognitive function SPMSQ score of patients who received GA+SA was lower compared with the score of patients who received simple GA (P < 0.05). However, the probability of respiratory system events in the observation group was lower (P < 0.05). Conclusion: In conclusion, GA+SA could significantly shorten the PRT and improve the recovery quality of elderly COPD patients. It can also reduce the postoperative inflammatory response and strengthen the pulmonary function and cognitive function. It also enhances the analgesic which is beneficial to patients' postoperative recovery. Therefore, GA+SA was a highly effective and safe anesthesia method for elderly patients with COPD, and it was worthy of clinical application.
... First, although geriatric assessments may help to recognize vulnerable patient groups and to adjust medical procedures to the specific needs of geriatric patients at early stages of hospitalization, they still have a low priority in the fast-paced daily routines of the acute hospital system (Schönstein et al., 2019). In general, older adults are at high risk to be exposed to therapeutic nihilism (Anderson, 2001;Butler, 1975;Chodosh et al., 2004;Oliver, 2008) in the acute hospital setting. ...
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Objective: Acute care hospital settings represent a challenging environment for vulnerable older patients such as those with dementia. In particular, ageist behavior as reflected in so-called elderspeak communication has been considered as a crucial factor contributing to neuropsychiatric symptoms, suboptimal medical decision making, and poorer treatment outcomes in patients with dementia. Despite its linkage with negative health outcomes, the bulk of previous research on elderspeak has been conducted in nursing home settings and did not simultaneously consider multiple contextual conditions. Following a contextually-driven framework, the present dissertation concentrated on everyday care interactions between older patients and nurses (micro-level) in two German acute hospital settings differing in patient characteristics and geriatric expertise (macro-level). Paper 1 focused on the communication behavior of cognitively impaired (CI) versus cognitively unimpaired (CU) older inpatients. Paper 2 investigated nurses’ emotional tone toward older inpatients with a particular focus on the role of the acute hospital setting and patients’ cognitive impairment. Paper 3 examined the role of proximal (cognitive and functional impairment) and distal contextual factors (acute hospital setting, psychogeriatric knowledge, and evaluative age stereotypes) in predicting the occurrence of elderspeak. Method: Data of all three papers were based on a cross-sectional study focusing on elderspeak in an acute internal medicine ward (n = 36 beds, mean length of stay = 4.9 days) and an acute geriatric ward (n = 35 beds; mean length of stay = 16.5 days). A total of 106 older patients participated in the study. Patients were between 66 and 96 years old (M ± SD Years = 83.08 ± 6.19). Half of the patients (49%) were severely cognitively impaired (M ± SD 6CIT = 10.80 ± 8.60) and 56% were female. In total, 34 registered nurses took part in the study. Nurses were between 22 and 59 years old (M ± SD Years = 38.93 ± 12.30). The majority of nurses were female (79%). Based on a mixed methods design, three types of data sources were used: (a) audio-recordings during the morning (49%) or evening care (51%), (b) patient data from the medical information system, and (c) standardized interviews with patients and nurses. The first paper was based on a psychometric study validating a tool to assess communication behavior in dementia (CODEM) for use in CI patients in the acute care hospital setting. Patients were observed by trained research assistants during a standardized interview situation and rated afterward. In the second paper, an emotional tone rating procedure was performed to differentiate between a person-centered and a controlling tone of nurses’ voice toward older inpatients (Cronbach’s α = .98 for both subscales). A total number of 92 audio-recorded clips were evaluated by 12 naïve raters (M ± SD Age = 32.75 ± 9.33 years) based on their impressions of nurses’ vocal qualities. The third paper was driven by psycholinguistic analysis using manual coding (κ = .85–.97) and computer-assisted procedures for extracting likely harmful (diminutives, collective pronoun substitutions, tag questions) and hybrid features of elderspeak (sentence fragments, mean length of utterances, speech rate, type-token ratio, complex units). Results: The first paper demonstrated that CODEM is a reliable and valid tool to examine the communication behavior of CI patients in the acute care hospital setting. CI patients significantly differed from CU patients in terms of an overall lower frequency of communication behavior as well as a higher occurrence of nonverbal when compared to verbal communication behavior. The second paper revealed that the emotional tone of nurses’ voice toward older patients was perceived as largely person-centered and not so much as control-centered. Finally, the third paper provided further evidence on the existence of likely harmful diminutives (61%), collective pronouns substitutions (70%), and tag questions (97%). An important finding of Paper 2 and 3 was that functional impairment more strongly contributed to controlling tones of nurses’ voice and elderspeak than cognitive impairment and acute hospital setting. Whereas a low percentage of older patients reported perceived age discrimination (2%), more than one third of older patients (36%) endorsed at least one type of ageist event during their hospital stay. Overall, nurses’ views on aging were largely negative. Conclusions: A large interindividual variability of communication resources and deficits has been demonstrated in acutely ill older inpatients. Furthermore, key features of elderspeak have been identified at the verbal and nonverbal communication level. Taken together, the present dissertation provides initial evidence for the occurrence of ageism and elderspeak in acute care hospital settings. Furthermore, it extends previous elderspeak research by discovering the dominant role of functional impairment that may be more strongly involved in the process of negative stereotype activation than cognitive impairment. The present work also provides a unique, multi-level, and interdisciplinary measurement approach for examining ageism in naturally occurring interactions. Such an ecologically valid approach may inform future studies and help to systematically combat ageism in high-risk groups. Finally, the current outbreak of ageism underpins that evidence-based interventions are urgently needed to overcome ageism and to establish a new narrative on aging in the public discourse.
