{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T13:03:34Z","timestamp":1789995814194,"version":"4.0.1"},"reference-count":35,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,9,19]],"date-time":"2026-09-19T00:00:00Z","timestamp":1789776000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Altered arousal may provide rapid prognostic information in older emergency department (ED) patients. Originally developed to monitor agitation and sedation in critically ill patients, the Richmond Agitation-Sedation Scale (RASS) provides a rapid measure of arousal. However, its prognostic value relative to the Glasgow Coma Scale (GCS) in older ED patients remains uncertain. We evaluated whether RASS was associated with clinical outcomes and provided information beyond GCS. Materials and Methods: This study was a single-center retrospective cohort study of nontraumatic ED patients aged \u2265 65 years from January 2024 through October 2025. Only the first ED visit per patient was included. The primary outcome was in-hospital mortality; secondary outcomes were hospital and intensive care unit (ICU) admission. RASS was modeled categorically to preserve deviations in both directions from 0. Multivariable logistic regression and DeLong AUC comparisons were performed. Results: Among 10,208 patients, 352 (3.4%) died, 2301 (22.5%) were hospitalized, and 856 (8.4%) were admitted to the ICU. Mortality increased from 2.2% at RASS 0 to 59.4% at \u22125 and 45.5% at +3. Hospital and ICU admission rates also increased in both directions from RASS 0 (all trend p &lt; 0.001). After adjustment for age, sex, vital signs, and GCS, both reduced arousal (RASS \u2264 \u22124: aOR, 4.93; 95% CI, 2.10\u201311.61) and agitation (RASS \u2265 +2: aOR, 5.16; 95% CI, 2.46\u201310.85) remained associated with mortality. RASS and GCS had similar discrimination for mortality (AUC, 0.683 vs. 0.679; p = 0.72), whereas their combination improved discrimination (AUC, 0.712; both comparisons p &lt; 0.001). Among patients with GCS 15, mortality was 9.9% with abnormal RASS versus 1.9% with RASS 0. Conclusions: RASS demonstrated a bidirectional association with adverse outcomes and provided prognostic information comparable to and complementary to GCS. Its rapid assessment may help identify high-risk older ED patients, including those with GCS 15.<\/jats:p>","DOI":"10.3390\/medicina62091803","type":"journal-article","created":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T10:25:43Z","timestamp":1789986343000},"page":"1803","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Prognostic Value of the Richmond Agitation-Sedation Scale for Mortality and Admission in Older Emergency Department Patients"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8936-3988","authenticated-orcid":false,"given":"Secdeg\u00fcl","family":"Co\u015fkun Ya\u015f","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, Faculty of Medicine, Gazi University, Ankara 06560, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7851-7881","authenticated-orcid":false,"given":"Mehmet Ali","family":"Aslaner","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Faculty of Medicine, Gazi University, Ankara 06560, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"376","DOI":"10.1111\/acem.14386","article-title":"Inclusion of older adults in emergency department clinical research: Strategies to achieve a critical goal","volume":"29","author":"Hunold","year":"2022","journal-title":"Acad. Emerg. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1016\/j.annemergmed.2010.04.015","article-title":"Older patients in the emergency department: A review","volume":"56","author":"Samaras","year":"2010","journal-title":"Ann. Emerg. Med."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Ukkonen, M., Jamsen, E., Zeitlin, R., and Pauniaho, S.L. (2019). Emergency department visits in older patients: A population-based survey. BMC Emerg. Med., 19.","DOI":"10.1186\/s12873-019-0236-3"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"508","DOI":"10.1016\/j.ajem.2020.10.075","article-title":"Should age be incorporated into the adult triage algorithm in the emergency department?","volume":"46","author":"Ginsburg","year":"2021","journal-title":"Am. J. Emerg. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.ejim.2023.03.018","article-title":"Older patients with nonspecific complaints at the Emergency Department are at risk of adverse health outcomes","volume":"112","author":"Peters","year":"2023","journal-title":"Eur. J. Intern. