Effect of ethinyl estradiol on the panic response to the panicogenic agent pentagastrin.

BACKGROUND: Panic disorder (PD) symptomatology has been reported to be altered by hormonal events or treatments which affect estrogen levels. Coryell et al. [Arch. Gen. Psychiatry, 39 (1982) 701-703; Am. J. Psychiatry, 143 (1986) 508-510] have suggested that the increased cardiovascular risk associated with PD is significantly greater in males, alluding to a potential cardioprotective effect of female hormones in the context of panic attacks. In the present study, we were, therefore, interested in elucidating the role of estrogen in modulating the behavioural and cardiovascular responses induced by the panicogenic agent pentagastrin, a cholecystokinin-B (CCK(B)) receptor agonist. METHODS: A double-blind cross-over placebo-controlled design with randomization of the order of a 3-day pretreatment of ethinyl estradiol (EE) (50 microg/day) or placebo was used to assess the effect of a 30-microg i.v. bolus injection of pentagastrin on panic symptom intensity and on increases in heart rate (DeltaHR), systolic (DeltaSBP) and diastolic (DeltaDBP) blood pressure following each pretreatment. Subjects were 9 male healthy controls and 11 male PD patients. RESULTS: EE pretreatment did not significantly reduce the pentagastrin-induced panic symptom scale (PSS) scores and had no effect on DeltaDBP or DeltaSBP. EE did, however, attenuate the pentagastrin-induced increase in HR in both PD patients and healthy controls. LIMITATIONS: Only male subjects were included in the present study; however, we are currently investigating the influence of female gonadal hormones on the panic response to pentagastrin in female PD patients and healthy controls. CONCLUSION: Our results suggest that estrogens may display cardioprotective effects in the context of panic attacks.

The influence of Type A behavior pattern on the response to the panicogenic agent CCK-4.

OBJECTIVES: Review of the literature equivocally suggests that subjects with Type A behavioral pattern (TABP) compared to subjects with Type B behavioral pattern display an increased sympathetic activity, a condition associated with sudden cardiac death. The objective of this study was to determine whether healthy subjects classified as Type A or Type B differed in their reactivity to the beta 1 and beta 2 receptor agonist isoproterenol and to the panicogenic agent cholecystokinin-tetrapeptide (CCK-4). By comparing reactivity to CCK-4 after pretreatment with placebo or propranolol, a beta 1 and beta 2 receptor antagonist, the role of the beta adrenergic system in the hypothesized increased response of Type A subjects to CCK-4 was also assessed. METHODS: The study used a randomized, double-blind, placebo-controlled design. Twenty-seven Type A or B subjects were included in the study. The reactivity to isoproterenol was assessed with the CD25 of isoproterenol (i.e., the intravenous dose of isoproterenol necessary to increase the heart rate of 25 bpm). The panic symptom response and the cardiovascular response to bolus injection of 50 microg of CCK-4 was assessed in subjects pretreated with either propranolol or placebo infusions prior to the CCK-4 challenge. An additional group of subjects was recruited and these subjects received a placebo infusion pretreatment before an injection of placebo. RESULTS: The CD25 was significantly greater in Type A subjects than in Type B subjects. No difference was found among the groups on behavioral sensitivity to the CCK-4 challenge. However, CCK-4-induced maximum increase in heart rate was greater in Type A subjects. CONCLUSION: Our finding that Type A subjects exhibited greater CD25 of isoproterenol and greater increases in heart rate following CCK-4 administration compared to Type B subjects suggests that peripheral beta-receptor sensitivity may be increased in individuals with TABP.

Arginine-vasopressin and oxytocin response to cholecystokinin-tetrapeptide.

This study examined the effects of i.v. administration of cholecystokinin-tetrapeptide (CCK-4) on plasma release of arginine vasopressin (AVP) and oxytocin (OT) in women with premenstrual dysphoric disorder (PMDD) and control women, during both the follicular phase and the luteal phase of their menstrual cycle. Plasma AVP and OT concentrations increased following CCK-4 administration. AVP and OT response to CCK-4 was similar for PMDD and control women and unaffected by menstrual cycle phase. AVP and OT may play a role in the hypothalamo-pituitary adrenal (HPA) axis activity associated with the panic response induced by CCK-4.

Feasibility and effectiveness of treatments for post-stroke depression in elderly inpatients: systematic review.

