Avelino-Silva, Thiago Junqueira

ABSTRACT Background Delirium predicts adverse outcomes in older emergency department (ED) patients, but many acutely ill patients without delirium have underlying cognitive impairment that goes unrecognized. Whether cognitive impairment screening improves risk prediction beyond delirium remains uncertain. We compared practical bedside screening strategies for delirium, cognitive impairment, or both for predicting 90‐day functional decline and mortality in older adults admitted from the ED. Methods A prospective cohort comprising patients aged ≥ 65 years admitted from the ED of a large hospital in São Paulo, Brazil. Trained professionals screened for delirium using the brief Confusion Assessment Method (bCAM) and for cognitive impairment using the 10‐point Cognitive Screener (10‐CS). Patients were classified as having normal cognition (bCAM negative, 10‐CS > 5), delirium (bCAM positive), or cognitive impairment without delirium (bCAM negative, 10‐CS ≤ 5). Blinded investigators assessed decline in basic activities of daily living (ADL) and mortality within 90 days of admission. Fine‐Gray models (death as a competing risk) and Cox models estimated associations with outcomes, adjusting for sociodemographic and clinical factors. Results Among 830 patients (mean age = 80 ± 9 years; women = 47%), 427 (51.5%) had normal cognition, 171 (20.6%) had delirium, and 232 (27.9%) had cognitive impairment without delirium. Among delirium‐negative patients with cognitive impairment, 52% had no documented dementia diagnosis or reported memory problems. Compared with normal cognition, cognitive impairment without delirium was associated with 90‐day functional ADL decline (sub‐HR = 1.60; 95% CI = 1.03–2.49) and mortality (HR = 2.31; 95% CI = 1.18–4.51), with risks similar to those observed in delirium. A staged strategy (bCAM first, then 10‐CS if bCAM negative) showed higher discrimination than delirium‐only or 10‐CS‐only screening. Conclusions Cognitive impairment without delirium is common, often unrecognized, and predicts 90‐day adverse outcomes in older patients admitted from the ED. A brief staged screening strategy integrating delirium assessment with cognitive impairment testing among delirium‐negative patients may enhance early detection of cognitive vulnerability and support care planning.

ABSTRACT Background Dementia often goes undetected in hospital settings, where cognitive assessments are challenging due to illness severity and delirium. This study aimed to (1) evaluate the accuracy of the Clinical Dementia Rating (CDR), based solely on knowledgeable informant reports, for detecting preexisting dementia and cognitive impairment in hospitalized patients compared to a gold‐standard diagnosis, (2) and compare its performance to the 16‐item Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE‐16). Methods This cross‐sectional study assessed consecutive patients aged ≥ 65 admitted to inpatient units from five hospitals in Brazil. The informant‐based CDR was administered to knowledgeable informants within 48 h of admission, capturing patients' cognitive status 3 months before hospitalization to avoid the influence of acute cognitive impairments. Blinded experts provided a gold standard clinical diagnosis of dementia or cognitive impairment no dementia (CIND) based on a 90‐min comprehensive assessment, including a standardized neuropsychology battery. Areas under the curve (AUC) examined diagnostic accuracy. Results Of 65 participants (mean age = 79.4 years; women = 54%), 34% had dementia and 32% had CIND . Compared to the gold standard, the informant‐based CDR showed excellent diagnostic accuracy for detecting dementia ( AUC = 0.92; 95% confidence interval [ CI ] = 0.86–0.98) and cognitive impairment ( AUC = 0.93; 95% CI = 0.88–0.98), with a cutoff of ≥ 1 showing 98% specificity for dementia and a cutoff of ≥ 0.5 showing 98% sensitivity for cognitive impairment. Compared to the IQCODE ‐16, the informant‐based CDR had similar performance in detecting dementia and a nonsignificant slight advantage in identifying cognitive impairment ( AUC = 0.93 vs. 0.84, p = 0.069), reducing unrecognized cognitive impairment based on medical record documentation from 70% to 2%. Conclusions Informant‐based CDR is a valid and efficient tool for detecting dementia and cognitive impairment in hospitalized older adults, supporting early diagnosis and guiding multidisciplinary interventions in acute care. Its use in routine hospitals may help clinicians reduce undetected cognitive impairment, enhance decision making, and improve patient care.

ABSTRACT Background Existing risk scores assessing geriatric vulnerability in the emergency department (ED) have shown limited predictive power, especially in diverse populations. We investigated the relationship of a quick and easy‐to‐administer geriatric vulnerability scoring system with functional decline and mortality in older patients admitted to multiple hospitals through the ED in the United States (US) and Brazil (BR). Method Federated, international, multicenter observational study of hospitalized ED patients aged ≥ 65 from US and BR. The six criteria from the PRO‐AGE score (Physical impairment, Recent hospitalization, Older age [≥ 90], Acute mental alteration, Getting thinner, and Exhaustion; 0–8; higher scores = greater vulnerability) were assessed on admission. We used proportional hazards models to investigate the relationships between PRO‐AGE score groups and 90‐day mortality and functional decline, defined as new dependence in activities of daily living (ADL) and instrumental ADL (IADL), after adjusting for age, sex, race and ethnicity, education, Charlson comorbidity score, and study site. Death was considered a competing event for the functional decline outcome. Results A total of 1390 patients were included (US = 560; Brazil = 830). The 90‐day risk of death was higher for the upper compared with the lower (reference) PRO‐AGE group in both cohorts (US: HR = 11.76; 95% confidence interval [CI] = 2.56–54.04; BR: HR = 12.29; 95% CI = 3.54–42.59), whereas the risk of new 90‐day ADL disability was higher for upper (HR = 2.08; 95% CI = 1.21–3.56) and middle groups (HR = 2.10; 95% CI = 1.35–3.27) in the US but only the upper group in BR (HR = 1.70; 95% CI = 1.02–2.85). Conclusion A higher PRO‐AGE score was associated with mortality and functional decline in older ED patients admitted to hospitals in the US and BR, demonstrating its generalizability as a geriatric vulnerability risk score.