Outcome of delirium in critically ill patients: systematic review and meta-analysis.

OBJECTIVES: To determine the relation between delirium in critically ill patients and their outcomes in the short term (in the intensive care unit and in hospital) and after discharge from hospital. DESIGN: Systematic review and meta-analysis of published studies. DATA SOURCES: PubMed, Embase, CINAHL, Cochrane Library, and PsychINFO, with no language restrictions, up to 1 January 2015. ELIGIBILITY CRITERIA FOR SELECTION STUDIES: Reports were eligible for inclusion if they were prospective observational cohorts or clinical trials of adults in intensive care units who were assessed with a validated delirium screening or rating system, and if the association was measured between delirium and at least one of four clinical endpoints (death during admission, length of stay, duration of mechanical ventilation, and any outcome after hospital discharge). Studies were excluded if they primarily enrolled patients with a neurological disorder or patients admitted to intensive care after cardiac surgery or organ/tissue transplantation, or centered on sedation management or alcohol or substance withdrawal. Data were extracted on characteristics of studies, populations sampled, identification of delirium, and outcomes. Random effects models and meta-regression analyses were used to pool data from individual studies. RESULTS: Delirium was identified in 5280 of 16,595 (31.8%) critically ill patients reported in 42 studies. When compared with control patients without delirium, patients with delirium had significantly higher mortality during admission (risk ratio 2.19, 94% confidence interval 1.78 to 2.70; P<0.001) as well as longer durations of mechanical ventilation and lengths of stay in the intensive care unit and in hospital (standard mean differences 1.79 (95% confidence interval 0.31 to 3.27; P<0.001), 1.38 (0.99 to 1.77; P<0.001), and 0.97 (0.61 to 1.33; P<0.001), respectively). Available studies indicated an association between delirium and cognitive impairment after discharge. CONCLUSIONS: Nearly a third of patients admitted to an intensive care unit develop delirium, and these patients are at increased risk of dying during admission, longer stays in hospital, and cognitive impairment after discharge.

Does type 2 diabetes increase rate of cognitive decline in older Mexican Americans?

Estimating effects of diabetes on cognitive change among older Mexican Americans is important, yet challenging, because diabetes and cognitive decline both predict mortality, which can induce survival bias. Older Mexican Americans in the Sacramento Area Latino Study on Aging (n=1634) completed Modified Mini-Mental State Exams (3MSE) and diabetes assessments up to 7 times (from 1998 to 2007). We examined baseline and new-onset diabetes and cognitive decline with joint longitudinal-survival models to account for death. At baseline, 32.4% of participants had diabetes and 15.8% developed diabetes during the study. During the study period, 22.8% of participants died. In joint longitudinal-survival models, those with baseline diabetes experienced faster cognitive decline (P=0.003) and higher mortality (hazards ratio=1.88; 95% confidence interval, 1.48-2.38) than those without diabetes. Cognitive decline and mortality were similar for those with new-onset diabetes and those without diabetes. For a typical person, 3MSE scores declined by 2.3 points among those without diabetes and 4.3 points among those with baseline diabetes, during the last 6 years of study. Ignoring the impact of death yielded a 17.0% smaller estimate of the effect of baseline diabetes on cognitive decline. Analyses that overlook the association between cognitive decline and mortality may underestimate the effect of diabetes on cognitive aging.

Neurological, functional, and cognitive stroke outcomes in Mexican Americans.

BACKGROUND AND PURPOSE: Our objective was to compare neurological, functional, and cognitive stroke outcomes in Mexican Americans (MAs) and non-Hispanic whites using data from a population-based study. METHODS: Ischemic strokes (2008-2012) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from patient or proxy interviews (conducted at baseline and 90 days poststroke) and medical records. Ethnic differences in neurological (National Institutes of Health Stroke Scale: range, 0-44; higher scores worse), functional (activities of daily living/instrumental activities of daily living score: range, 1-4; higher scores worse), and cognitive (Modified Mini-Mental State Examination: range, 0-100; lower scores worse) outcomes were assessed with Tobit or linear regression adjusted for demographics and clinical factors. RESULTS: A total of 513, 510, and 415 subjects had complete data for neurological, functional, and cognitive outcomes and covariates, respectively. Median age was 66 (interquartile range, 57-78); 64% were MAs. In MAs, median National Institutes of Health Stroke Scale, activities of daily living/instrumental activities of daily living, and Modified Mini-Mental State Examination score were 3 (interquartile range, 1-6), 2.5 (interquartile range, 1.6-3.5), and 88 (interquartile range, 76-94), respectively. MAs scored 48% worse (95% CI, 23%-78%) on National Institutes of Health Stroke Scale, 0.36 points worse (95% CI, 0.16-0.57) on activities of daily living/instrumental activities of daily living score, and 3.39 points worse (95% CI, 0.35-6.43) on Modified Mini-Mental State Examination than non-Hispanic whites after multivariable adjustment. CONCLUSIONS: MAs scored worse than non-Hispanic whites on all outcomes after adjustment for confounding factors; differences were only partially explained by ethnic differences in survival. These findings in combination with the increased stroke risk in MAs suggest that the public health burden of stroke in this growing population is substantial.

