Elizabeth G. Archambault, MSW, LICSW

Hospitalization is a critical time for older patients with cognitive impairment. Past research has found that hospitalized older adults with cognitive dysfunction have more rapid cognitive decline, increased morbidity and mortality, and higher costs of healthcare utilization.[1, 2, 3] Those with preexisting cognitive dysfunction, such as dementia, are most susceptible to the negative impacts of hospitalization.[4, 5, 6, 7, 8] Identification of cognitive deficits upon admission is important for risk stratification of patients and prevention of negative hospital health events.

Frontline healthcare providers are underequipped to detect acute cognitive dysfunction.[9, 10] Current practice and research for the detection of cognitive dysfunction in the acute care setting utilizes instruments that require training[11] and are relatively lengthy (>5 minutes).[12] Although these cognitive screening tests are accurate and reliable, the time requirement is not feasible in a fast‐paced clinical setting. A possible alternative is the use of ultra‐brief cognitive screening instruments (<1 minute) that have the potential to identify those individuals requiring additional evaluation and follow‐up. These brief instruments are composed of screening tools that emphasize core features of acute cognitive dysfunction such as level of arousal or attention.[13, 14, 15, 16] Arousal, the ability to respond to or interact with the environment,[15] is an important component of cognition because it is generally preserved in chronic cognitive disorders (eg, dementia). Thus, an alteration in arousal may be a harbinger of more acute impairment[17] in need of evaluation, and in these lowered states of arousal it may be difficult to test for attention.[18] Attention is a broadly defined cognitive domain indicating focus.[19] Older adults, regardless of preexisting cognitive dysfunction, warrant additional cognitive testing if levels of arousal or attention are altered[20, 21] due to the significant relationship to delirium, which is associated with adverse events in this population. Recent research has demonstrated that these brief cognitive screening instruments provide information about the risk for delirium and are a strong test for clinical characteristics of delirium.[16, 21]

The purpose of this analysis was to demonstrate the clinical outcomes of poor performance on ultrabrief assessments arousal and attention by frontline staff using a quality improvement database. Specific objectives include determining (1) the association of poor performance on brief cognitive assessments and hospital outcomes and (2) the inter‐relationship between alterations in the levels of arousal and attention on in‐hospital and discharge outcomes.

METHODS

RESULTS

DISCUSSION

Impaired performance on a one‐time assessment of arousal or attention during hospitalization demonstrated a relationship with in‐hospital and discharge outcomes. Relative to normal levels of arousal and attention, alterations in attention, level of arousal, or both were associated with progressively negative consequences. Combined with the prognostic value, the administration of ultra‐brief cognitive screening measures may have value in the identification of patients who would benefit from additional screening, supporting prior work in this area.[23] The brevity of the assessments enhances clinical utility and implementation potential.

Cognitive function during hospitalization has been associated with many negative outcomes including delirium, falls, pressure ulcers, and functional decline.[3, 33, 34, 35, 36, 37] The findings of this analysis are consistent with previous studies and provide important clinical implications. First, prior work in cognitive screening has focused on more time‐consuming instruments.[12] By focusing on brief instruments, particularly those under 1 minute that do not require paper or props, a user‐friendly tool that is associated with health outcomes is provided.

In addition, this analysis demonstrates that each assessment, when used individually, has some prognostic significance associated with the identification of delirium or other types of cognitive impairment. When used alone, abnormal scores on the mRASS or MOYB may be indicative of individuals requiring further cognitive assessment, supporting previous research.[16, 23] Individuals with abnormal scores on both the mRASS and MOYB identify a high‐risk group in need of further clinical assessment for delirium (Figure 1). Neither of these assessments are meant to be used as the only means to diagnosis delirium, but together they identify key clinical characteristics of delirium (arousal and attention).[16, 18, 21] Considering the significant negative consequences associated with delirium, it is not surprising that tools identifying core features of delirium, such as those presented here, would also be associated with in‐hospital and discharge outcomes.