To determine the feasibility and effectiveness of antidepressive treatments for post-stroke depression in elderly medical inpatients, MEDLINE was searched for potentially relevant articles published from January 1987 to August 1997 using the keywords "depression or depressive disorder" (exploded) and "aged." Thirteen reports met the following inclusion criteria: (1) published in English or French; (2) minimum age criterion of 55 and over or mean age 65 and over; (3) post-stroke subjects admitted to a medical, geriatric, or rehabilitation service; (4) used accepted criteria for depression; (5) examined treatment(s) for depression; and (6) reported outcomes as a depression diagnosis and/or symptom level. Data were abstracted independently from each article by two reviewers. The limited evidence suggests contraindications to treatment of 83% of a group to receive a heterocyclic antidepressant compared with 11% of a group to receive a selective serotonin reuptake inhibitor (SSRI); rates of discontinuation and study completion are similar for heterocyclics, SSRIs and psychostimulants. All of the treatments appear to be at least modestly effective in the short term.

Power comparison of robust approximate and non-parametric tests for the analysis of cross-over trials.

The main advantage of cross-over designs in practice is the use of a smaller number of subjects to produce treatment comparisons with sufficient precision. Bellavance and Tardif proposed a non-parametric approach to test the hypotheses of direct treatment and carry-over effects for the three-treatment three-period and six sequences cross-over design and showed the high asymptotic efficiency of their approach relative to the classical F-test based on ordinary least squares (OLS). In a more recent paper, Ohrvik suggested another non-parametric method for the analysis of cross-over trials. The power of these two non-parametric approaches is evaluated for small sample sizes via simulations, and compared to the power of the usual analysis of variance model based on OLS and a modified F-test approximation that take into account the correlation structure of the repeated measurements within subjects. Different covariance structures, sample sizes, and probability distributions for the responses, namely normal and gamma, are used in the simulations to evaluate the power and robustness of these different methods of analysis.

Pharmacokinetics of morphine and its glucuronidated metabolites in burn injuries.

OBJECTIVE: To investigate the effects of major thermal burn injury and continuous intravenous morphine infusion on the disposition of morphine and its glucuronidated metabolites, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) once a week for three weeks. CASE SUMMARIES: Five patients with major first-, second-, or third-degree burn injuries received long-term intravenous morphine infusion. The required dose varied greatly (from 4 to 39.5 mg/h). The steady-state concentrations of morphine, M3G, and M6G ranged from 20 to 452, 29 to 3436, and 20 to 1240 mumol/L, respectively. The systemic clearance (Cls) of morphine ranged from 14.8 to 40.3 mL/min/kg and did not change over time. The ratios of M6G and M3G to morphine were not affected by dose, even with the wide variation of intravenous dosage. Morphine kinetics appeared to be first-order. Mean recovery of morphine, M3G, and M6G in urine was 1.7 +/- 1.0%, 42.0 +/- 16.8%, and 11.8 +/- 3.2%, respectively, and renal clearance ranged from 8 to 64, 26 to 325, and 59 to 589 mL/min, respectively. Mean pain intensity ratings at rest remained low and stable (0.7 +/- 0.9 on day 7, 0.4 +/- 0.3 on day 14, 0 +/- 0 on day 21). DISCUSSION: To our knowledge, this is the first published report describing morphine, M3G, and M6G disposition in patients with major thermal burn injury. The Cls of morphine is similar to that observed in other patient populations and healthy subjects, suggesting that the presence of major burn injuries or a continuous morphine infusion over a three-week period may not contribute significantly to the variability among individuals. In these cases, the renal clearance of morphine and its glucuronides was within the range of values reported for other populations of patients and healthy subjects. Recovery of morphine and its glucuronides in urine was also similar to that in healthy individuals. CONCLUSIONS: These cases suggest that the effects of major burn injuries and of long-term intravenous infusion of morphine did not seem to modify morphine, M3G, and M6G disposition. Among patients with burn injuries, the severity of burns of duration of administration are not a cause of nonlinear kinetic of morphine or of morphine resistance. The morphine infusion rate was substantially variable and not directly related to its clearance, suggesting that monitoring of morphine should be focused on the clinical response.

Prevalence and detection of delirium in elderly emergency department patients.