... Such an instrument, despite being widely cited in the international scientific literature [6][7][8][9][10][11] and having versions in other languages 6,11,13,14 , has not yet been translated and culturally adapted to the Brazilian Portuguese language; the versions used by SPMSQ in Brazil correspond to free adaptations or to its Spanish version 9 . This hinders its use by researchers and professionals in clinical practice, decreasing the availability of valid and reliable tools to support the identification of cognitive conditions and their degree of impairment in old people. ...
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Objetivo Adaptar culturalmente o Short Portable Mental Status Questionnaire (SPMSQ) de Pfeiffer para uso no Brasil. Métodos O processo envolveu as seguintes fases: tradução inicial; síntese das traduções; retrotradução; revisão por um comitê de especialistas com experts da área para analisar a validade aparente e de conteúdo, contemplando as equivalências semântica, idiomática, cultural, conceitual e clareza e, por fim, um pré-teste com a população alvo. Resultados Na tradução inicial e na retrotradução ocorreram discordâncias entre os tradutores, em 19 e 7 itens respectivamente, que posteriormente foram discutidos e conciliados pelo comitê. O comitê de especialistas sugeriu modificações desde o layout até adequações de termos técnicos para facilitar a aplicabilidade dos profissionais e para tornar o instrumento final mais claro e compreensível para a população-alvo. No pré-teste, 36,6% dos avaliados demonstraram dificuldades no entendimento de um item do questionário; o item foi substituído, a escala foi reaplicada obtendo 100% de compreensão. Conclusão O estudo demonstrou que a versão brasileira do SPMSQ estabelecida como Breve Escala de Capacidade Cognitiva apresentou-se transculturalmente adaptada, com seus itens considerados claros e compreensíveis pelos especialistas e pela população-alvo. O instrumento adaptado contribui por se tratar de uma ferramenta breve de avaliação disponível para rastrear a capacidade cognitiva dos idosos. É recomendado a análise das propriedades psicométricas, estabelecendo o grau de validade e confiabilidade, o qual já está em desenvolvimento pelos autores deste estudo.
Introduction: Older adults constitute a large and growing proportion of the population and have unique care needs in the emergency department (ED) setting. The geriatric ED accreditation program aims to improve emergency care provided to older adults by standardizing care provided across accredited geriatric EDs (GED) and through implementation of geriatric-specific care processes. The purpose of this study was to evaluate select care processes at accredited level 1 and level 2 GEDs. Methods: This was a cross-sectional analysis of a cohort of level 1 and level 2 GEDs that received accreditation between May 7, 2018 and March 1, 2021. We a priori selected five GED care processes for analysis: initiatives related to delirium, screening for dementia, assessment of function and functional decline, geriatric falls, and minimizing medication-related adverse events. For all protocols, a trained research assistant abstracted information on the tool used or care process, which patients received the interventions, and staff members were involved in the care process; additional information was abstracted specific to individual care processes. Results: A total of 35 level 1 and 2 GEDs were included in this analysis. Among care processes studied, geriatric falls were the most common (31 GEDs, 89%) followed by geriatric pain management (25 GEDs, 71%), minimizing the use of potentially inappropriate medications (24 EDs, 69%), delirium (22 GEDs, 63%), medication reconciliation (21 GEDs, 60%), functional assessment (20 GEDs, 57%), and dementia screening (17 GEDs, 49%). For protocols related to delirium, dementia, function, and geriatric falls, sites used an array of different screening tools and there was heterogeneity in who performed the screening and which patients were assessed. Medication reconciliation protocols leveraged pharmacists, pharmacy technicians and/or nurses. Protocols on avoiding potentially inappropriate medication administration generally focused on ED administration of medications and used the BEERs criteria, and few sites indicated whether pain medications protocols had dosing modifications for age and/or renal function. Conclusion: This study provides a snapshot of care processes implemented in level 1 and level 2 accredited GEDs and demonstrates significant heterogeny in how these care processes are implemented.