Figure 1

The quality improvement design of this project allowed the recording of outcomes in those who were unable or refused to complete the screening. This may be a potentially high‐risk group who would otherwise go unnoticed. A recent editorial from the American and European Delirium Societies highlights that individuals who are unable or refuse to complete testing due to impaired arousal are neglected in the most recent American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition definition of delirium.[18] Further work to identify and intervene on behalf of individuals who are unable to complete testing will aid in understanding arousal and its relationship to delirium and other disorders.

This analysis provides additional insight in the selection of measures of arousal and attention. Level of arousal is a complex concept that involves components of awareness and alertness, including external stimuli and self‐awareness.[38, 39, 40] As an ultra‐brief measure of arousal level, the mRASS incorporates both external stimuli (asking an open‐ended question) and self‐awareness (describing current state) to determine basic cognitive function. Attention can be defined as the selection of stimuli for further cognitive processing.[40] Attention is an umbrella term referring to many cognitive processes, ranging from sustained attention and working memory to executive function such as set shifting and multitasking. Ultra‐brief measures of attention, such as MOYB, are basic tasks of sustained attention with components of working memory.[19] An alteration in attention may be indicative of a more significant global change in cognition[41] beyond basic cognitive function assessed by administration of the mRASS, such as delirium.[42] The relationship between level of arousal and attention is complex, and arguments have been made that one has to have a certain level of arousal to attend to a stimuli, whereas others have found that one has to have a certain level of attention.[18, 39, 40] Administration of both the mRASS and MOYB is a useful bedside tool for clinicians to examine both basic cognitive function and more complex tasks of attention.

The quality improvement nature of this work has limitations and strengths that deserve mention. The significant strength of this work is the robust sample size. Also, trained staff not involved in the direct clinical care of patients administered the cognitive screens, suggesting that nonclinically trained personnel could be utilized for risk assessment. The major limitation is the restricted amount of covariate data that were collected. Data for this project were collected to operationalize and demonstrate the impact and business case of a delirium risk modification program,[17] limiting the ability to perform adjustment for other covariates such as comorbidity and reason for admission. Also, due to the nature of this project, a diagnosis of delirium was not determined. A limitation of excluding in‐hospital deaths from the cost analysis was that some individuals at high risk died early, thus costing less overall. Generalizability is limited by an over‐representation of males within a single setting. Further use and understanding of mRASS and MOYB in other population is warranted and welcomed. Use of MOYB is also a limitation considering that scores are not standardized across patients or settings.[26] Data regarding administration time of either of these tools were not collected; therefore, determining that these are ultra‐brief assessments (<1 minute) is based on estimates. As such, these measures should not be the sole source of information for clinical evaluation and diagnosis.

CONCLUSION

This work found that impaired performance on brief cognitive assessments of arousal and attention in hospitalized patients were associated with restraint use, in‐hospital mortality, longer LOS, less discharge home, and hospital costs. Routine screening of older patients with brief, user‐friendly cognitive assessments upon admission can identify those who would benefit from additional assessment and intervention to alleviate individual and economic burdens.

Hospitalization is a critical time for older patients with cognitive impairment. Past research has found that hospitalized older adults with cognitive dysfunction have more rapid cognitive decline, increased morbidity and mortality, and higher costs of healthcare utilization.[1, 2, 3] Those with preexisting cognitive dysfunction, such as dementia, are most susceptible to the negative impacts of hospitalization.[4, 5, 6, 7, 8] Identification of cognitive deficits upon admission is important for risk stratification of patients and prevention of negative hospital health events.

Frontline healthcare providers are underequipped to detect acute cognitive dysfunction.[9, 10] Current practice and research for the detection of cognitive dysfunction in the acute care setting utilizes instruments that require training[11] and are relatively lengthy (>5 minutes).[12] Although these cognitive screening tests are accurate and reliable, the time requirement is not feasible in a fast‐paced clinical setting. A possible alternative is the use of ultra‐brief cognitive screening instruments (<1 minute) that have the potential to identify those individuals requiring additional evaluation and follow‐up. These brief instruments are composed of screening tools that emphasize core features of acute cognitive dysfunction such as level of arousal or attention.[13, 14, 15, 16] Arousal, the ability to respond to or interact with the environment,[15] is an important component of cognition because it is generally preserved in chronic cognitive disorders (eg, dementia). Thus, an alteration in arousal may be a harbinger of more acute impairment[17] in need of evaluation, and in these lowered states of arousal it may be difficult to test for attention.[18] Attention is a broadly defined cognitive domain indicating focus.[19] Older adults, regardless of preexisting cognitive dysfunction, warrant additional cognitive testing if levels of arousal or attention are altered[20, 21] due to the significant relationship to delirium, which is associated with adverse events in this population. Recent research has demonstrated that these brief cognitive screening instruments provide information about the risk for delirium and are a strong test for clinical characteristics of delirium.[16, 21]