BACKGROUND: Delirium is a complex medical disorder associated with high morbidity and mortality among elderly patients. The goals of our study were to determine the prevalence of delirium in emergency department (ED) patients aged 65 years and over and to determine the sensitivity and specificity of a conventional clinical assessment by an ED physician for the detection of delirium in the same population. METHODS: All elderly patients presenting to the ED in a primary acute care, university-affiliated hospital who were triaged to the observation room on a stretcher because of the severity of their illness were screened for delirium by a research psychiatrist using the Mini-Mental State Examination and the Confusion Assessment Method. The diagnosis of "delirium" or an equivalent term by the ED physician was determined by 2 methods: completion of a mental status checklist by the ED physician and chart review. The prevalence of delirium and the sensitivity and specificity of the ED physician's clinical assessment were calculated with their 95% confidence intervals. The demographic and clinical characteristics of patients with detected delirium and those with undetected delirium were compared. RESULTS: A sample of 447 patients was screened. The prevalence of delirium was 9.6% (95% confidence interval 6.9%-12.4%). The sensitivity of the detection of delirium by the ED physician was 35.3% and the specificity, 98.5%. Most patients with delirium had neurologic or pulmonary diseases, and most patients with detected delirium had neurologic diseases. INTERPRETATION: Despite the relatively high prevalence of delirium in elderly ED patients, the sensitivity of a conventional clinical assessment for this condition is low. There is a need to improve the detection of delirium by ED physicians.

Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit.

STUDY OBJECTIVE: A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration in the emergency department for patients 65 years and older, predicts adverse health outcomes during the 6 months after the ED visit. In this study, we investigated whether the ISAR tool can also predict acute care hospital utilization in the same population. METHODS: Patients 65 years and older who visited the EDs of 4 acute care Montreal hospitals during the weekday shift over a 3-month period were enrolled. At the initial (index) ED visit, 27 self-report screening questions (including the 6 ISAR items) were administered. The number of acute care hospital days during the 6 months after the index visit were abstracted from the provincial hospital discharge database. High utilization was defined as the top decile of the distribution of acute care hospital days. RESULTS: Among 1,620 patients with linked data, a score of 2+ on the ISAR tool predicted high hospital utilization with a sensitivity of 73% and a specificity of 51%; the area under the receiver operating characteristic curve was 0.68. The ISAR tool also performed well in subgroups defined by disposition (admitted versus discharged) and by age (65 to 74 years versus 75 years and older). CONCLUSION: The ISAR tool, a 6-item self-report questionnaire, can be used in the ED to identify elderly patients who will experience high acute care hospital utilization as well as adverse health outcomes.

Tracking cognitive decline in Alzheimer's disease using the mini-mental state examination: a meta-analysis.

OBJECTIVES: To estimate the annual rate of change scores (ARC) on the Mini-Mental State Examination (MMSE) in Alzheimer's disease (AD) and to identify study or population characteristics that may affect the ARC estimation. METHODS: MEDLINE was searched for articles published from January 1981 to November 1997 using the following keywords: AD and longitudinal study or prognosis or cognitive decline. The bibliographies of review articles and relevant papers were searched for additional references. All retrieved articles were screened to meet the following inclusion criteria: (a) original study; (b) addressed cognitive decline or prognosis or course of AD; (c) published in English; (d) study population included AD patients with ascertainable sample size; (e) used either clinical or pathological diagnostic criteria; (f) longitudinal study design; and (g) used the MMSE as one of the outcome measures. Data were systematically abstracted from the included studies, and a random effects regression model was employed to synthesize relevant data across studies and to evaluate the effects of study methodology on ARC estimation and its effect size. RESULTS: Of the 439 studies screened, 43 met all the inclusion criteria. After 6 studies with inadequate or overlapping data were excluded, 37 studies involving 3,492 AD patients followed over an average of 2 years were included in the meta-analysis. The pooled estimate of ARC was 3.3 (95% confidence interval [CI]: 2.9-3.7). The observed variability in ARC across studies could not be explained with the covariates we studied, whereas part of the variability in the effect size of ARC could be explained by the minimum MMSE score at entry and number of assessments. CONCLUSIONS: A pooled average estimate of ARC in AD patients was 3.3 points (95% CI: 2.9-3.7) on the MMSE. Significant heterogeneity of ARC estimates existed across the studies and cannot be explained by the study or population characteristics investigated. Effect size of ARC was related to the initial MMSE score of the study population and the number of assessments.

Return to the emergency department among elders: patterns and predictors.

