Abstract
Objective
To investigate the association between impaired arousal on admission and 30-day mortality
in acutely ill older adults.
Design
Retrospective cohort study.
Setting and Participants
Patients age +65 years admitted to the geriatric ward of a tertiary university hospital
from 2010 to 2018 in Sao Paulo, Brazil.
Methods
Participants were evaluated on admission according to a standardized comprehensive
geriatric assessment model. Delirium was detected using the short version of the Confusion
Assessment Method (Short-CAM). We used 2 alternative criteria to define impaired arousal:
lethargy, stupor, or coma according to the Short-CAM; and a Glasgow Coma Scale (GCS)
score of ≤13. Our primary outcome was time-to-death in 30 days, and we used Cox proportional
hazards models to explore the association between impaired arousal and decreased survival.
Results
We included 1554 admissions with a mean age of 81 years and of whom 61% were women.
Overall, prevalent delirium was observed in 28% of the cases. We found that in 33%
of admissions, patients were lethargic, stuporous, or comatose, and that in 23%, they
had GCS scores of ≤13. General 30-day mortality was 19% but reached 32% in patients
with GCS scores of ≤13. Impaired arousal was independently associated with lower survival
in 30 days, both when defined using Short-CAM criteria [lethargy + stupor + coma:
hazard ratio (HR) 2.33, 95% confidence interval (CI) 1.66‒3.27] and GCS scores (GCS
12‒13: HR 1.62, 95% CI 1.13‒2.33; GCS ≤ 11: HR 2.53, 95% CI 1.68‒3.80). In interaction
analyses, we confirmed our results in patients who had impaired arousal but were neither
delirious (lethargy + stupor + coma: HR 2.16, 95% CI 1.44‒3.24; GCS ≤ 11: HR 3.07;
95% CI 1.50‒6.29) nor demented (lethargy + stupor + coma: HR 1.95, 95% CI 1.15‒3.28).
Conclusions and Implications
Level of arousal on admission was an independent predictor of 30-day survival in acutely
ill older adults, regardless of delirium or baseline dementia. Clinicians should be
aware that even if unsure of whether a patient has delirium, arousal assessment can
provide crucial clinical and prognostic insight.
Keywords
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Article info
Publication history
Published online: January 20, 2020
Footnotes
This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors.
The authors declare no conflicts of interest.
Identification
Copyright
© 2019 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