The Hispanic paradox and predictors of mortality in an aging biethnic cohort of Mexican Americans and European Americans: the san antonio longitudinal study of aging.

OBJECTIVES: To examine predictors of mortality in aging Mexican Americans (MAs) and European Americans (EAs). DESIGN: Longitudinal, observational cohort study. SETTING: Socioeconomically diverse neighborhoods in San Antonio, Texas. PARTICIPANTS: Community-dwelling adults aged 65 and older (394 MA; 355 EA) who completed the baseline examination (1992-96) of the San Antonio Longitudinal Study of Aging (SALSA) and for whom vital status was ascertained over an average 8.2 years of follow-up. MEASUREMENTS: Ethnic group was classified using a validated algorithm. Hazard ratios (HRs) for mortality were estimated using Cox proportional hazards models with age, sex, ethnic group, education, income, frailty, diabetes mellitus with and without complications, comorbidity, cognition, depressive symptoms, and body mass index included as predictors in sequential models. RESULTS: At baseline, MAs had a higher prevalence of diabetes mellitus and frailty and lower socioeconomic status (SES) than EAs. The age- and sex-adjusted ethnic HR (MA vs EA) for mortality was 1.54 (95% confidence interval (CI) = 1.17-2.03). After adjusting for SES, the ethnic HR was no longer significant (HR = 1.16, 95% CI = 0.83-1.61). In the final model, comorbidity, diabetes mellitus with complications, depressive symptoms, and cognitive impairment were significant independent risk factors for mortality. CONCLUSION: Contrary to the Hispanic paradox, MAs were at greater risk of mortality than EAs. SES differences largely explained this ethnic disparity. Significant independent predictors of mortality, regardless of ethnic group, were diabetes mellitus with complications, comorbidity, depressive symptoms, and cognitive impairment. Mortality reduction in older MAs requires attention to socioeconomic disparities and disease factors.

[Postoperative survival among nonagenarians: a retrospective study]. / Sobrevida postoperatoria en pacientes nonagenarios: Estudio pronóstico en cohorte retrospectiva 2001-2010, Clínica Dávila.

BACKGROUND: As the Chilean population ages, anesthesiologists are regularly faced with elderly and even nonagenarian people undergoing surgical procedures. AIM: To determine the postoperative survival time in nonagenarians and its risk factors at a private clinic. MATERIAL AND METHODS: Review of medical records of the clinic, searching for patients aged 90 years or older, which were subjected to a surgical procedure between 2001 and 2012. Certification of survival or death was obtained from the clinical records or death certification at the National Identification Service. Survival analysis was made using Kaplan-Meier and Gompertz regression. RESULTS: The medical records of 167 patients, aged 90 to 101 years (64% women), were reviewed. Sixty four percent had an underlying cardiovascular disease; in 37%, cognitive impairment. Hip fracture surgery was the most common procedure. One intraoperative death occurred. Five percent of patients died one month after surgery. The median survival time was two years and the longest, seven years. According to Gompertz probability regression, the predictors of death were the presence of cardiac disease (Hazard ratio (HR): 1.91, 95% confidence intervals (95% CI): 1.16; 3.16), cognitive impairment (HR: 2.10,95% CI: 1.32; 3,22), cancer (HR:2.10,95% CI: 1.32; 3.22), requirement of transfusion (HR: 1.79, 95% CI: 1.13; 2.83) and an American Society of Anesthesiologists (ASA) Class III classification (HR: 1.95, IC95%: 1.21; 3.15). CONCLUSIONS: In nonagenarian patients undergoing surgery; 50% mortality was observed 2 years after surgery. The presence of cardiac disease, cognitive impairment, cancer, transfusion and a Class IIIASA classification were predictors of death.