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Background: Clozapine is well known for its efficacy and clinical superiority compared to other antipsychotics in treatment-resistant schizophrenia (TRS). However, it is frequently underutilized worldwide because of its acute adverse events, as well as for its long-term cardiometabolic and hematological consequences. Objective: The aim of the study was to evaluate 5-year safety in chronic TRS inpatients with continuous clozapine use. Methods: Patients with TRS and clozapine treatment were evaluated for 5 years. All participants were assessed using the Brief Psychiatric Rating Scale (BPRS), Glasgow Antipsychotic Side-effect Scale for Clozapine (GASS-C), Social Performance Scale (PSP) and Short Portable Mental Status Questionnaire (SPMSQ). Clinical, cardiometabolic and hematological data were collected periodically. General linear models (GLM) repeated measures controlling for CLZ dose were utilized to determine differences in variables across the time. Results: Overall, 189 inpatients were screened for study participation. The final sample included twenty-one TRS patients (16 males, 76%) with an average age of 57.6 years, all with 5-year continuous use of clozapine (mean dose 266 mg/day). There was not a significant effect of time on BPRS (p=0.774), PSP (p=0.855) and SPMSQ (p=0.066); differences remained not significant after controlling for CLZ dose (p=0.585, p=0.467 and p=0.105, respectively). No changes were found in blood and clinical parameters except for red blood cell count, which decreased over time (p=0.024; η2= 0.952). Patients reported a significant BMI decrease (-8.98 kg, p=0.008) between baseline and 5 years last observation. Conclusion: The findings show how the application of a structured dietary, clinical and therapeutic monitoring program in psychiatric care facilities could allow the safe and effective long-term cardiometabolic and hematological management of clozapine. The unique role that clozapine plays in the current treatment of patients with TRS requires greater clinical awareness. Although its acute and chronic side effects are notorious, its safety management is feasible and broadens its potential practical application.
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The increased pressure on primary care makes it important for other health care providers, such as community pharmacists, to collaborate with general practitioners in activities related to chronic disease care. Therefore, the objective of the present project was to develop a protocol of action that allows close pharmacist-physician collaboration to carry out a coordinated action for very early detection of cognitive impairment (CI). Methods: A comparative study to promote early detection of CI was conducted in 19 community pharmacies divided into two groups: one group with interprofessional collaboration (IPC) and one group without interprofessional collaboration (NonIPC). IPC was defined as an interactive procedure involving all pharmacists, general practitioners and neurologists. A total of 281 subjects with subjective memory complaints were recruited. Three tests were used in the community pharmacies to detect possible CI: Memory Impairment Screening, Short Portable Mental State Questionnaire, and Semantic Verbal Fluency. Individuals with at least one positive cognitive test compatible with CI, were referred to primary care, and when appropriate, to the neurology service. Finally, we evaluated the differences in clinical and diagnostic follow-up in both groups after six months. Results: The NonIPC study group included 38 subjects compatible with CI referred to primary care (27.54%). Ten were further referred to a neurology department (7.25%) and four of them (2.90%) obtained a confirmed clinical diagnosis of CI. In contrast, in the IPC group, 46 subjects (32.17%) showed results compatible with CI and were referred to primary care. Of these, 21 (14.68%) were subsequently referred to a neurology service, while the remaining 25 were followed up by primary care. Nineteen individuals out of those referred to a neurology service obtained a confirmed clinical diagnosis of CI (13.29%). The percentage of subjects in the NonIPC group referred to neurology and the percentage of subjects diagnosed with CI, was significantly lower in comparison to the IPC group ( p -value = 0.0233; p- value = 0.0007, respectively). Conclusions: The creation of IPC teams involving community pharmacists, general practitioners, and neurologists allow for increased detection of patients with CI or undiagnosed dementia and facilitates their clinical follow-up. This opens the possibility of diagnosis in patients in the very early stages of dementia, which can have positive implications to improve the prognosis and delay the evolution of the disease.
