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Original Research |

Cognitive Impairment: An Independent Predictor of Excess Mortality: A Cohort Study

Greg A. Sachs, MD; Ravan Carter, MA; Laura R. Holtz, BS, CCRP; Faye Smith, MA; Timothy E. Stump, MA; Wanzhu Tu, PhD; and Christopher M. Callahan, MD
[+] Article and Author Information

From Indiana University Center for Aging Research, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, Indiana.


Presented in part at the annual meetings of the American Geriatric Society, Orlando, Florida, 12–15 May 2010, and the Agency for Healthcare Research and Quality, Bethesda, Maryland, 27–29 September 2010.

Grant Support: By grant R21 HS17630 from the Agency for Healthcare Research and Quality.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2945.

Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Sachs (e-mail, sachsg@iupui.edu).

Requests for Single Reprints: Greg A. Sachs, MD, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Wishard Memorial Hospital, 1001 West 10th Street, Indianapolis, IN 46202-2879; e-mail, sachsg@iupui.edu.

Current Author Addresses: Dr. Sachs: Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Wishard Memorial Hospital, 1001 West 10th Street, Indianapolis, IN 46202-2879.

Ms. Carter, Ms. Holtz, Ms. Smith, and Dr. Callahan: Regenstrief Institute, 410 West 10th Street, HITS 2000, Indianapolis, IN 46202.

Mr. Stump and Dr. Tu: Division of Biostatistics, Indiana University School of Medicine, 410 West 10th Street, HITS 3000, Indianapolis, IN 46202.

Author Contributions: Conception and design: G.A. Sachs, W. Tu, C.M. Callahan.

Analysis and interpretation of the data: G.A. Sachs, R. Carter, F. Smith, T.E. Stump, W. Tu, C.M. Callahan.

Drafting of the article: G.A. Sachs, T.E. Stump, W. Tu, C.M. Callahan.

Critical revision of the article for important intellectual content: G.A. Sachs, C.M. Callahan.

Final approval of the article: G.A. Sachs, T.E. Stump, W. Tu, C.M. Callahan.

Provision of study materials or patients: L.R. Holtz, C.M. Callahan.

Statistical expertise: T.E. Stump, W. Tu.

Obtaining of funding: G.A. Sachs, C.M. Callahan.

Administrative, technical, or logistic support: G.A. Sachs, L.R. Holtz, F. Smith, C.M. Callahan.

Collection and assembly of data: G.A. Sachs, R. Carter, C.M. Callahan.


Ann Intern Med. 2011;155(5):300-308. doi:10.7326/0003-4819-155-5-201109060-00007
Text Size: A A A

Background: Dementia is a leading cause of death among older adults, but less is known about the mortality risk associated with milder forms of cognitive impairment.

Objective: To determine whether cognitive impairment is independently associated with increased long-term mortality in primary care patients aged 60 years and older.

Design: Linkage of electronic health records from a cohort recruited between January 1991 and May 1993 with data from the National Death Index through 31 December 2006.

Setting: A public safety-net hospital and its community health centers.

Patients: 3957 older adults aged 60 to 102 years who were screened at scheduled primary care appointments.

Measurements: At baseline, patients were screened for cognitive impairment by using the Short Portable Mental Status Questionnaire and were categorized into groups with no, mild, or moderate to severe cognitive impairment. Baseline data from comprehensive electronic health records were linked with vital status obtained from the National Death Index. Kaplan–Meier survival curves compared time to death for the groups with cognitive impairment. Cox proportional hazards models controlled for mortality risk factors.

Results: At baseline, 3157 patients had no cognitive impairment, 533 had mild impairment, and 267 had moderate to severe impairment. Overall, 2385 of the 3957 patients (60.3%) died during the observation period: 1812 (57.4%) patients with no cognitive impairment, 363 (68.1%) patients with mild impairment, and 210 (78.7%) patients with moderate to severe impairment. Both mild and moderate to severe cognitive impairment were associated with increased mortality hazard independent of other mortality risk factors (hazard ratio, 1.184 [95% CI, 1.051 to 1.334] and for mild impairment 1.447 [CI, 1.235 to 1.695] for moderate to severe impairment). Median survival for all 3957 participants was 129 months. Median survival for participants with no, mild, and moderate to severe cognitive impairment was 138, 106, and 63 months, respectively.

Limitations: Cognition was assessed only at enrollment by using a screening instrument. Participants were drawn from a single safety-net health system and had low educational and socioeconomic status, which limits generalizability to other populations. Changes in cognition, function, and comorbid conditions were not measured over time.

Conclusion: Both mild and moderate to severe cognitive impairment as identified by the Short Portable Mental Status Questionnaire are associated with an increased risk for mortality.

Primary Funding Source: Agency for Healthcare Research and Quality.

Figures

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Figure 1.
Study flow diagram.

SPMSQ = Short Portable Mental Status Questionnaire.

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Figure 2.
Kaplan–Meier survival curves comparing time to death for patients with no, mild, and moderate to severe cognitive impairment.
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Figure 3.
Kaplan–Meier survival curves comparing moderate to severe cognitive impairment with 2 control groups without impairment.*

* Patients with moderate to severe cognitive impairment were matched to patients without impairment on age, race and education.

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Summary for Patients

Does Cognitive Impairment Increase the Risk for Death in Older Adults?

The full report is titled “Cognitive Impairment: An Independent Predictor of Excess Mortality. A Cohort Study.” It is in the 6 September 2011 issue of Annals of Internal Medicine (volume 155, pages 300-308). The authors are G.A. Sachs, R. Carter, L.R. Holtz, F. Smith, T.E. Stump, W. Tu, and C.M. Callahan.

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