Functional cognitive screening instruments and their clinical utility with older adults in the emergency department: A systematic review

Cognitive screening is a vital part of geriatric emergency department (ED) care. Performance-based functional cognitive measures may better identify impairments and predict post-discharge outcomes in daily activities. Currently, there is no evidence base informing the selection of suitable functional cognition instruments for emergency care. We conducted a systematic review to find psychometrically sound clinically useful instruments for assessing functional cognition in older adults in the ED. Six databases were searched to identify performance-based instruments measuring functional cognition and related psychometric studies, using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). Studies with a mean age under 65 were excluded. Clinical utility in the ED was evaluated using a newly updated, author-designed, criterion-based consensus matrix. Results were synthesised into a best-evidence summary. We identified 28 instruments and 44 adaptations across 138 studies assessing eight of the nine measurement properties. Construct validity (discriminative and convergent) was most frequently evaluated (87%). Three instruments met all eight clinical utility criteria; however, none have been tested in ED: the Texas Functional Living Scale (moderate-high sufficient construct validity); the Menu Task (moderate-high sufficient construct validity, low-very low sufficient internal consistency and reliability), and the Pillbox Test (moderate sufficient predictive, high sufficient discriminative, moderate inconsistent convergent validity). Overall, 61% of psychometric studies were rated as very good methodological quality. Our study is the first to identify existing instruments with established psychometric evidence that also meet clinical utility criteria for use with older adults in the ED. Robust studies are urgently needed to evaluate predictive validity for post-discharge outcomes.