Sobrevida postoperatoria en pacientes nonagenarios: Estudio pronóstico en cohorte retrospectiva 2001-2010, Clínica Dávila / Postoperative survival among nonagenarians: A retrospective study

Background: As the Chilean population ages, anesthesiologists are regularly faced with elderly and even nonagenarian people undergoing surgical procedures. Aim: To determine the postoperative survival time in nonagenarians and its risk factors at a private clinic. Material and Methods: Review of medical records of the clinic, searching for patients aged 90 years or older, which were subjected to a surgical procedure between 2001 and 2012. Certification ofsurvival or death was obtainedfrom the clinical records or death certification at the National Identification Service. Survival analysis was made using Kaplan-Meier and Gompertz regression. Results: The medical records of167 patients, aged 90 to 101 years (64% women), were reviewed. Sixty four percent had an underlying cardiovascular disease; in 37%, cognitive impairment. Hip fracture surgery was the most common procedure. One intraoperative death occurred. Five percent ofpatients died one month after surgery. The median survival time was two years and the longest, seven years. According to Gompertz probability regression, the predictors of death were the presence of cardiac disease (Hazard ratio (HR): 1.91, 95% confidence intervals (95% CI): 1.16; 3.16), cognitive impairment (HR: 2.10,95% CI: 1.32; 3,22), cancer (HR:2.10,95% CI: 1.32; 3.22), requirement of transfusion (HR: 1.79, 95% CI: 1.13; 2.83) and an American Society of Anesthesiologists (ASA) Class III classification (HR: 1.95, IC95%: 1.21; 3.15). Conclusions: In nonagenarian patients undergoing surgery; 50% mortality was observed 2 years after surgery. The presence of cardiac disease, cognitive impairment, cancer, transfusion and a Class IIIASA classification were predictors of death.

Dementia incidence and mortality in middle-income countries, and associations with indicators of cognitive reserve: a 10/66 Dementia Research Group population-based cohort study.

BACKGROUND: Results of the few cohort studies from countries with low incomes or middle incomes suggest a lower incidence of dementia than in high-income countries. We assessed incidence of dementia according to criteria from the 10/66 Dementia Research Group and Diagnostic and Statistical Manual of Mental Disorders (DSM) IV, the effect of dementia at baseline on mortality, and the independent effects of age, sex, socioeconomic position, and indicators of cognitive reserve. METHODS: We did a population-based cohort study of all people aged 65 years and older living in urban sites in Cuba, the Dominican Republic, and Venezuela, and rural and urban sites in Peru, Mexico, and China, with ascertainment of incident 10/66 and DSM-IV dementia 3-5 years after cohort inception. We used questionnaires to obtain information about age in years, sex, educational level, literacy, occupational attainment, and number of household assets. We obtained information about mortality from all sites. For participants who had died, we interviewed a friend or relative to ascertain the likelihood that they had dementia before death. FINDINGS: 12,887 participants were interviewed at baseline. 11,718 were free of dementia, of whom 8137 (69%) were reinterviewed, contributing 34,718 person-years of follow-up. Incidence for 10/66 dementia varied between 18·2 and 30·4 per 1000 person-years, and were 1·4-2·7 times higher than were those for DSM-IV dementia (9·9-15·7 per 1000 person-years). Mortality hazards were 1·56-5·69 times higher in individuals with dementia at baseline than in those who were dementia-free. Informant reports suggested a high incidence of dementia before death; overall incidence might be 4-19% higher if these data were included. 10/66 dementia incidence was independently associated with increased age (HR 1·67; 95% CI 1·56-1·79), female sex (0·72; 0·61-0·84), and low education (0·89; 0·81-0·97), but not with occupational attainment (1·04; 0·95-1·13). INTERPRETATION: Our results provide supportive evidence for the cognitive reserve hypothesis, showing that in middle-income countries as in high-income countries, education, literacy, verbal fluency, and motor sequencing confer substantial protection against the onset of dementia. FUNDING: Wellcome Trust Health Consequences of Population Change Programme, WHO, US Alzheimer's Association, FONACIT/ CDCH/ UCV.

Frailty and cognitive impairment as predictors of mortality in older Mexican Americans.