The purpose of this analysis was to demonstrate the clinical outcomes of poor performance on ultrabrief assessments arousal and attention by frontline staff using a quality improvement database. Specific objectives include determining (1) the association of poor performance on brief cognitive assessments and hospital outcomes and (2) the inter‐relationship between alterations in the levels of arousal and attention on in‐hospital and discharge outcomes.

METHODS

RESULTS

DISCUSSION

Impaired performance on a one‐time assessment of arousal or attention during hospitalization demonstrated a relationship with in‐hospital and discharge outcomes. Relative to normal levels of arousal and attention, alterations in attention, level of arousal, or both were associated with progressively negative consequences. Combined with the prognostic value, the administration of ultra‐brief cognitive screening measures may have value in the identification of patients who would benefit from additional screening, supporting prior work in this area.[23] The brevity of the assessments enhances clinical utility and implementation potential.

Cognitive function during hospitalization has been associated with many negative outcomes including delirium, falls, pressure ulcers, and functional decline.[3, 33, 34, 35, 36, 37] The findings of this analysis are consistent with previous studies and provide important clinical implications. First, prior work in cognitive screening has focused on more time‐consuming instruments.[12] By focusing on brief instruments, particularly those under 1 minute that do not require paper or props, a user‐friendly tool that is associated with health outcomes is provided.

In addition, this analysis demonstrates that each assessment, when used individually, has some prognostic significance associated with the identification of delirium or other types of cognitive impairment. When used alone, abnormal scores on the mRASS or MOYB may be indicative of individuals requiring further cognitive assessment, supporting previous research.[16, 23] Individuals with abnormal scores on both the mRASS and MOYB identify a high‐risk group in need of further clinical assessment for delirium (Figure 1). Neither of these assessments are meant to be used as the only means to diagnosis delirium, but together they identify key clinical characteristics of delirium (arousal and attention).[16, 18, 21] Considering the significant negative consequences associated with delirium, it is not surprising that tools identifying core features of delirium, such as those presented here, would also be associated with in‐hospital and discharge outcomes.

Figure 1

The quality improvement design of this project allowed the recording of outcomes in those who were unable or refused to complete the screening. This may be a potentially high‐risk group who would otherwise go unnoticed. A recent editorial from the American and European Delirium Societies highlights that individuals who are unable or refuse to complete testing due to impaired arousal are neglected in the most recent American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition definition of delirium.[18] Further work to identify and intervene on behalf of individuals who are unable to complete testing will aid in understanding arousal and its relationship to delirium and other disorders.

This analysis provides additional insight in the selection of measures of arousal and attention. Level of arousal is a complex concept that involves components of awareness and alertness, including external stimuli and self‐awareness.[38, 39, 40] As an ultra‐brief measure of arousal level, the mRASS incorporates both external stimuli (asking an open‐ended question) and self‐awareness (describing current state) to determine basic cognitive function. Attention can be defined as the selection of stimuli for further cognitive processing.[40] Attention is an umbrella term referring to many cognitive processes, ranging from sustained attention and working memory to executive function such as set shifting and multitasking. Ultra‐brief measures of attention, such as MOYB, are basic tasks of sustained attention with components of working memory.[19] An alteration in attention may be indicative of a more significant global change in cognition[41] beyond basic cognitive function assessed by administration of the mRASS, such as delirium.[42] The relationship between level of arousal and attention is complex, and arguments have been made that one has to have a certain level of arousal to attend to a stimuli, whereas others have found that one has to have a certain level of attention.[18, 39, 40] Administration of both the mRASS and MOYB is a useful bedside tool for clinicians to examine both basic cognitive function and more complex tasks of attention.

