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The MDS-CHESS scale: a new measure to predict mortality in institutionalized older people
Abstract
OBJECTIVES: To develop a scale predicting mortality and other adverse outcomes associated with frailty. DESIGN: Observational study based on Minimum Data Set (MDS) 2.0 and mortality data. SETTING: Ontario chronic hospitals. PARTICIPANTS: All chronic hospital patients (N = 28,495) assessed with the MDS 2.0 after mandatory implementation in July 1996 followed until May 1999. MEASUREMENTS: MDS 2.0 assessments done as part of normal practice mainly by registered nurses or multidisciplinary teams in a chronic hospital. Mortality data are available from the accompanying discharge tracking form. RESULTS: The MDS‐Changes in Health, End‐stage disease and Symptoms and Signs (CHESS) score is a composite measure addressing changes in health, end‐stage disease, and symptoms and signs of medical problems. It is a strong predictor of mortality ( P < . 0001) independent of the effects of age, sex, activities of daily living impairment, cognition, and do‐not‐resuscitate orders. It is also strongly associated with physician activity, complex medical procedures, and pain ( P < . 001 for each dependent variable). CONCLUSIONS: The CHESS score provides a useful new MDS‐based test to predict mortality and to measure instability in health as a clinical outcome.
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“Frail older people receiving inpatient CGA are more likely to return home, less likely to experience cognitive or functional decline and have lower in-hospital mortality (111).”
From Frailty in elderly people (2013) · cites this paper as [111]
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“The process, provided it is closely linked to interventions, is associated with superior outcomes (111)”
From Frailty in elderly people (2013) · cites this paper as [111]
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“0: the MDS Depression Rating Scale (DRS) [91,92]; the Cognitive Performance Scale (CPS) [93-95]; and, the Changes in Health, Endstage disease Symptoms & Signs Scale (CHESS) [96].”
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Self-citationFisher, K., Seow, H. Y., Cohen, J., Declercq, A., Freeman, S., & Guthrie, D. M. (2014) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2014.08.008 · Cited by 37
“Health instability and illness severity were measured using the Changes in Health, End-stage disease and Signs and Symptoms (CHESS) scale, which identifies individuals at risk of serious health decline/mortality.(40)”
MethodRurality and Nursing Home Quality: Results from a National Sample of Nursing Home Admissions
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Trajectory of End-of-Life Pain and Other Physical Symptoms among Cancer Patients Receiving Home Care
Seow, H. Y., Guthrie, D. M., Stevens, T., Barbera, L. C., Burge, F., McGrail, K. M., Chan, K., Peacock, S. J., & Sutradhar, R. (2021) · Current Oncology · doi:10.3390/curroncol28030153 · Cited by 35
“Other non-pain-related physical symptoms included (i) shortness of breath; (ii) delirium; (iii) experienced one or more falls; (iv) ulcers; (v) constipation; (vi) high health instability defined as a score of ≥4 out of 5 on the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS)) [18]; (vii) loss o…”
BackgroundInfluentialPredictors for Unplanned Hospitalization of New Home Care Clients
Rönneikkö, J. K., Mäkelä, M., Jämsen, E., Huhtala, H., Finne‐Soveri, H., Noro, A., & Valvanne, J. (2016) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14486 · Cited by 35
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“We also included the Changes in Health and End-Stage Signs and Symptoms (CHESS) Scale as a measure of clinical instability [15].”
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The wish to die among palliative home care clients in Ontario, Canada: A cross-sectional study
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“Clinical summary scales, embedded within the interRAI PC, also include: Changes in Health, End-stage disease, and Signs and Symptoms (CHESS) scale, a measure of health instability ranging from 0 (no instability in health) to 6 (highly unstable health) [25]; Cognitive Performance Scale (CPS), measuring level of cogniti…”
MethodKerminen, H., Huhtala, H., Jäntti, P., Valvanne, J., & Jämsen, E. (2020) · BMC Geriatrics · doi:10.1186/s12877-020-01550-7 · Cited by 34
“35 188/231 (81) 1057/1957 (54) 188/1088 [17] 1057/1100 (96)”
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“Dyspnea, appetite problems and the ADL SHS score were eliminated because each of these directly relates to items used in calculating the CHESS score [41].”