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.archger.2015.08.016","article-title":"Atypical presentations of older adults at the emergency department and associated factors","volume":"62","author":"Limpawattana","year":"2016","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1111\/acem.12569","article-title":"Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: A systematic review and meta-analysis","volume":"22","author":"Carpenter","year":"2015","journal-title":"Acad. Emerg. Med."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Maccauro, V., Cacciamani Fanelli, P.M., Della Polla, D.A., Bonadia, N., De Matteis, G., Piccioni, A., Gasbarrini, A., Sandroni, C., Franceschi, F., and Covino, M. (2026). One Score Fits All? A Narrative Review on Early Warning Scores for Older Adults in the Emergency Department in the Era of Personalized Medicine. J. Pers. Med., 16.","DOI":"10.3390\/jpm16020098"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Kim, K.T., and Cho, Y.W. (2026). Altered Level of Consciousness in a Tertiary Emergency Department: Etiologies, Mortality, and Outcomes. J. Clin. Med., 15.","DOI":"10.3390\/jcm15052037"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.ajem.2016.10.004","article-title":"Etiologies and delirium rates of elderly ED patients with acutely altered mental status: A multicenter prospective study","volume":"35","author":"Aslaner","year":"2017","journal-title":"Am. J. Emerg. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"290","DOI":"10.1016\/j.ajem.2021.10.034","article-title":"Increased short-term mortality among patients presenting with altered mental status to the emergency department: A cohort study","volume":"51","author":"Stanich","year":"2022","journal-title":"Am. J. Emerg. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"844","DOI":"10.1016\/S1474-4422(14)70120-6","article-title":"The Glasgow Coma Scale at 40 years: Standing the test of time","volume":"13","author":"Teasdale","year":"2014","journal-title":"Lancet Neurol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1338","DOI":"10.1164\/rccm.2107138","article-title":"The Richmond Agitation-Sedation Scale: Validity and reliability in adult intensive care unit patients","volume":"166","author":"Sessler","year":"2002","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2983","DOI":"10.1001\/jama.289.22.2983","article-title":"Monitoring sedation status over time in ICU patients: Reliability and validity of the Richmond Agitation-Sedation Scale (RASS)","volume":"289","author":"Ely","year":"2003","journal-title":"JAMA"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1111\/acem.12706","article-title":"The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients","volume":"22","author":"Han","year":"2015","journal-title":"Acad. Emerg. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"772","DOI":"10.1002\/jhm.2276","article-title":"Impaired arousal at initial presentation predicts 6-month mortality: An analysis of 1084 acutely ill older patients","volume":"9","author":"Han","year":"2014","journal-title":"J. Hosp. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"658","DOI":"10.1002\/jhm.2415","article-title":"Comparison of mental-status scales for predicting mortality on the general wards","volume":"10","author":"Zadravecz","year":"2015","journal-title":"J. Hosp. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1016\/S1474-4422(24)00454-X","article-title":"Unique considerations in the assessment and management of traumatic brain injury in older adults","volume":"24","author":"Depreitere","year":"2025","journal-title":"Lancet Neurol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"710","DOI":"10.1093\/aje\/kwk052","article-title":"Relaxing the rule of ten events per variable in logistic and Cox regression","volume":"165","author":"Vittinghoff","year":"2007","journal-title":"Am. J. Epidemiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1525","DOI":"10.1093\/jamia\/ocac093","article-title":"The harm of class imbalance corrections for risk prediction models: Illustration and simulation using logistic regression","volume":"29","author":"Timmerman","year":"2022","journal-title":"J. Am. Med. Inform. Assoc."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.ajem.2023.10.022","article-title":"Clinical assessment and short-term mortality prediction of older adults with altered mental status using RASS and 4AT tools","volume":"75","author":"Demirtakan","year":"2024","journal-title":"Am. J. Emerg. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1016\/j.jamda.2015.10.002","article-title":"The Effect of an Impaired Arousal on Short- and Long-Term Mortality of Elderly Patients Admitted to an Acute Geriatric Unit","volume":"17","author":"Bellelli","year":"2016","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Telles, G.P., Ferreira, I.B.B., Carvalho de Menezes, R., do Carmo, T.A., David Pugas, P.L., Marback, L.F., Arriaga, M.B., Fukutani, K.F., Neto, L.P., and Agareno, S. (2020). Comparison of a modified Sequential Organ Failure Assessment Score using RASS and FOUR. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0229199"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e114","DOI":"10.1097\/SLA.0000000000004484","article-title":"Multicenter International Cohort Validation of a Modified Sequential Organ Failure Assessment Score Using the Richmond Agitation-sedation Scale","volume":"276","author":"Rakhit","year":"2022","journal-title":"Ann. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1097\/CCM.0000000000001375","article-title":"Validity of a Modified Sequential Organ Failure Assessment Score Using the Richmond Agitation-Sedation Scale","volume":"44","author":"Vasilevskis","year":"2016","journal-title":"Crit. Care Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"3295","DOI":"10.1089\/neu.2021.0199","article-title":"Diagnosing Level of Consciousness: The Limits of the Glasgow Coma Scale Total Score","volume":"38","author":"Bodien","year":"2021","journal-title":"J. Neurotrauma."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1093\/ageing\/afx174","article-title":"Impaired cognition is associated with adverse outcome in older patients in the Emergency Department; the Acutely Presenting Older Patients (APOP) study","volume":"47","author":"Lucke","year":"2018","journal-title":"Age Ageing"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1016\/j.annemergmed.2025.02.003","article-title":"Outcomes of Older Adults With Delirium Discharged From the Emergency Department","volume":"86","author":"Howick","year":"2025","journal-title":"Ann. Emerg. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/j.ajem.2022.05.058","article-title":"Delirium prevalence in geriatric emergency department patients: A systematic review and meta-analysis","volume":"59","author":"Chen","year":"2022","journal-title":"Am. J. Emerg. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1186\/s40635-025-00795-z","article-title":"Serum biomarkers of delirium in critical illness: A systematic review of mechanistic and diagnostic evidence","volume":"13","author":"Cervoni","year":"2025","journal-title":"Intensive Care Med. Exp."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"522","DOI":"10.7861\/clinmed.2022-0426","article-title":"NEWS2 and the older person","volume":"22","author":"Vardy","year":"2022","journal-title":"Clin. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1016\/j.ajem.2025.06.033","article-title":"Comparison of early warning scores for predicting outcomes in adult and older patients in emergency department: Multicenter study","volume":"96","author":"Bae","year":"2025","journal-title":"Am. J. Emerg. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"12584","DOI":"10.1038\/s41598-025-97764-z","article-title":"The clinical frailty scale improves risk prediction in older emergency department patients: A comparison with qSOFA, NEWS2, and REMS","volume":"15","author":"Chung","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Kemp, K., Alakare, J., Harjola, V.P., Strandberg, T., Tolonen, J., Lehtonen, L., and Castr\u00e9n, M. (2020). National Early Warning Score 2 (NEWS2) and 3-level triage scale as risk predictors in frail older adults in the emergency department. BMC Emerg. Med., 20.","DOI":"10.1186\/s12873-020-00379-y"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1007\/s12028-018-0630-9","article-title":"The Full Outline of UnResponsiveness (FOUR) Score and Its Use in Outcome Prediction: A Scoping Systematic Review of the Adult Literature","volume":"31","author":"Almojuela","year":"2019","journal-title":"Neurocrit Care"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/9\/1803\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T12:13:20Z","timestamp":1789992800000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/9\/1803"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,19]]},"references-count":35,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["medicina62091803"],"URL":"https:\/\/doi.org\/10.3390\/medicina62091803","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,19]]}}}