OBJECTIVES: 1) To describe the pattern of return visits to the emergency department (ED) among elders over the six months following an index visit; 2) to identify the predictors of early return (within 30 days) and frequent return (three or more return visits in six months); and 3) to evaluate a newly developed screening tool for functional decline, Identification of Seniors At Risk (ISAR), with regard to its ability to predict return visits. METHODS: Subjects were patients aged 65 years or more who visited the EDs of four Canadian hospitals during the weekday shift over a three-month recruitment period. Excluded were patients who: could not be interviewed, due either to their medical conditions or to cognitive impairment, and no other informant was available; refused linkage of study data; or were admitted to hospital at the initial (index) visit. Measures made at the index ED visit included: 27 self-report screening questions on social, physical, and mental risk factors, medical history, use of hospital services, medications, and alcohol. Six of these questions comprised the ISAR scale. Return visits and diagnoses during the six months after the index visit were abstracted from the utilization database. RESULTS: Among 1,122 patients released from the ED, 492 (43.9%) made one or more return visits; 216 (19.3%) returned early and 84 (7.5%) returned frequently. Earlier returns were more likely than later returns to be for the same diagnosis (p = 0.003). Using logistic regression, hospitalization during the previous six months, feeling depressed, and certain diagnoses predicted both early and frequent returns. Also, a history of heart disease, having ever been married, and not drinking alcohol daily predicted early return; a history of diabetes, a recent ED visit, and lack of support predicted frequent use. CONCLUSIONS: In the first month after an ED visit, return rates are highest and are more likely to be for the same diagnosis. Both medical and social factors predict early and frequent returns to the ED; patients at increased risk of return can be quickly identified with a short, self-report questionnaire. The ISAR screening tool, developed to identify patients at increased risk of functional decline, can also identify patients who are more likely to return to the ED.

Outcomes in a referral cohort of patients with anxiety disorders.

This study describes 6- and 12-month outcomes in a referral cohort with anxiety disorders and identifies treatment and prognostic factors related to these outcomes. Patients were recruited at three general hospital clinics, two psychologist-run clinics, and one psychiatric hospital clinic. Outcomes included severity of symptoms, physical and mental health status, and subjective global change in problem severity. Of 254 patients eligible for follow-up, 165 (65.0%) completed a follow-up questionnaire. Methods of treatment included consultation with return to the primary care physician (38.2%); or continued treatment at the clinic, with medications (16.4%), psychotherapy (22.4%), or both (23.0%). Both severity of symptoms and mental health status improved but remained abnormal at follow-up. In multiple logistic regression, subjective global improvement was related to a diagnosis of panic disorder only, treatment with psychotherapy, and type of referral. Change over time in symptom severity was related to clinic type, and change over time in mental health was related to clinic type and duration of previous treatment.

Feasibility and effectiveness of treatments for depression in elderly medical inpatients: a systematic review.

To determine the feasibility and effectiveness of treatments for depressed elderly medical inpatients, MEDLINE was searched for potentially relevant articles published from January 1987 to August 1997, using the keywords "depression or depressive disorder" (exploded) and "aged." The bibliographies of relevant articles were searched for additional references. Fifteen reports met the following inclusion criteria: (a) published in English or French; (b) minimum age criterion of 55 and over or mean age 65 and over; (c) subjects admitted to the medical service of an acute care hospital; (d) used accepted criteria for depression; (e) examined treatment(s) for depression; and (f) reported outcomes as a depression diagnosis and/or symptom level. Information was abstracted independently from each article by two reviewers, tabulated, and compared. The limited evidence suggests contraindications to treatment in 38% to 87% of subjects who received a heterocyclic antidepressant compared to 4% of subjects who received the selective serotonin reuptake inhibitor (SSRI) fluoxetine; rates of discontinuation and study completion were similar for heterocyclics, the SSRIs, and psychostimulants. All of the treatments (including social support/psychotherapy) appeared to be at least modestly effective in the short term.

First lifetime back pain and psychiatry treatment: psychological factors and recovery in compensated workers.

The role of psychological factors in recovery from first lifetime low back pain (LBP) was explored in this study. Consecutive clients from one physiatry clinic in Montreal who had LBP of less than 3 months' duration, were on sick leave and receiving workers' compensation benefits, and reported the current event as first lifetime LBP were enrolled. Psychological factors that fluctuate with current events (Psychiatric Symptom Index) and remain stable over time (General Well Being Scale) were assessed. Outcomes were late return to work (> 31 days) and 1 year incidence of compensated recurrence. Results from two multivariate models indicated lower psychological distress predicted late return to work, and higher well being, higher aggressiveness, and lower anxiety predicted compensated recurrence. Researchers concluded psychological factors do not impact clients with all types of LBP in the same way. For individuals lacking prior LBP experience, better psychological functioning increased lengthy work absence. Thus, awareness of the clients' psychological profiles and previous LBP experiences may benefit recovery.