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“In the ANCOVA, we adjusted for resident covariates of age, CPS, DRS and CHESS.”
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Implementing Frailty Measures in the Canadian Healthcare System
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Self-citationNutritional status and delirium in long-term care elderly individuals
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Deprescribing in Nursing Home Residents on Polypharmacy: Incidence and Associated Factors
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“The CHESS scale ranges from zero to five, where high CHESS levels have been independently associated with greater likelihood of an adverse event and greater risk of mortality in home care populations (Doran et al., 2013; Hirdes, Frijters, & Teare, 2003; Hirdes et al., 2014).”
Self-citationAssociation between oral health and general health indicators in older adults
Tran, T. D., Krausch‐Hofmann, S., Duyck, J. A. J., Mello, J. D. A., Lepeleire, J. D., Declerck, D., Declercq, A., & Lesaffre, E. M. E. H. (2018) · Scientific Reports · doi:10.1038/s41598-018-26789-4 · Cited by 31
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“The following inter-RAI scales are utilized in this study: Changes in Health, End-stage disease and Signs and Symptoms (CHESS) score (a measure of health instability) [23,24]; Activities of Daily Living Self-performance Hierarchy Scale [25,26]; Instrumental Activities of Daily Living Performance Scale [26,27]; Cogniti…”
MethodSelf-citationReliability of standardized assessment for adults who are deafblind
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“Higher scores on the CHESS are associated with reduced survival over time [11–12].”
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“The Changes in Health, End-Stage Disease and Symptoms and Signs (CHESS) scale, which is a MDS composite measure of clinical instability and predicts adverse outcomes including mortality among NH residents, was used as a summary case-mix control [20].”
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“†CHESS = Changes in Health, End-stage disease, Signs and Symptoms Scale [23].”
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“Scores on the CHESS range from 0 (no instability in health) to 5 (highly unstable health) (Hirdes et al., 2003).”
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Cable-Williams, B. E., & Wilson, D. M. (2014) · International Journal of Older People Nursing · doi:10.1111/opn.12045 · Cited by 30
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“This study used the following validated scales and algorithms from the interRAI Home Care assessment: Activities of Daily Living Hierarchy Scale (ADLH) ranges from 0 to 6 with higher levels indicating greater difficulty in performing activities of daily living [26]; Cognitive Performance Scale 2 (CPS2) ranges from 0 t…”
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“Higher CHESS scores predict mortality, institutionalization and hospitalization in older adults across care settings.(29,36,37) The MAPLe differentiates clients into five priority levels (low to very high) based on level of cognitive and ADL impairment, behavioural issues, environmental concerns and self-reliance.”
BackgroundSelf-citationAligning policy objectives and payment design in palliative care
Duckett, S. J. (2018) · BMC Palliative Care · doi:10.1186/s12904-018-0294-4 · Cited by 28
“Importantly, the risk of death in a nursing home can be predicted reasonably well [123].”
BackgroundPotentially inappropriate management of depressive symptoms among Ontario home care clients
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“23 24 Furthermore, the use of tests of association for selecting predictor variables, data-driven categorisation or speci fi cation of functional form and stepwise variable selection procedures can result in models with an overstated predictive ability and increase the risk of type I error.”
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“…End-stage disease, and Signs and Symptoms ~CHESS! scale uses MDS 2.0 data to identify patients at risk for serious decline in health or mortality ~Hirdes et al., 2003!. Scoring is based on the presence of: vomiting, dehydration, weight loss, leaving 25% of food uneaten, and shortness of breath;…”
BackgroundInfluentialSelf-citationFoebel, A. D., Ballóková, A. L., Wellens, N. I. H., Fialová, D., Milisen, K., Liperoti, R., & Hirdes, J. P. (2015) · BMC Geriatrics · doi:10.1186/s12877-015-0127-8 · Cited by 26
“The Changes in Health, End-stage disease and Signs and Symptoms (CHESS) score provided information about instability of the health status [31].”