The quality improvement nature of this work has limitations and strengths that deserve mention. The significant strength of this work is the robust sample size. Also, trained staff not involved in the direct clinical care of patients administered the cognitive screens, suggesting that nonclinically trained personnel could be utilized for risk assessment. The major limitation is the restricted amount of covariate data that were collected. Data for this project were collected to operationalize and demonstrate the impact and business case of a delirium risk modification program,[17] limiting the ability to perform adjustment for other covariates such as comorbidity and reason for admission. Also, due to the nature of this project, a diagnosis of delirium was not determined. A limitation of excluding in‐hospital deaths from the cost analysis was that some individuals at high risk died early, thus costing less overall. Generalizability is limited by an over‐representation of males within a single setting. Further use and understanding of mRASS and MOYB in other population is warranted and welcomed. Use of MOYB is also a limitation considering that scores are not standardized across patients or settings.[26] Data regarding administration time of either of these tools were not collected; therefore, determining that these are ultra‐brief assessments (<1 minute) is based on estimates. As such, these measures should not be the sole source of information for clinical evaluation and diagnosis.

CONCLUSION

This work found that impaired performance on brief cognitive assessments of arousal and attention in hospitalized patients were associated with restraint use, in‐hospital mortality, longer LOS, less discharge home, and hospital costs. Routine screening of older patients with brief, user‐friendly cognitive assessments upon admission can identify those who would benefit from additional assessment and intervention to alleviate individual and economic burdens.

Hospitalization is a critical time for older patients with cognitive impairment. Past research has found that hospitalized older adults with cognitive dysfunction have more rapid cognitive decline, increased morbidity and mortality, and higher costs of healthcare utilization.[1, 2, 3] Those with preexisting cognitive dysfunction, such as dementia, are most susceptible to the negative impacts of hospitalization.[4, 5, 6, 7, 8] Identification of cognitive deficits upon admission is important for risk stratification of patients and prevention of negative hospital health events.

Frontline healthcare providers are underequipped to detect acute cognitive dysfunction.[9, 10] Current practice and research for the detection of cognitive dysfunction in the acute care setting utilizes instruments that require training[11] and are relatively lengthy (>5 minutes).[12] Although these cognitive screening tests are accurate and reliable, the time requirement is not feasible in a fast‐paced clinical setting. A possible alternative is the use of ultra‐brief cognitive screening instruments (<1 minute) that have the potential to identify those individuals requiring additional evaluation and follow‐up. These brief instruments are composed of screening tools that emphasize core features of acute cognitive dysfunction such as level of arousal or attention.[13, 14, 15, 16] Arousal, the ability to respond to or interact with the environment,[15] is an important component of cognition because it is generally preserved in chronic cognitive disorders (eg, dementia). Thus, an alteration in arousal may be a harbinger of more acute impairment[17] in need of evaluation, and in these lowered states of arousal it may be difficult to test for attention.[18] Attention is a broadly defined cognitive domain indicating focus.[19] Older adults, regardless of preexisting cognitive dysfunction, warrant additional cognitive testing if levels of arousal or attention are altered[20, 21] due to the significant relationship to delirium, which is associated with adverse events in this population. Recent research has demonstrated that these brief cognitive screening instruments provide information about the risk for delirium and are a strong test for clinical characteristics of delirium.[16, 21]

The purpose of this analysis was to demonstrate the clinical outcomes of poor performance on ultrabrief assessments arousal and attention by frontline staff using a quality improvement database. Specific objectives include determining (1) the association of poor performance on brief cognitive assessments and hospital outcomes and (2) the inter‐relationship between alterations in the levels of arousal and attention on in‐hospital and discharge outcomes.

METHODS

RESULTS

DISCUSSION

Impaired performance on a one‐time assessment of arousal or attention during hospitalization demonstrated a relationship with in‐hospital and discharge outcomes. Relative to normal levels of arousal and attention, alterations in attention, level of arousal, or both were associated with progressively negative consequences. Combined with the prognostic value, the administration of ultra‐brief cognitive screening measures may have value in the identification of patients who would benefit from additional screening, supporting prior work in this area.[23] The brevity of the assessments enhances clinical utility and implementation potential.