Characteristics and treatment of women with antenatal and postpartum depression.

OBJECTIVE: Investigations of the efficacy of treatment for non-psychotic pregnancy-related mood disorders are scarce. Thus, a prospective, longitudinal study of six months duration, involving ninety-six index cases and forty-five healthy women as a reference group, was implemented to determine the response of mood, parenting stress and dyadic adjustment to an eclectic management. METHOD: In this naturalistic study, the index cases were offered treatment consistent with their symptoms, context, and level of compliance. All women received individual psychotherapy combining strategies from Interpersonal and Cognitive Behavioral Psychotherapy and/or Marital Interventions and Pharmacology. Rating scales (Dyadic Adjustment Scale, Hamilton Rating Scale for Depression, Edinburgh Postnatal Depression Scale, Child Stress Inventory) scored monthly, were used to measure the response to treatment over time. RESULTS: Depressive symptoms are generally alleviated by the second to third month of treatment. Dyadic discord accentuated by traditional sex role expectations and child care stress exacerbated by low self-esteem persisted throughout the trial at levels significantly different from the untreated reference group. CONCLUSIONS: Short-term interventions are cost-effective for the relief of mood disorders. However, creative solutions, during an era of economic restraints, are required to extend treatment sufficiently to address couple conflicts and facilitate the transition to parenthood for index cases.

Validity of an activities of daily living questionnaire among older patients in the emergency department.

The objective of this study was to determine the validity of French and English versions of the Older American Resources and Services (OARS) activities of daily living (ADL) questionnaire using a premorbid reference period among older emergency department (ED) patients. A sample of 404 ED patients aged 65 and over participating in a study of functional decline was invited to participate in a clinical assessment shortly after their ED visit. The OARS ADL questionnaire was administered either to the patient or a proxy informant at the ED visit. The clinical assessment was conducted by a nurse, blind to the OARS score, using the Functional Autonomy Measurement System (SMAF). Disability scores for the OARS and SMAF were computed, based on the patient's premorbid status. Assessments were conducted in 213 patients (52.7%). The OARS summary scores, a total and an ordinal score, were highly correlated with the SMAF total disability score (Spearman's r of 0.80 and 0.79, respectively). Similar correlations were found for French and English versions. The OARS ADL questionnaire with a premorbid reference period appears to be valid when administered in the ED, both in French and English.

Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool.

OBJECTIVES: To develop a self-report screening tool to identify older people in the emergency department (ED) of a hospital at increased risk of adverse health outcomes, including: death, admission to a nursing home or long-term hospitalization, or a clinically significant decrease in functional status. DESIGN: Prospective (6-month) follow-up study of a cohort of ED patients aged 65 and older. SETTING: The EDs of four acute-care hospitals in Montreal, Quebec, Canada. PARTICIPANTS: Community-dwelling patients aged 65 and older who came to the EDs during the weekday shift over a 3-month recruitment period. Patients were excluded if they could not be interviewed either because of their medical condition or because of cognitive impairment and no other informant was available. MEASUREMENTS: Measures ascertained at the ED visit included: 27 self-report screening questions on social, physical, and mental risk factors; medical history; use of hospital services, medications, and alcohol; and the Older American Resources and Services (OARS) activities of daily living (ADL) scale. At follow-up, the OARS scale was readministered by telephone, and other adverse health outcomes were ascertained. RESULTS: Among 1673 patients who completed the follow-up measures, 488 (29.2%) had an adverse health outcome. Scale development and selection methods included logistic regression, receiver operating characteristic curves, and expert judgment. The proposed screening tool (ISAR) comprises six self-report questions on functional dependence (premorbid and acute change), recent hospitalization, impaired memory and vision, and polymedication. The tool performed well in the total cohort aged 65 and older, and in sub-groups defined by disposition (admitted or released from ED), language of questionnaire administration (French or English), information source (patient or other), and other characteristics. CONCLUSIONS: The ISAR is a short self-report questionnaire that can quickly identify older patients in the ED at increased risk of several adverse health outcomes and those with current disability.

