The Clock-in-the-Box, a brief cognitive screen, is associated with failure to return home in an elderly hospitalized sample

Abstract

Purpose

Cognitive screening upon hospital admission can provide important information about the patient’s ability to process information during the inpatient stay. The Clock-in-the-Box (CIB) is a rapidly administered cognitive screening measure which has been previously validated with cognitive screening and neuropsychological assessments. The purpose of this study is to demonstrate the predictive validity of the CIB for discharge location among a sample of older medical inpatients.

Patients and methods

Hospitalized Veterans (N=218), aged 55 years and older, were recruited on the day after admission after they gave their consent. These participants completed the CIB, the Montreal Cognitive Assessment, and self-report measures of daily functioning. Using logistic regression models, the bivariable and multivariable impact of the cognitive screening and functional assessments were examined for their ability to predict whether the participants did not return home after hospitalization (eg, admission to subacute rehabilitation facilities or nursing facilities).

Results

The participants were older (mean 71.5±9.5 years) and predominantly male (92.7%). The CIB score was independently associated with discharge to locations other than home (odds ratio =0.72, 95% confidence interval =0.60–0.87, P=0.001) and remained associated after adjusting for demographics, prehospitalization functional abilities, and Montreal Cognitive Assessment score (adjusted odds ratio =0.55, 95% confidence interval =0.36–0.83, P=0.004).

Conclusion

The current evidence, combined with its brevity and ease of use, supports the use of the CIB as a cognitive screen for inpatient older adults, in order to help inform clinical treatment decisions and discharge planning.

Keywords:

• cognition
• screening
• aging
• hospitalization
• care transition

Supplementary materials

Figure S1 Relation between CIB total score and MoCA score.

Notes: Median, 25th, and 75th percentiles are indicated by the box; range is displayed by the bars.

Abbreviations: CIB, Clock-in-the-Box; MoCA, Montreal Cognitive Assessment.

Table S1 Age and education normative values for CIB total score

Acknowledgments

We are indebted to the Veterans who participated in our delirium and fall reduction programs. We are thankful for the guidance of the Department of Veterans Affairs (VA) Boston Healthcare System (VABHS) Boston Delirium Task Force, and Patient Safety Officers for their continued collaboration to improve the outcomes for the Veterans we serve. The Clock-in-the-Box was developed by Dr Grande, with contributions from Dr Milberg. All authors were VA employees at that time.

Support for this study was provided by the Delirium Patient Safety Center of Inquiry from the VA Office of Patient Safety. The funders had no influence in the conduct, analysis, or interpretation of the study data.

Dr Jackson was funded by a VA Fellowship in Advanced Geriatrics. Dr Rudolph is supported by the VA Health Services Research and Development Center of Innovation in Long Term Services and Supports (CIN 13-419) and the VA QUERI- Geriatrics and Extended Care Partnered Evaluation Center for Community Nursing Homes (PEC 15-465). The views expressed here are the opinion of the authors and do not represent the official policy of the VA.

Author contributions

All authors had access to the data and played a role in writing this manuscript. JLR contributed to the study design; KD, EA, BK, and JLR contributed to the acquisition of data; JLR participated in data analysis; CEJ, JLR, LJG, JAD, and WPM were involved in data interpretation; and CEJ, LJG, KD, EA, BK, WPM, and JLR were involved in preparation of the manuscript. All authors contributed toward data analysis, drafting and revising the paper and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.