Busra Canbaz, MD Gunes Arik, MD Gozde Sengul Aycicek, MD Ozgur Kara, MD Fatih Sumer, MD Zekeriya Ulger, MD Division of Geriatrics, Department of Internal Medicine, Gazi University, Ankara, Turkey ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed equally to this letter. Sponsor’s Role: None. REFERENCES 1. Provencher V, Sirois MJ, Ouellet M-C et al. Decline in activities of daily liv- ing after a visit to a Canadian emergency department for minor injuries in independent older adults: Are frail older adults with cognitive impairment at greater risk? J Am Geriatr Soc 2015;63:860–868. 2. Hustey FM, Meldon SW, Smith MD et al. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 2003;41:678–684. 3. Han JH, Zimmerman EE, Cutler N et al. Delirium in older emergency department patients: Recognition, risk factors, and psychomotor subtypes. Acad Emerg Med 2009;16:193–200. RESPONSE TO CANBAZ AND COLLEAGUES To the Editor: In Canbaz and colleagues’ thoughtful com- ments 1 on our recent article, 2 they noted that, even with- out a precipitating trauma, older adults may experience functional decline over time. They thus questioned the absence of a control group to support that the observed decline was the result of injuries that would not have happened otherwise. We would like to clarify that our hypothesis was not to prove that trauma was the reason for the observed new activity of daily living (ADL) dis- abilities but was rather that older adults who developed these disabilities after injuries are frailer and more cogni- tively impaired than those who did not. Nonetheless, a substudy was conducted (manuscript in preparation) com- paring ADL disabilities over time in older adults with injuries and those with medical conditions (matched on age, sex, baseline ADL function, comorbidities, frailty) discharged from emergency departments (EDs). Prelimi- nary results indicate that new disabilities in both groups were similar but that individuals with medical conditions were more fearful of falling, more likely to use a walking aid, and more likely to use the ED and had much less social support than injured older adults. Canbaz and colleagues also state that delirium is common in EDs, which we completely agree with. Delir- ium was an exclusion criterion in the study. This was more clearly stated in other studies from our team. 3,4 In addition, because all subjects were fit for discharge home from the ED, the risk of missclassifying individuals with delirium as having persistent cognitive impairment was minimal. To answer the question about possible misclassification due to the Montreal Cognitive Assessment (MoCA) cutoff (23/30) used for in-person evaluations, Table 1 compares the initial published risk ratios (RRs) with those found when a MoCA cutoff of 21 is used and shows that the results were very similar to the initial findings. 2 Twenty- three percent of older adults were below this, which is com- parable to the 25.4% of older adults evaluated in telephone interviews (Modified Telephone Interview for Cognitive Status (TICS-m) cutoff 31/50). We believe that our findings of greater risk of new ADL disabilities with increasing frailty and cognitive impairment are valid. Unfortunately, separate comparative analyses on MoCA and TICS-m sub- sets could not be performed adequately. With fewer sub- jects (MoCA subset especially) and given the number of parameters to be estimated, we encountered convergence failures of the multivariate models. We thank Canbaz and colleagues for their interest in our work and hope exchanges like this will continue to help improve research in EDs that are engaged in improving care of older adults. Marie-Jos ee Sirois, PhD Facult e de Medicine, Universit e Laval, Qu ebec, Qu ebec, Canada Centre de Recherche, Centre Hospitalair Universitaire de Qu ebec, Qu ebec, Qu ebec, Canada V eronique Provencher, PhD Sherbrooke University, Sherbrooke, Qu ebec, Canada Table 1. Comparison of Montreal Cognitive Assess- ment (MoCA) Cutoff of 23/30 in Provencher and Col- leagues 1 with MoCA Cutoff of 21/30 in the Same Data Set Participant Status MoCA Cutoff 23/30 MoCA Cutoff 21/30 Risk Ratio (95% Confidence Interval) a 3 months Frail with cognitive impairment 1.89 (1.38–2.59) 1.90 (1.36–2.65) Frail without cognitive impairment 1.47 (1.00–2.15) 1.59 (1.12–2.26) Nonfrail with cognitive impairment 1.09 (0.77–1.54) 1.22 (0.86–1.75) 6 months Frail with cognitive impairment 2.09 (1.45–3.00) 1.99 (1.35–2.92) Frail without cognitive impairment 1.78 (1.15–2.74) 1.90 (1.35–2.92) Nonfrail with cognitive impairment 1.49 (1.04–2.13) 1.64 (1.14–2.35) Reference group confrail without cognitive impairment. a Adjusted for age, comorbidities, and baseline instrumental activity of daily living status. JAGS JANUARY 2016–VOL. 64, NO. 1 LETTERS TO THE EDITOR 241