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Objectives The Short Portable Mental Status Questionnaire is a brief cognitive tool designed to screen cognitive impairment in geriatric inpatients and outpatients. The validity and reliability of this tool have not been studied in Iran so far. Therefore, this study was conducted to assess the diagnostic properties of the SPMSQ for detection of cognitive disorders in elderly and determine an appropriate cutoff point based on respondents’ level of education. Methods This cross-sectional study was conducted through face to face interviews on a sample of 156 patients (≥60 years) referred to neurology and geriatric clinics of Ziaiyan hospital, Tehran University of Medical Sciences. Regarding the type of cognitive impairment, Participants were divided into two groups; those with cognitive disorders (n = 96) and healthy (n = 60). The level of literacy was also considered in each of the groups. Results The Cronbach's alpha coefficient for the SPMSQ was 0.88. In terms of the concurrent validity, a correlation coefficient between SPMSQ and GDS was higher in the literate group compared to the illiterate patients, while in the illiterate group, the SPMSQ had a higher correlation with AMT compared to the other tools. Based on DSM-5, the cutoff point of SPMSQ was 4 in the illiterate elderly patients and the sensitivity and specificity of the tool were at 86.4 and 88.2%, respectively. However, in the literate patients, the cutoff point was 3 and the sensitivity and specificity were 83 and 93.7%, respectively. Also, two components, namely orientation and long-term memory/concentration were determined for the SPMSQ using the factor analysis. Conclusion The Iranian version of SPMSQ has a favorable validity and reliability for diagnosing cognitive disorders and can be used for cognitive screening of illiterate older adults.
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Background: older adults admitted to hospital are often cognitively impaired. It is not clear whether the presence of cognitive impairment conveys an additional risk for poor hospital outcomes in this patient population. Objectives: to determine whether cognitive impairment in hospitalised older adults is independently associated with poor outcomes. Design: retrospective cohort study using electronic, routinely collected data from linked clinical and administrative databases. Setting: large, acute district general hospital in England. Participants: 21,399 incident emergency admissions of people aged ≥75, screened for cognitive impairment, categorised to 3 groups: (i) cognitive impairment with a diagnosis of dementia, (ii) cognitive impairment with no dementia diagnosis, (iii) no cognitive impairment. Methods: multivariable logistic regression and Fine and Gray competing risks survival models were employed to explore associations between cognitive impairment and mortality (in-hospital alone, and in-hospital plus up to 30 days after discharge), time to hospital discharge, and hospital readmission within 30 days of discharge. Covariates included age, severity of illness, main diagnosis, comorbidities and nutritional risk. Results: twenty-seven percent of patients had cognitive impairment; of these, 61.5% had a diagnosis of dementia and 38.5% did not. Patients with cognitive impairment and no diagnosis of dementia were most likely to die in hospital or be readmitted, they also had the longest hospital stays. Cognitive impairment was independently associated with mortality in hospital (Odds Ratio 1.34 [1.17–1.55] with dementia; Odds Ratio 1.78 [1.52–2.07] without), mortality in hospital or within 30 days of discharge (Odds Ratio 1.66 [1.48–1.86]; Odds Ratio 1.67 [1.46–1.90]); readmission (Odds Ratio 1.21 [1.04–1.40]; Odds Ratio 1.47 [1.25–1.73]), and increased time until discharge (sub-hazard ratio 0.80 [0.76–0.83]; sub-hazard ratio 0.66 [0.63–0.69]). Conclusions: cognitive impairment is associated with an increased risk of adverse outcomes in hospitalised older people with an unscheduled admission, by increasing hospital mortality, extending hospital stays and increasing frequency of readmissions. Future research should focus on understanding the mechanisms contributing to poorer outcomes in this population.
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The number of older patients admitted to emergency departments (ED) increases continuously. The Identification of Seniors at Risk (ISAR) score is currently recommended to screen patients in German ED, but its appropriateness is being criticized. ISAR scores and clinical characteristics from 98 emergency admissions (EA), 80 from acute geriatrics (AG) and 89 from a geriatric rehabilitation (GR) unit were compared retrospectively. No significant differences were found between groups, being the ISAR score positive in 87.7% of EA, 94.9% of AG and 94.4% of GR cases. None of positively identified geriatric patients in the EA was transferred to the geriatric ward of competence. EA patients showed significantly higher number of functional impairments (p = 0.001) and higher BI score (p < 0.0001) compared to AG and GR groups. A higher ISAR score threshold and additional functional information might be needed to better select patients in need of prompt treatment by a geriatric team.