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“Variables for each level of the Changes in Health, End-Stage Disease and Symptoms and Signs (CHESS) scale, which is predictive of declining health, were also included (Hirdes, Frijters, and Teare 2003).”
BackgroundA profile of older community-dwelling home care clients with heart failure in Ontario
Foebel, A. D., Hirdes, J. P., Heckman, G. A., Tyas, S. L., & Tjam, E. Y. (2011) · Chronic diseases in Canada · doi:10.24095/hpcdp.31.2.01 · Cited by 25
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“Both the RAI-HC and the RAI-MDS 2.0 produce scales and other measures reported here, including the Cognitive Performance Scale (Morris et al. 1994), Activities of Daily Living Hierarchy Scale (Morris et al. 1999), Changes in Health, End-Stage Disease and Signs and Symptoms (CHESS) Scale (Hirdes et al. 2003), Depressio…”
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Regional variations of care in home care and long-term care: a retrospective cohort study
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InfluentialSelf-citationSun, W., Doran, D. M., Wodchis, W. P., & Peter, E. H. (2017) · BMC Health Services Research · doi:10.1186/s12913-017-2103-9 · Cited by 23
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“The CHESS scale is a measure of likelihood of mortality, ranging from 0 to 5, with higher scores indicating higher risk of death.(25) Lastly, we also included variables to indicate whether there were written physician orders to limit Vol.”
BackgroundRules to Identify Persons with Frailty in Administrative Health Databases
Urquhart, R., Giguere, A. M. C., Lawson, B. J., Kendell, C., Holroyd-Leduc, J. M., Puyat, J. H., Kazanjian, A., Straus, S. E., & Johnston, G. M. (2017) · Canadian Journal on Aging / La Revue canadienne du vieillissement · doi:10.1017/s0714980817000393 · Cited by 23
Levy, C. R., Kheirbek, R., Alemi, F., Wojtusiak, J., Sutton, B. S., Williams, A. R., & Williams, A. E. (2014) · Journal of Palliative Medicine · doi:10.1089/jpm.2014.0130 · Cited by 22
“These investigators examined nineteen diagnostic categories: (1) diabetes mellitus, (2) arteriosclerotic heart disease, (3) cardiac dysrhythmias, (4) congestive heart failure, (5) hypertension, (6) peripheral vascular disease, (7) stroke, (8) Alzheimer’s disease, (9) seizure disorder, (10) Parkinson’s disease, (11) ch…”
Guthrie, D. M., Williams, N., Beach, C., Maxwell, C. J., Mills, D. S., Mitchell, L. A., Reid, R. C., & Poss, J. W. (2020) · Journal of Applied Gerontology · doi:10.1177/0733464820920102 · Cited by 22
“The scale ranges from 0 (no instability) to 5 (severe health instability), and for each one-point increase on the CHESS scale, there is nearly a twofold increased risk of death (Hirdes et al., 2003).”
BackgroundBaseline Frailty as a Predictor of Survival After Critical Care
Turcotte, L., Zalucky, A. A., Stall, N. M., Downar, J., Rockwood, K. J., Theou, O., McArthur, C., & Heckman, G. A. (2021) · CHEST Journal · doi:10.1016/j.chest.2021.06.009 · Cited by 21
A Review of Health Surveillance in Older Adults with Intellectual and Developmental Disabilities
Ouellette-Kuntz, H. M. J., Martin, L., & McKenzie, K. (2015) · International review of research in developmental disabilities · doi:10.1016/bs.irrdd.2015.03.004 · Cited by 21
Maxwell, C. J., Vu, M., Hogan, D. B., Patten, S. B., Jantzi, M., Kergoat, M., Jetté, N., Bronskill, S. E., Heckman, G. A., & Hirdes, J. P. (2013) · Drugs & Aging · doi:10.1007/s40266-013-0083-y · Cited by 21
“Included were the following validated scales derived from assessment items: (1) Cognitive Performance Scale (CPS) (range 0–6) [48]; (2) Activities of Daily Living (ADL) Self-Performance Hierarchy Scale (range 0–6) [49]; (3) Changes in Health, End-stage Disease, and Signs and Symptoms (CHESS) Scale (a measure of health…”
MethodSelf-citationIsmail, Z., Arenovich, T., Granger, R., Grieve, C., Willett, P., Patten, S. B., & Mulsant, B. H. (2014) · International Psychogeriatrics · doi:10.1017/s1041610214002002 · Cited by 21
“The number of medical comorbidities was measured by the CHESS score, which was designed to provide a single, parsimonious summary variable rather than a collection of individual items (Hirdes et al., 2003).”