Cognitive function during hospitalization has been associated with many negative outcomes including delirium, falls, pressure ulcers, and functional decline.[3, 33, 34, 35, 36, 37] The findings of this analysis are consistent with previous studies and provide important clinical implications. First, prior work in cognitive screening has focused on more time‐consuming instruments.[12] By focusing on brief instruments, particularly those under 1 minute that do not require paper or props, a user‐friendly tool that is associated with health outcomes is provided.

In addition, this analysis demonstrates that each assessment, when used individually, has some prognostic significance associated with the identification of delirium or other types of cognitive impairment. When used alone, abnormal scores on the mRASS or MOYB may be indicative of individuals requiring further cognitive assessment, supporting previous research.[16, 23] Individuals with abnormal scores on both the mRASS and MOYB identify a high‐risk group in need of further clinical assessment for delirium (Figure 1). Neither of these assessments are meant to be used as the only means to diagnosis delirium, but together they identify key clinical characteristics of delirium (arousal and attention).[16, 18, 21] Considering the significant negative consequences associated with delirium, it is not surprising that tools identifying core features of delirium, such as those presented here, would also be associated with in‐hospital and discharge outcomes.

Figure 1

The quality improvement design of this project allowed the recording of outcomes in those who were unable or refused to complete the screening. This may be a potentially high‐risk group who would otherwise go unnoticed. A recent editorial from the American and European Delirium Societies highlights that individuals who are unable or refuse to complete testing due to impaired arousal are neglected in the most recent American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition definition of delirium.[18] Further work to identify and intervene on behalf of individuals who are unable to complete testing will aid in understanding arousal and its relationship to delirium and other disorders.

This analysis provides additional insight in the selection of measures of arousal and attention. Level of arousal is a complex concept that involves components of awareness and alertness, including external stimuli and self‐awareness.[38, 39, 40] As an ultra‐brief measure of arousal level, the mRASS incorporates both external stimuli (asking an open‐ended question) and self‐awareness (describing current state) to determine basic cognitive function. Attention can be defined as the selection of stimuli for further cognitive processing.[40] Attention is an umbrella term referring to many cognitive processes, ranging from sustained attention and working memory to executive function such as set shifting and multitasking. Ultra‐brief measures of attention, such as MOYB, are basic tasks of sustained attention with components of working memory.[19] An alteration in attention may be indicative of a more significant global change in cognition[41] beyond basic cognitive function assessed by administration of the mRASS, such as delirium.[42] The relationship between level of arousal and attention is complex, and arguments have been made that one has to have a certain level of arousal to attend to a stimuli, whereas others have found that one has to have a certain level of attention.[18, 39, 40] Administration of both the mRASS and MOYB is a useful bedside tool for clinicians to examine both basic cognitive function and more complex tasks of attention.

The quality improvement nature of this work has limitations and strengths that deserve mention. The significant strength of this work is the robust sample size. Also, trained staff not involved in the direct clinical care of patients administered the cognitive screens, suggesting that nonclinically trained personnel could be utilized for risk assessment. The major limitation is the restricted amount of covariate data that were collected. Data for this project were collected to operationalize and demonstrate the impact and business case of a delirium risk modification program,[17] limiting the ability to perform adjustment for other covariates such as comorbidity and reason for admission. Also, due to the nature of this project, a diagnosis of delirium was not determined. A limitation of excluding in‐hospital deaths from the cost analysis was that some individuals at high risk died early, thus costing less overall. Generalizability is limited by an over‐representation of males within a single setting. Further use and understanding of mRASS and MOYB in other population is warranted and welcomed. Use of MOYB is also a limitation considering that scores are not standardized across patients or settings.[26] Data regarding administration time of either of these tools were not collected; therefore, determining that these are ultra‐brief assessments (<1 minute) is based on estimates. As such, these measures should not be the sole source of information for clinical evaluation and diagnosis.

CONCLUSION

This work found that impaired performance on brief cognitive assessments of arousal and attention in hospitalized patients were associated with restraint use, in‐hospital mortality, longer LOS, less discharge home, and hospital costs. Routine screening of older patients with brief, user‐friendly cognitive assessments upon admission can identify those who would benefit from additional assessment and intervention to alleviate individual and economic burdens.