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Objective: to investigate whether cognitive impairment, measured early after Emergency Department (ED) arrival and irrespective of its cause, is independently associated with functional decline or mortality after 3 and 12 months in older ED patients. Design and setting: a prospective multi-centre cohort study in all Acutely Presenting Older Patients visiting the Emergency Department (APOP study) of three hospitals in the Netherlands. Participants: 2,130 patients, ≥70 years. Measurements: data on demographics, disease severity and geriatric characteristics were collected during the first hour of the ED visit. Cognition was measured using the 6-Item-Cognitive-Impairment-Test ('6CIT'). Cognitive impairment was defined as 6CIT ≥11, self-reported dementia or the inability to perform the cognition test. The composite adverse outcome after 3 and 12 months was defined as a 1-point decrease in Katz Activities of Daily Living (ADL), new institutionalisation or mortality. Multivariable regression analysis was used to assess whether cognitive impairment independently associates with adverse outcome. Results: of 2,130 included patients, 588 (27.6%) had cognitive impairment at baseline and 654 patients (30.7%) suffered from adverse outcome after 3 months. Cognitive impairment associated with increased risk for adverse outcome (adjusted odds ratio (OR) 1.72, 95%CI 1.37-2.17). After 12 months, 787 patients (36.9%) suffered from adverse outcome. Again, cognitive impairment independently associated with increased risk for adverse outcome (adjusted OR 1.89, 95%CI 1.46-2.46). ORs were similar for patients who were discharged home versus hospitalised patients. Conclusion: cognitive impairment measured during the early stages of ED visit, irrespective of the cause, is independently associated with adverse outcome after 3 and 12 months in older patients.
Introduction: Many screening instruments to predict adverse health outcomes in older patients visiting the emergency department (ED) have been developed, but successful implementation has been hampered because they are insufficiently validated or not tailored for the intended use of everyday clinical practice. The present study aims to refine and validate an existing screening instrument (the APOP screener) to predict 90-day functional decline or mortality in older ED patients. Methods: Consecutive older patients (≥70 years) visiting the EDs of four hospitals were included and prospectively followed. First, an expert panel used predefined criteria to decide which independent predictors (including demographics, illness severity and geriatric parameters) were suitable for refinement of the model predicting functional decline or mortality after 90 days. Second, the model was cross-validated in all four hospitals and predictive performance was assessed. Additionally, a pilot study among triage nurses experiences and clinical usability of the APOP screener was conducted. Results: In total 2629 older patients were included, with a median age of 79 years (IQR 74-84). After 90 days 805 patients (30.6%) experienced functional decline or mortality. The refined prediction model included age, gender, way of arrival, need of regular help, need help in bathing/showering, hospitalization the prior six months and impaired cognition. Calibration was good and cross-validation was successful with a pooled area under the curve of 0.71 (0.69-0.73). In the top 20% patients predicted to be at highest risk in total 58% (95%CI 54%-62%) experienced functional decline or mortality. Triage nurses found the screener well suited for clinical use, with room for improvement. Conclusion: In conclusion, optimization of the APOP screener resulted in a short and more simplified screener, which adequately identifies older ED patients at highest risk for functional decline or mortality. The findings of the pilot study were promising for clinical use.
Background: older adults are frequent users of emergency services and demonstrate high rates of adverse outcomes following emergency care. Objective: to perform a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool, to determine its predictive value in identifying adults ≥65 years at risk of functional decline, unplanned emergency department (ED) readmission, emergency hospitalisation or death within 180 days after index ED visit/hospitalisation. Methods: a systematic literature search was conducted in PubMed, EMBASE, CINAHL, EBSCO and the Cochrane Library to identify validation and impact analysis studies of the ISAR tool. A pre-specified ISAR score of ≥2 (maximum score 6 points) was used to identify patients at high risk of adverse outcomes. A bivariate random effects model generated pooled estimates of sensitivity and specificity. Statistical heterogeneity was explored and methodological quality was assessed using validated criteria. Results: thirty-two validation studies (n = 12,939) are included. At ≥2, the pooled sensitivity of the ISAR for predicting ED return, emergency hospitalisation and mortality at 6 months is 0.80 (95% confidence interval (CI) 0.70-0.87), 0.82 (95% CI 0.74-0.88) and 0.87 (95% CI 0.75-0.94), respectively, with a pooled specificity of 0.31 (95% CI 0.24-0.38), 0.32 (95% CI 0.24-0.41) and 0.35 (95% CI 0.26-0.44). Similar values are demonstrated at 30 and 90 days. Three heterogeneous impact analysis studies examined the clinical implementation of the ISAR and reported mixed findings across patient and process outcomes. Conclusion: the ISAR has modest predictive accuracy and may serve as a decision-making adjunct when determining which older adults can be safely discharged.