MethodSocial Engagement After Nursing Home Admission: Racial and Ethnic Disparities and Risk Factors
Bliss, D. Z., Harms, S. L., Eberly, L. E., Savik, K., Gurvich, O. V., Mueller, C., Wyman, J. F., & Virnig, B. A. (2015) · Journal of Applied Gerontology · doi:10.1177/0733464815617285 · Cited by 21
“The average mortality risk score (Hirdes et al., 2003) ranged from 1.3 in AIANs to 2.0 in APIs on a 6-point scale.”
BackgroundInfluentialVariation in Emergency Department Transfer Rates from Nursing Homes in Ontario, Canada
Gruneir, A., Bronskill, S. E., Newman, A. M., Bell, C. M., Gozdyra, P., Anderson, G., & Rochon, P. A. (2016) · Healthcare policy · doi:10.12927/hcpol.2016.24940 · Cited by 21
“0), a comprehensive clinical assessment tool (Hirdes et al. 2003; Morris et al. 1994, 1999) mandated for use in Ontario.”
BackgroundMethodInfluentialFernandes, S., Davidson, J. G. S., & Guthrie, D. M. (2017) · Palliative & Supportive Care · doi:10.1017/s1478951517000128 · Cited by 24
“A cutoff of 4 points or higher was chosen because of its strong ability to predict mortality (Hirdes et al., 2003).”
BackgroundMethodPredicting Future Health Transitions Among Newly Admitted Nursing Home Residents With Heart Failure
Heckman, G. A., Hirdes, J. P., Hébert, P. C., Morinville, A., Amaral, A. C. K.-B., Costa, A. P., & McKelvie, R. S. (2018) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2018.10.031 · Cited by 21
Self-citationThe MDS Challenging Behavior Profile for long-term care
Gerritsen, D. L., Achterberg, W. P., Steverink, N., Pot, A. M., Frijters, D. H. M., & Ribbe, M. W. (2008) · Aging & Mental Health · doi:10.1080/13607860701529882 · Cited by 20
Self-citationFactors Associated With Pharmacologic Treatment of Osteoporosis in an Older Home Care Population
Vik, S., Jantzi, M., Poss, J. W., Hirdes, J. P., Hanley, D. A., Hogan, D. B., & Maxwell, C. J. (2007) · The Journals of Gerontology Series A · doi:10.1093/gerona/62.8.872 · Cited by 20
“Our analyses also included four health index measures previously developed and validated for use with the RAI-HC tool: (i) the Activities of Daily Living (ADL) self-performance hierarchy scale (range 0–6) (27); (ii) the Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score (range 0–5) (28); (iii) t…”
MethodSelf-citationPoss, J. W., McGrail, K. M., McGregor, M. J., & Ronald, L. A. (2020) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2020.04.034 · Cited by 19
Using the “Surprise Question” in Nursing Homes
Rice, J., Hunter, L., Hsu, A. T., Donskov, M., Luciani, T., Toal-Sullivan, D., Welch, V. A., & Tanuseputro, P. (2017) · Journal of Palliative Care · doi:10.1177/0825859717745728 · Cited by 19
Trends in antipsychotic prescribing among long‐term care residents receiving hospice care
Gerlach, L. B., Fashaw‐Walters, S. A., Strominger, J., Ogarek, J. A., Zullo, A. R., Daiello, L. A., Teno, J. M., Shireman, T. I., & Bynum, J. (2021) · Journal of the American Geriatrics Society · doi:10.1111/jgs.17172 · Cited by 18
Outcomes of advance care directives after admission to a long-term care home: DNR the DNH?