OBJECTIVE: Examine the association between frailty and cognitive impairment as predictors of mortality over a 10-year period in a selected sample of older Mexican Americans. DESIGN: Longitudinal analyses using data from the Hispanic Established Populations for the Epidemiologic Study of the Elderly (1995-96/2004-05). SETTING: Five southwestern states: Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: Mexican Americans aged 67 and older with complete information on the frailty index and the Mini Mental State Examination (MMSE) (n=1,815). MEASUREMENTS: Cognitive impairment determined by a score in the MMSE < 21. Frailty defined as three or more of the following components: 1) weight-loss, 2) weakness, 3) self-reported exhaustion, 4) slow walking speed, and 5) low physical activity level. Sociodemographic characteristics and chronic medical conditions were used as covariates. Mortality was determined using the National Death Index or by proxy. RESULTS: As MMSE score declines over time, the percent of frail individuals increases in a linear fashion. Frailty and cognitive impairment are independent risk factors for mortality after controlling for all covariates (HR 2.03 95% CI 1.57-2.62; HR 1.26 95% CI 1.05-1.52, respectively). When both cognitive impairment and frailty were added to the model, HR for individuals with cognitive impairment was no longer statistically significant. CONCLUSION: The relation between frailty and cognitive impairment needs careful analysis in this population to establish pathways increasing mortality and decreasing quality of life. Our results suggest frailty is a stronger predictor of mortality for older Mexican Americans than cognitive impairment.

Time orientation and executive functions in the prediction of mortality in the elderly: Epidoso study.

OBJECTIVE: To analyze the predictive ability of a functional cognitive index of mortality in the elderly. METHODS: Cohort study performed with 1,667 elderly individuals aged more than 65 years and living in the city of São Paulo, Southeastern Brazil, between 1991 and 2001. Functional cognitive index was constructed from time orientation and executive functions (going shopping and taking medication), controlled by sociodemographic variables, life habits, morbidity, self-perception of health, hospitalization, edentulism and social support. Deaths occurred during this period were analyzed with family members in home interviews, notary public offices and records from the Fundação Seade (State System of Data Analysis Foundation), until 2003. Crude and adjusted relative risks were calculated with their respective 95% confidence intervals, using bivariate and multiple analysis with Poisson regression and p<0.05. RESULTS: In the final multivariate model, the following independent risk factors were identified by the index: partial loss of time orientation or executive functions (RR=1.37; 95% CI: 1.03;1.83); total loss of orientation and partial loss of functions (RR=1.71; 95% CI: 1.24;2.37); partial loss of orientation and total loss of functions (RR=1.76; 95% CI: 1.35;2.28); and total loss of orientation and functions (RR=1.64; 95% CI: 1.30;2.06). As regards health conditions, the following were observed: hospitalization (RR=1.45; 95% CI: 1.22;1.73); diabetes (RR=1.20; 95% CI: 1.00;1.44); and total edentulism (RR=1.34; 95% CI: 1.09;1.66). Monthly contact with relatives was identified as a protective factor (RR=0.83; 95% CI: 0.69;1.00). CONCLUSIONS: The Functional Cognitive Index can help clinicians and health planners to make decisions on strategies for follow-up and prevention of treatable causes of cognitive deficit and functional loss to reduce mortality in the elderly.

Orientação temporal e funções executivas na predição de mortalidade entre idosos: estudo Epidoso / Time orientation and executive functions in the prediction of mortality in the elderly: Epidoso study

OBJETIVO: Analisar a capacidade preditiva de índice cognitivo funcional para mortalidade entre idosos. MÉTODOS: Estudo de coorte realizado com 1.667 idosos acima de 65 anos residentes no município de São Paulo, SP, no período 1991-2001. O índice cognitivo funcional foi construído a partir da orientação temporal e funções executivas (fazer compras e tomar medicação), controlado por variáveis sociodemográficas, hábitos de vida, morbidade, autopercepção de saúde, internação, edentulismo e suporte social. Os óbitos ocorridos no período foram investigados com familiares em entrevistas domiciliares, em cartórios e registros da Fundação Seade (até 2003). Foram calculados riscos relativos brutos e ajustados com respectivos intervalos com 95 por cento de confiança por meio de análise bivariada e múltipla com regressão de Poisson, adotando-se p<0,05. RESULTADOS: No modelo multivariado final os fatores de risco independentes identificados pelo índice foram: perda parcial da orientação temporal ou funções executivas (RR=1,37; IC 95 por cento: 1,03;1,83); perda total da orientação e parcial das funções (RR=1,71; IC 95 por cento: 1,24;2,37); perda parcial da orientação e total das funções (RR=1,76; IC 95 por cento: 1,35;2,28); perda total da orientação e das funções (RR=1,64; IC 95 por cento: 1,30;2,06), Quanto às condições de saúde: internação (RR=1,45; IC 95 por cento: 1,22;1,73); diabetes (RR=1,20; IC 95 por cento: 1,00;1,44); edentulismo total (RR=1,34; IC 95 por cento: 1,09;1,66). Relacionamento mensal com parentes foi identificado como fator protetor (RR=0,83; IC 95 por cento: 0,69;1,00). CONCLUSÕES: O Índice Cognitivo Funcional pode auxiliar clínicos e planejadores em decisões sobre estratégias de seguimento e prevenção de causas tratáveis de déficit cognitivo e perda funcional para diminuir a mortalidade entre os idosos.