Background: Older patients experience high rates of adverse outcomes after an emergency department (ED) visit. Early identification of those at high risk could guide preventive interventions and tailored treatment decisions, but available models perform poorly in discriminating those at highest risk. The present study aims to develop and validate a prediction model for functional decline and mortality in older patients presenting to the ED. Methods: A prospective follow-up study in patients aged ≥ 70, attending the EDs of the LUMC, the Netherlands (derivation) and Alrijne Hospital, the Netherlands (validation) was conducted. A baseline assessment was performed and the main outcome, a composite of functional decline and mortality, was obtained after 90 days of follow-up. Results: In total 751 patients were enrolled in the Leiden University Medical Center of whom 230 patients (30.6%) experienced the composite outcome and 71 patients (9.5%) died. The final model for the composite outcome resulted in an area under the curve (AUC) of 0.73 (95% CI 0.67-0.77) and was experienced in 69% of the patients at highest risk. For mortality the AUC was 0.79 (95% CI 0.73-0.85) and 36% of the patients at highest risk died. External validation in 881 patients of Alrijne Hospital showed an AUC of 0.71 (95% CI 0.67-0.75) for the composite outcome and 0.67 (95% CI 0.60-0.73) for mortality. Conclusion: We successfully developed and validated prediction models for 90-day composite outcome and 90-day mortality in older emergency patients. The benefits for patient management by implementing these models with preventive interventions have to be investigated.
An ageing population is straining reliable and timely access to emergency department (ED) care for all patients worldwide.1–6 Compared with younger populations, older adults have lengthier ED evaluations are more frequently admitted, and if discharged, return to the ED more often but still leave the ED dissatisfied with the care delivered.7–9 In response to an ageing demographic, Emergency Medicine and Geriatric organisations in the UK and USA released evidence-based and consensus-based guidelines to optimise the care and outcomes for this population.10 ,11 Over the past decade, professional organisations,10 ,12 residency educators13 and quality improvement experts have advocated that geriatric risk stratification instruments be widely employed in adult EDs worldwide, while researchers simultaneously supported development of more accurate instruments.14 One immediately palpable challenge for clinicians (physicians, mid-level providers, nurses) and policy-makers is to identify accurately the most vulnerable older adults, real time in the busy ED and have them receive more intensive, geriatric-focused ED care.15 ,16 One recommendation from the US guidelines highlighted the need for risk-stratification of older adults using instruments like the Identification of Seniors at Risk (ISAR) tool.12 ,17 In the ED environment, an ideal geriatric ‘vulnerability’ screening instrument would be precise and reliable for a broad spectrum of presenting illnesses and injuries, including illnesses and injuries of variable severity managed across heterogeneous healthcare settings, and for patients with differing levels of socioeconomic and health literacy states.18 The original ISAR was developed …
The number of people with functional limitations, cognitive impairment and disability with unscheduled, unintended contact to emergency departments seeking acute medical care is increasing. With this, the problem of how to identify elderly people in need for acute geriatric care has evolved. The best solution to the problem would be to perform comprehensive geriatric assessment during the initial contact; however, comprehensive geriatric assessment is considered too complex and therefore not feasible for emergency departments. Instead, screening instruments have been developed and proposed. In this narrative review, selected screening instruments are discussed. The instrument best studied in various settings and countries is the Identification of Seniors At Risk (ISAR) screening tool which contains six simple questions that are easy to administer and can be assessed even in urgent situations. In recent years, several studies have examined the validity of ISAR in different European countries. Most of these studies, including one German study and a recent systematic review, confirmed the validity of ISAR. Unfortunately, evidence is conflicting, as some studies found only weak or even no association between ISAR and negative health outcomes. Other instruments have been investigated to a lesser extent and do not indicate obvious advantages over ISAR. Despite growing evidence in the field, there are still many uncertainties. Further research is needed to solve existing inconsistencies and to assess how elderly patients screened positive for acute geriatric care needs can best be managed further.