title: The Effect of an Impaired Arousal on Short- and Long-Term Mortality of Elderly Patients Admitted to an Acute Geriatric Unit.
abstract: OBJECTIVE
  Impaired arousal is associated with negative outcomes in intensive care units, but studies in acute medical wards are scanty. The study aim was to evaluate the association between impaired arousal, as measured using an ultrabrief screen, and risk of both 1- and 6-month mortality and discharge to nursing home (NH) or hospice.
  
  
  METHODS
  Prospective cohort study with 6-month follow-up.
  
  
  METHODS
  An acute geriatric unit (AGU) of a university-based hospital in Northern Italy.
  
  
  METHODS
  All patients aged 65 years or older, admitted to the AGU between September 2012 and February 2015.
  
  
  METHODS
  The modified Richmond Agitation Sedation Scale (m-RASS) was used to assess patients' arousal; a score of 0 denotes normal arousal, scores ranging from +1 to +4 denote increased arousal, and scores ranging from -1 to -5 denote decreased levels. The association of m-RASS scores with 6-month mortality was assessed by a Kaplan-Meier analysis. The impact of impaired arousal, defined by the m-RASS as anything other than "awake and alert," was determined using Cox proportional hazard regression for 1- and 6-month mortality after admission and logistic regressions were used for discharge to NH or hospice. The models were adjusted for age, sex, dementia, Sequential Organ Failure Assessment score, and disability.
  
  
  RESULTS
  Patients (n = 2477) had a mean age of 84 years, and were predominantly women (59.8%). Impaired arousal on admission was present in 644 (25.9%) patients: 33 (1.3%) were comatose (m-RASS = -5), 56 (2.3%) awakened to pain only (m-RASS = -4), 43 (1.7%) were very drowsy (m-RASS = -3), 93 (3.8%) drowsy (m-RASS = -2), and 212 (8.6%) were slightly drowsy (m-RASS = -1), but there were also 110 (4.4%) patients with restlessness, 75 (3.0%) with agitation, 17 (0.7%) with severe agitation, and 3 (0.1%) with combative behavior. Globally, 337 patients died within 1 month and 689 patients within 6 months. After adjustment for covariates, patients with impaired arousal had a significantly higher chance of having died at 1-month (adjusted hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.22-2.03) and 6-month follow-up (adjusted HR 1.31, 95% CI 1.10-1.57). Those with impaired arousal were more likely to be discharged to a new NH (odds ratio [OR] 1.75, 95% CI 1.19-2.57) or to hospice (OR 1.96, 95% CI 1.18-3.23) than those without impaired arousal.
  
  
  CONCLUSIONS
  An abnormal arousal level is an independent predictor of increased risk of 1- and 6-month mortality and of discharge to a new NH or hospice. The assessment of arousal with m-RASS should be routinely performed on all older patients on admission to acute hospital wards to screen potentially critical conditions.
authors.affiliation: Department of Health Sciences, University of Milano-Bicocca, Monza, Italy; Geriatric Unit, S. Gerardo Hospital, Monza, Italy; Geriatric Research Group, Brescia, Italy. Electronic address: giuseppe.bellelli@unimib.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Bellelli
authors.affiliation: Department of Rehabilitation, Redaelli Geriatric Institute, Milan, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Mazzone
authors.affiliation: Geriatric Research Group, Brescia, Italy; Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Morandi
authors.affiliation: Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy; Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Latronico
authors.affiliation: Department of Health Sciences, University of Milano-Bicocca, Monza, Italy.
authors.forename: Sabrina
authors.initials: S
authors.lastname: Perego
authors.affiliation: Department of Health Sciences, University of Milano-Bicocca, Monza, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Zazzetta
authors.affiliation: Department of Health Sciences, University of Milano-Bicocca, Monza, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Mazzola
authors.affiliation: Department of Health Sciences, University of Milano-Bicocca, Monza, Italy; Geriatric Unit, S. Gerardo Hospital, Monza, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Annoni
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001143:Arousal; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006760:Hospitalization; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units; D007558:Italy / Q000453:epidemiology; D008297:Male; D016016:Proportional Hazards Models; D011446:Prospective Studies
keywords: Arousal; delirium; elderly; hospice; institutionalization; mortality