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RehabMeasures Instrument

Identification of Seniors At Risk

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Purpose

A self-reporting tool used to:

  • Identify elderly patients (65 and older) at risk of adverse health outcomes, including: functional decline, revisits to the emergency department (ED), hospitalizations, institutionalization, and mortality within 6 months after being seen in the ED
  • Identify those with severe disability at the time of an ED visit

Link to Instrument

Instrument Details

Acronym ISAR

Cost

Not Free

Key Descriptions

  • Six yes/no questions
  • Total scale range is from 0 to 6
  • Item is scored 1 if the patient reports having the problem and 0 if not
  • Item scores are summed
  • Maximum score = 6; scores 2 indicate the individual may be at higher risk and should be assessed further
  • Provide administration instructions if possible or refer to publication or other place they can be found

Number of Items

6

Time to Administer

5 minutes

Less than 5 minutes

Required Training

No Training

Instrument Reviewers

Leslie Buckner, PT

ICF Domain

Participation

Considerations

  • The ISAR is a screening tool and should not be used as a single tool in clinical decision making.  It is not a diagnostic tool.  It should be used identify those who need specialty services and possible for referral for a full geriatric assessment. It has been found to have poor predictive validity
  • Patients usually excluded are those who cannot provide reliable information, are not cognitively intact, or who were expected to die within 24 hrs.  An informant can provide the information for the patient (ie. family member)
  • Although not currently validated in other settings, the ISAR may warrant additional testing in the outpatient clinic setting and in the hospital.  There is another version of the ISAR called the ISAR-HP that has been used in hospitals.

Older Adults and Geriatric Care

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Cut-Off Scores

Adults 65+ years old: (Singler et al., 2014; n=520 German adults in ED)

  • At 28 days
    • ISAR >=2 : 24.8% (low specificity), 88.8% (high sensitivity)
    • ISAR >=3 : 49.3% (moderate specificity), 71.2% (moderate sensitivity)
  • At 180 days
    • ISAR >=2 : 27.3%(low specificity), 90.1% (high sensitivity)
    • ISAR >=3 : 52.7% (moderate specificity), 73.8% (moderate sensitivity)
  • Despite high sensitivity, low specificity was seen by this author as a reason to choose the ISAR >= 3 to decrease the number of false positive screenings for the combined endpoint.

 (Dendukuri et al., 2004; Study 1 n=1,122, Study 2 n=1,889)

  • Cut-off point of 2 had greater sensitivity in predicting severe functional impairment, detecting depression, detecting increased depressive symptoms, and frequent use of community health centers.

(Suffoletto et al., 2016; n=202 United States adults)

  • The optimum ISAR cut-off score for screening was >=2 with high sensitivity of 91% and low specificity of 19%

Normative Data

Patients with Previous Mobility Deficits: (Singler et al., 2014)

  • ISAR score 0-1 (n=95): 8.4% with previous mobility deficits
  •  ISAR score >=2 (n=425): 50.6% with previous mobility deficits

(Salvi et al., 2009; n=200 Italian adults)

  • Katz ADL score for ISAR 0-1: mean 5.5 (1.1)
  • Katz ADL score for ISAR ³2: mean 3 (2.3)

Fall History: (Edmans et al., 2013; n=667 UK adults)

  • ISAR score 0-1 (median age 78; n= 205): 23.4% presented with falls
  •  ISAR score >=2 (median age 81; n=462): 24.5% presented with falls

Using >= 3 medications: (Dendukuri et al., 2004)

  • ISAR score 0-1: Study 1-(n=608): 17.8%; Study 2- (n=132): 25%
  • ISAR score 2-6: Study 1-(n=514): 69.1%; Study 2- (n=288): 79.1%

Admitted to Hospital from ED visit: (Salvi et al., 2009)

  • ISAR score 0-1 (median age 78.3 (7.5); n= 59)- 44% admitted to hospital
  •  ISAR score >=2 (median age 81.2 (7.2); n=141)-63.8% admitted to hospital

(Asomaning &Loftus, 2014; n=258; United States adults)

  • ISAR score negative [ie <=2] (n=100)- 23% admitted to hospital
  • ISAR score  positive[ie >=2] (n=158)- 50% admitted to hospital

Gender: (Singler et al., 2014)

  • ISAR score >=2: 62.6% were women

(Edmans et al., 2013)

  • ISAR score >=2: 60.4% were women

Age: (Asomaning &Loftus, 2014)