OBJECTIVE: To analyze the predictive ability of a functional cognitive index of mortality in the elderly. METHODS: Cohort study performed with 1,667 elderly individuals aged more than 65 years and living in the city of São Paulo, Southeastern Brazil, between 1991 and 2001. Functional cognitive index was constructed from time orientation and executive functions (going shopping and taking medication), controlled by sociodemographic variables, life habits, morbidity, self-perception of health, hospitalization, edentulism and social support. Deaths occurred during this period were analyzed with family members in home interviews, notary public offices and records from the Fundação Seade (State System of Data Analysis Foundation), until 2003. Crude and adjusted relative risks were calculated with their respective 95 percent confidence intervals, using bivariate and multiple analysis with Poisson regression and p<0.05. RESULTS: In the final multivariate model, the following independent risk factors were identified by the index: partial loss of time orientation or executive functions (RR=1.37; 95 percent CI: 1.03;1.83); total loss of orientation and partial loss of functions (RR=1.71; 95 percent CI: 1.24;2.37); partial loss of orientation and total loss of functions (RR=1.76; 95 percent CI: 1.35;2.28); and total loss of orientation and functions (RR=1.64; 95 percent CI: 1.30;2.06). As regards health conditions, the following were observed: hospitalization (RR=1.45; 95 percent CI: 1.22;1.73); diabetes (RR=1.20; 95 percent CI: 1.00;1.44); and total edentulism (RR=1.34; 95 percent CI: 1.09;1.66). Monthly contact with relatives was identified as a protective factor (RR=0.83; 95 percent CI: 0.69;1.00). CONCLUSIONS: The Functional Cognitive Index can help clinicians and health planners to make decisions on strategies for follow-up and prevention of treatable causes of cognitive deficit and functional loss to reduce mortality in the elderly.

[Impact of cognitive deficit on survival among elderly residents in the community]. / Impacto del déficit cognitivo en la supervivencia de ancianos residentes en la comunidad.

OBJECTIVE: To analyze cognitive deficit as a risk factor for death in elderly residents in the community and its relationship with variables related to sociodemographic factors, physical health, and functional capacity. MATERIAL AND METHODS: A prospective study was carried out in the city of Santa Cruz, Brazil, in 310 randomly selected elderly individuals who were followed-up for 53 months. Predictive factors were sociodemographic and neuropsychiatric variables, physical health, and functional capacity. The statistical methods used were bivariate analysis (survival analysis), and Cox regression (multivariate analysis) with respective hazard ratios (HR). A value of P<.05 was considered statistically significant and 95% confidence intervals (CI) were calculated. RESULTS: A total of 60 (20.5%) elderly residents died during the study. The main cause of death was cardiovascular disease. The mean time until death was approximately 24.8 months. The main risk factors identified in Cox analysis were cognitive deficit (HR=4.22), stroke (HR=3.08) and dependency for basic activities of daily living (HR=3.55). CONCLUSIONS: Cognitive deficit is an independent risk factor for death. The results of the present study could be useful in formulating future health policies aiming to reduce mortality in the elderly.

[Risk factors for mortality among elderly people]. / Fatores de risco para mortalidade em idosos.