Prognosis of depression in elderly community and primary care populations: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this study was to determine the prognosis of depression in elderly community and primary care populations. METHOD: MEDLINE and PsycINFO were searched for potentially relevant articles published from January 1981 to November 1996 and from January 1984 to November 1996, respectively. The bibliographies of relevant articles were searched for additional references. Twelve studies met the following five inclusion criteria: original research, published in English or French, study population of community residents or primary care patients, subjects' mean age 60 years and over, and reported affective state as an outcome. The validity of the studies was assessed according to the criteria for prognostic studies described by the Evidence-Based Medicine Working Group. Information about the population, proportion of depressed subjects detected and treated by primary care physicians, length of follow-up, outcomes, and prognostic factors was systematically abstracted from each report. RESULTS: All of the studies had some methodologic limitations. A meta-analysis of outcomes at 24 months estimated that 33% of subjects were well, 33% were depressed, and 21% had died. There was statistically significant heterogeneity in the outcomes across studies. The length of follow-up and lower age limit for enrollment explained part of the heterogeneity for the percent well but not for the other outcomes. Physical illness, disability, cognitive impairment, and more severe depression were associated with worse outcomes but inconsistently so. CONCLUSIONS: Depression in elderly community and primary care populations has a poor prognosis, is perhaps chronic or relapsing or both, and is probably undertreated. Despite the methodologic limitations of the studies and this meta-analysis, these findings seem to support efforts to develop detection and treatment programs for depression in these populations.

Low incidence of severe adverse effects after mandibular ridge reconstruction using hydroxylapatite.

The short and long term adverse effects after ridge reconstruction using hydroxylapatite (HA) are presented in this study. The HA was inserted using a modified tunnelling technique, followed by a lowering of the floor of the mouth and a vestibuloplasty using split thickness skin graft, 4-6 weeks later. The study comprised 637 patients followed for a period of 1 to 10 years (mean 6.0+/-2.6 years). Major loss of HA was seen in 17 patients (2.7%). Donor site visibility (skin graft) appeared to improve greatly over the years from 29.2% to 8.8% at the latest follow-up. Neurosurgery deficits also improved from 11.6% (paraesthesia and dysaesthesia) to 4.6%. Long term follow-up revealed a high percentage of patient satisfaction (97%), indicating that the low incidence of severe adverse effects of the procedure does play a significant role in the appreciation of the procedure and prosthetic care.

Sensitivity to CCK-4 in women with and without premenstrual dysphoric disorder (PMDD) during their follicular and luteal phases.

The authors determined whether women with premenstrual dysphoric disorder (PMDD) exhibit a heightened sensitivity to the panicogenic effects of CCK-4 administration and whether this enhanced sensitivity to CCK-4 would vary with the phase of the menstrual cycle at the time of CCK-4 injection. Twenty-one normal controls and 18 PMDD women were randomly assigned to receive the first and second CCK-4 injection during the follicular phase and the luteal phase or vice versa. PMDD women showed a greater anxiety and panic response to CCK-4. These preliminary results suggest that the CCK-B system may play a role in the pathophysiology of PMDD.

Screening for geriatric problems in the emergency department: reliability and validity. Identification of Seniors at Risk (ISAR) Steering Committee.

OBJECTIVE: To determine the test-retest reliability and concurrent criterion validity of a self-report ED screening questionnaire for adverse outcomes in elders. METHODS: A cohort of 1,885 patients aged > or = 65 years were recruited from the EDs of 4 Montreal hospitals. Patients were excluded if they could not be interviewed because of their clinical status or cognitive impairment and no informant was available. The screening questionnaire, administered in the ED, contained 27 items on social, physical, and mental risk factors, medical history, and use of hospital services, medications, and alcohol. A random sample of 404 patients were invited to participate in a clinical assessment 1-3 weeks after the ED visit, that included re-administration of the screening questionnaire, and standardized instruments to assess disability, social resources, depression, alcohol use and abuse, and current medications. RESULTS: Study data were collected from 221 patients (54.7%), of whom 193 were included in the test-retest reliability analyses and 213 in the analyses of concurrent validity. The concordance correlation coefficient for test-retest reliability of the risk factor score was 0.78 (95% confidence interval: 0.71, 0.83; n=193). Several screening questions showed moderately good agreement with the appropriate criterion standard, particularly those on visual and hearing impairment, depression, and use of medications. The best subset of 9 screening questions explained approximately half of the variance in the total disability score. CONCLUSIONS: The screening questionnaire score has good test-retest reliability, but individual screening questions have, at best, modest concurrent validity. The final set of screening questions should be selected based on their predictive validity.