Two Brief Steps, Better Foresight: Cognitive Screening and Adverse Outcomes in Older Adults Admitted From the Emergency Department

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.