  • ISAR score negative [ie <=2](n=100): mean age 76.6 (7.5)
  • ISAR score  positive[ie >=2] (n=158): mean age 80.9 (8.5)

(Salvi et. al, 2009)

  • ISAR score >= 2: mean age 81.2 (7.2)
  • ISAR score 0-1: mean age 78.3 (7.5)

(Suffoletto et al., 2016)

  • Mean age of those who reached the combined endpoint of (ED visit, post discharge hospitalization or death with 30 days of initial ED visit) was 77 (7.8)

Test/Retest Reliability

Adults 65+ years old in an ED: (McCusker et al., 1998; n=404)

  • Excellent test-retest reliability of the total risk factor score (ICC=.78)

Criterion Validity (Predictive/Concurrent)

Predictive validity:

Adults 65+ years old: (Rosted et al., 2004; n=278; mean age=78 years)

  • Adequate correlation found between patient’s ISAR score and the number of days spent in the hospital (Pearson’s r=0.36, p=0.00)and their number of health problems (Pearson’s r=0.55, p=0.00)
  • Adequate correlation found between the ISAR score and readmissions within one (g=0.32; p=0.02) and three months (g=0.51; p=0.00)

 (Buurmann et al., 2011, n=381; performed in a Netherlands EDt)

  • Poor correlation with death- AUC: 0.58
  • Poor correlation with hospital admission- AUC: 0.59
  • Poor correlation with recurrent visit to ED- AUC: 0.59
  • Poor correlation with poor outcomes (combined)-AUC: 0.60

(Salvi et al., 2012)

  • Poor correlation with return visit to ED-AUC: 0.61
  • Poor correlation with hospital admission-AUC: 0.61
  • Adequate correlation with death-AUC: 0.75

(Dendukuri et al., 2004)

  • Adequate correlation with severe functional impairment-AUC: 0.86 (both studies)
  • Poor correlation with frequent ED visits-Study 1 AUC: 0.61, Study 2 AUC: 0.68
  • Poor correlation with frequent hospitalization- Study 1 AUC: 0.66, Study 2 AUC: 0.68 
  • For increased depressive symptoms: moderate sensitivity 73% and specificity 57% (Study 2)
  • For frequent emergency room usage (>=2 visits): moderate sensitivity 71% and specificity 60% (Study 2)
  • For frequent hospitalization (>=11days): moderate sensitivity 70% and specificity 58% (Study 2)
  • For frequent use of community health center (10 visits): moderate sensitivity 73% and specificity 59% (Study 2) 
  • Ability of the questions to predict severe functional impairment: high sensitivity-94%, moderate specificity-58%
  • Ability of the questions to predict depression: high sensitivity-83%, moderate specificity-63%

(Singler et al., 2014)

  • Poor correlation for combined endpoint on day 28- AUC: 0.621
  • Poor correlation for combined endpoint on day 180- AUC: 0.661
  • RR (relative risk):
    • ISAR >=2 : 1.77 (28 days), 2.20 (180 days) increased risk
    • ISAR >=3 : 1.61 (28 days), 3.14 (180 days) increased risk

(Edmans et al., 2013; cutoff score>=2)

  • Moderate Sensitivity- ISAR >=2 : 71% (at 90 day follow-up)
  • Low Specificity- ISAR >=2 : 43% (at 90 day follow-up)

 (Buurman et al., 2011; ISAR cutoff score >=2)

  • Moderate Sensitivity- 65% (at 120 days follow-up)
  • ModerateSpecificity- 54% (at 120 days follow-up)

 (McCusker et al., 1999; n=1,854; Cut-off score ISAR >=2)

  • Moderate Sensitivity- 72% (at 6 month follow-up)
  • Moderate Specificity- 58% (at 6 month follow-up)
  • Adequate correlation with adverse outcome- AUC=0.71

(McCusker et al., 1998)

  • The questions with the highest level of both sensitivity and specificity were those on visual and hearing impairment as well as those on medications (sensitivity >=60% and specificity >=90%)

(Salvi et al., 2009)

  • All items of the ISAR were able to predict the composite outcome (OR- >2.2 and r below 0.014) except polypharmacy (OR-1.72, r =0.20)

(Suffoletto et al., 2016)

  • The ISAR risk factor with the best prognostic accuracy of poor outcome at 30 days was the concurrent use of >= 3 medications with a high sensitivity of 93% and a low specificity of 13%

(Salvi et al., 2009)

