The following is a summary of “Clinical assessment and short-term mortality prediction of older adults with altered mental status using RASS and 4AT tools,” published in the January 2024 issue of Emergency Medicine by Demirtakan, et al.

Altered mental status (AMS) is a common cause of admission to emergency departments (EDs) among older adults, often attributed to delirium, stupor, or coma. Identifying underlying factors and anticipating clinical outcomes is crucial for effectively managing these patients. For a study, researchers sought to elucidate and compare the clinical outcomes and underlying factors among older patients presenting with delirium, stupor, and coma. The secondary objective was to assess the 30-day mortality risk in these patients.

The prospective observational study included patients aged 65 years and older presenting with new-onset neurological and cognitive symptoms or worsening baseline mental status. Patients with no change in baseline mental status within 48 hours and those requiring urgent interventions were excluded. The patients were assessed using the Richmond Agitation-Sedation Scale (RASS) and 4 ‘A’s Test (4AT) and classified into three groups: stupor/coma, delirium, and no stupor/coma or delirium (no-SCD). Statistical analyses were performed to compare these groups, and 30-day mortality risks were assessed using Cox survival analysis and the Kaplan-Meier curve.

A total of 236 eligible patients were included, with 56 (23.7%), 94 (40.6%), and 86 (36.4%) forming the stupor/coma, delirium, and no-SCD groups, respectively, based on RASS and 4AT scores. There were no significant differences in gender, mean age, or medical comorbidities among the three groups. Neurological (34.7%), infectious (19.4%), and respiratory (19.0%) diseases were the primary factors contributing to AMS. Post-hoc analysis revealed similar Charlson Comorbidity Index (CCI) scores between the delirium and stupor/coma groups. The 30-day mortality rates were significantly higher in the stupor/coma group (42.%) compared to the delirium (15.9%) and no-SCD (12.8%) groups (P < 0.005). The hazard ratio for 30-day mortality in the stupor/coma group was 2.79 (95% CI: 1.36–5.47, P= 0.005).

AMS poses significant challenges in ED management, and utilizing RASS and 4AT tests can aid emergency physicians in assessment. Neurological, infectious, and respiratory diseases are major contributors to AMS-related morbidity. While long-term mortality predictors (CCI scores) were similar across delirium, stupor, and coma groups, short-term mortality was significantly higher in stupor/coma patients, with a 2.8-fold increased risk of 30-day mortality compared to other groups.

Reference: sciencedirect.com/science/article/abs/pii/S0735675723005570