OBJECTIVE: The risk factors for diseases and premature deaths are important in drawing up preventive measures. This study had the aim of analyzing the risk factors for death among elderly people. METHODS: This study was carried out among participants in the SABE (Health, Wellbeing and Aging) study, in the city of São Paulo in 2000. Interviews were conducted with 2,143 elderly people (60 years old or over), using a standardized questionnaire for the SABE study. The sample was obtained from census tracts, in two stages, with replacements and with probability proportional to the population, and with supplementation of the sample of people aged 75 years or over. The final data were weighted so that they could be expanded. Between the two data collection times, there were 38 deaths which comprised study sample. Logistic regression was utilized for the data analysis, with a significance level of 5%. RESULTS: The risk factors found were: locomotion difficulty, advanced age, male gender, self-assessment of health as "bad" and difficulty in going to the bathroom, OR=3.15; 2.93; 2.90; 2.69 and 2.51, respectively. CONCLUSIONS: The results may contribute towards the adoption of preventive measures for elderly people, with the aim of diminishing the expected number of fatal outcomes.

Cognitive impairment and mortality in older mexican americans.

OBJECTIVES: To examine the extent to which cognitive status and decline in cognitive status predict mortality in older Mexican Americans. DESIGN: Longitudinal cohort. SETTING: Older Mexican Americans residing in five southwestern states in the United States. PARTICIPANTS: Two thousand six hundred twenty-five persons aged 65 and older living in Texas, New Mexico, Colorado, Arizona, and California. MEASUREMENTS: The cognitive function of participants was assessed using the Mini-Mental State Examination (MMSE) in 1993-94 and again in 1995-96. Cognitive decline was defined using two sets of criteria: a drop to 17 or less (moderate-severe cognitive impairment) on the MMSE at 2-year follow-up and a decrease of at least four points, a threshold change in scores that was used to predict mortality in this sample. Cox proportional hazards models were conducted to examine the association between the MMSE and increased risk for mortality, after controlling for sociodemographic characteristics, medical conditions, and depressive symptoms. RESULTS: Five-year mortality risk was significantly associated with persons in the moderately-severely cognitively impaired category (hazard ratio (HR) = 2.35, P <.001). Moreover, mild cognitive impairment was also predictive of mortality in older Mexicans (HR = 1.45, P <.001). Two-year declines in cognitive functioning, particularly in persons who had declined to the moderate-severe impairment category (HR = 2.23, P <.001) and those who dropped at least four points on the MMSE (HR = 1.30, P <.001), were predictive of mortality 3 years later, after controlling for important variables. CONCLUSIONS: Baseline moderate-severe and mild cognitive status and 2-year decline in cognitive functioning independently predict mortality in older Mexican Americans. Although age and selected medical conditions have been reported as the more salient predictors of mortality, cognitive functioning should be considered part of identifying older persons at high risk for underlying medical conditions and mortality.

Dependence in activities of daily living and cognitive impairment strongly predicted mortality in older urban residents in Brazil: a 2-year follow-up.

OBJECTIVES: To identify a set of predictors of mortality among residents in the community, before any physical, biochemical, or image examination is performed, that could be collected on a routine standardized basis, to help the clinician define a patient follow-up strategy and the health planner make decisions regarding the care of older people. DESIGN: A household follow-up study, with an evaluation at baseline and 2 years later. SETTING: Residential area, with a low rate of in- and outmigration, in Sao Paulo, a large industrialized urban center in southeastern Brazil. PARTICIPANTS: One thousand six hundred sixty-seven older urban residents in the community (65+), from different socioeconomic backgrounds, enrolled after a study area census. INTERVENTION: Structured home interview with Brazilian Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire, previously validated in Portuguese. MEASUREMENTS: A logistic regression model for the risk of dying in the period was developed, having as independent variables, sociodemographic characteristics plus six other dimensions: subjective self-evaluation of health, past medical history, use of health services, dependence in activities of daily living (ADLs), mental health, and cognitive status. RESULTS: There were 146 deaths (9%) in the cohort during the follow-up interval. The variables that appeared as independent predictors of death in the final logistic regression model were: gender (relative risk (RR) = 2.8 (males)), age (RR = 2.0 (80+ vs. 65-69)), hospitalization in the previous 6 months (RR = 2.4 (at least one)), dependence in ADLs (RR = 3.0 (assistance required for 7 vs. 0 ADLs)); and cognitive impairment (RR = 1.9 (Mini-Mental State Examination 18 vs. 30)). CONCLUSION: These findings suggest that in developing countries such as Brazil, an assessment of dependence in daily living and cognitive status should be an essential part of any health evaluation of an older person, not only because these variables represent potentially high independent mortality risks, but also because they can be easily and reliably assessed, using well-validated instruments, and may be susceptible to intervention.