  • High Adjusted OR (adjusted odds ratio) for composite outcome=4.85, r<0.0001
  • High Adjusted OR (adjusted odds ratio) for frequent ED return=4.69, r<0.0019
  • Moderate Adjusted OR (adjusted odds ratio) for functional decline=2.98, r=0.016
  • Moderate Adjusted OR (adjusted odds ratio) for admission to hospital=2.07, r=0.043
  • Low Adjusted OR (adjusted odds ratio) for early ED revisit=1.67, r=0.20
  • High Hazard Ratio- 6.9

Adults 70+ years old in an acute medical unit: (Edmans, 2013)

  • Poor correlation with death- AUC :0.62
    • PPV-6%, NPV-97%
  • Poor correlation with move to care home-AUC: 0.65
    • PPV-1%, NPV-99%
  • Poor correlation with readmission- AUC:0.60
    • PPV-29%, NPV-79%
  • Poor correlation with increase in dependency- AUC :0.62
    • PPV-24%, NPV-88%
  • Poor correlation with reduced mental well being- AUC :0.50
    • PPV-45%, NPV-54%
  • Poor correlation with reduced quality of life- AUC: 0.56
    • PPV-53%, NPV-60%
  • Poor correlation with any adverse outcome- AUC: 0.60
    • PPV-79%, NPV-32%
  • Adequate correlation with high total health and social care costs-AUC :0.70
    • PPV-13%, NPV-96%

Construct Validity

Adults 65+ years old in an ED: (Salvi et al., 2012; n=2,057; mean age 81.7)

  • Adequate correlation between ISAR and Triage Risk Screening Tool (TRST): Pearson r=0.539

Content Validity

  • Items were developed from a literature review of general factors and specific questions that predict functional decline
  • Potential screening questions were sent to multidisciplinary hospital and community-based health professionals who were asked to prioritize questions addressing each topic of interest
  • These test items were then pretested on a sample of ED patients to determine ease of comprehension
  • Twenty-seven questions were initially used.  Those questions were then studied to determine which screening questions were the best subset for predicting a disability at 6 months later
  • This 27 item questionnaire was then refined to 6 items

Bibliography

Asomaning N, Loftus C. Indentification of Seniors at Risk (ISAR) screening tool in the emergency department: Implementation using the plan-do-study-act model and validation results. Journal of Emergency Nursing 2014; 40(4): 357-364.

Buurman BM, van den Berg W, Korevaar JC, Milisen K, de Haan RJ and de Rooij SE. Risk for poor outcomes in older patients discharged from an emergency department: feasibility of four screening instruments. Eur J Emerg Med 2011; 18: 215-220.

Dendukuri N, McCusker J, Belzile E. The Identification of Seniors at Risk screening tool: further evidence of concurrent and predictive validity. Journal of American Geriatrics Society. 2004; 52: 290-296.

Edmans J, Bradshaw L, Gladman JR, FranklinM, Berdunov V, Elliott R and Conroy SP. The Identification of Seniors at Risk (ISAR) score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units. Age Ageing. 2013; 42: 747-753.

McCusker J, Bellvance F, Cardin S. Trepanier S. Screening for geriatric problems in the emergency deparment: reliability and validity. Academic Emergency Medicine. 1998; 5(9): 883-893.

McCusker J, Bellavance F, Cardin S, Trepanier S, Verdon J and Ardman O. Detection of older people at increased risk of adverse health out-comes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc 1999; 47: 1229-1237.

Rosted E, Schultz M, Dynesen H, Dahl M, Sorensen M, Sanders S. The Identification of Seniors at Risk screening tool is useful for predicting acute readmissions. Danish Medical Journal 2014; 61(5):A4828

Salvi F, Morichi V, Grilli A, et.al. Predictive validity of the Identification of Seniors at Risk (ISAR) screening tool in elderly patients presenting to two Italian emergency deparments. Aging Clinical and Experimental Research. 2009; 21:69-75.

Salvi F, Morichi V, Lorenzetti B, et al. Risk stratification of older patients in the emergency department: comparison between the identification of seniors at risk and triage risk screening tool. Rejuvenation Research. 2012; 15(2): 288-294.

Singler K, Heppner HJ, Skutetzky A, Sieber C, Christ M and Thiem U. Predictive validity of the identification of seniors at risk screening tool in a german emergency department setting. Gerontology 2013; 60: 413-419.

Suffoletto B, Miller T, Shah R, Callaway C, Yealy D. Predicting older adults who return to the hospital or die within 30 days of emergency department care using the ISAR tool: subjective versus objective risk factors. Emergency Medicine Journal. 2016; 33: 4-9.

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