Adekpedjou, R., Heckman, G. A., Hébert, P. C., Costa, A. P., & Hirdes, J. P. (2022) · BMC Geriatrics · doi:10.1186/s12877-021-02699-5 · Cited by 18
“Table 1 The CHESS Scale The CHESS scale: The RAI MDS 2.0 is completed by trained assessors.”
BackgroundMethodInfluentialSelf-citationHakkarainen, T. W., Ayoung-Chee, P. R., Alfonso, R., Arbabi, S., & Flum, D. R. (2014) · Journal of Surgical Research · doi:10.1016/j.jss.2014.06.002 · Cited by 20
“The MDS-MMRI predicts 6-mo mortality using 14 different variables and two interactions spanning demographic, disease process, clinical signs and symptoms, and adverse events.”
BackgroundMethodInfluentialKeller, H., Chambers, L. W., Fergusson, D. A., Niezgoda, H., Parent, M., Caissie, D., & Lemire, N. (2012) · Canadian Journal on Aging / La Revue canadienne du vieillissement · doi:10.1017/s0714980812000268 · Cited by 18
Factors Associated With Terminally Ill People Who Want to Die
Cheung, G., Martínez-Ruiz, A., Knell, R., O’Callaghan, A., & Guthrie, D. M. (2020) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2020.04.003 · Cited by 18
Deinstitutionalization in Ontario, Canada: Understanding Who Moved When
Martin, L., & Ashworth, M. (2010) · Journal of Policy and Practice in Intellectual Disabilities · doi:10.1111/j.1741-1130.2010.00261.x · Cited by 18
Luo, H., Lou, V. W. Q., Chen, C., & Chi, I. (2020) · The Gerontologist · doi:10.1093/geront/gny120 · Cited by 18
Stephens, C. E., Sackett, N. B., Govindarajan, P., & Lee, S. J. (2014) · BMC Geriatrics · doi:10.1186/1471-2318-14-35 · Cited by 17
“The MDS-Changes in Health, End-stage disease and Symptoms and Signs (CHESS) scale, was used to account for overall health status [40].”
MethodHUANG, T.-Y. J., Wei, Y. J., Moyo, P., Harris, I., Lucas, J. A., & Simoni‐Wastila, L. (2015) · Journal of the American Geriatrics Society · doi:10.1111/jgs.13606 · Cited by 19
“Functional status was measured using available MDS scales at baseline assessment, including physical function according to activity of daily living (ADL) status,(30) cognitive function according to the MDS Cognition Scale,(31) and relevant signs and symptoms according to the Changes in Health, End-Stage Disease and Sy…”
MethodFoebel, A. D., Hirdes, J. P., Lemick, R., & Tai, J. (2015) · AIDS Care · doi:10.1080/09540121.2015.1058893 · Cited by 17
“…scales are the Cognitive Performance Scale (CPS) (Morris et al., 1994), ADL Hierarchy Scale (Morris, Fries, & Morris, 1999), the pain scale, the Changes in Health, End-stage disease, and Signs and Symptoms (CHESS) Score (Hirdes et al., 2003, 2014), and the DRS (Burrows et al., 2000), respectively.”
MethodSelf-citationBlekken, L. E., Vinsnes, A. G., Gjeilo, K. H., Norton, C. S., Mørkved, S., Salvesen, Ø. O., & Nakrem, S. (2016) · Journal of Advanced Nursing · doi:10.1111/jan.12932 · Cited by 17
“Health instability (CHESS) showed a significant protective effect for FI.”
MethodInfluentialHirdes, J. P., Bernier, J., Garner, R., Finès, P., & Jantzi, M. (2018) · Quality of Life Research · doi:10.1007/s11136-018-1800-0 · Cited by 17
“interRAI assessments can be used to derive a variety of clinical scales that can be employed in cross-sector comparisons, including measures of depressive symptoms [6, 43], pain [14], functional status [35], frailty and health instability [2, 21, 25], and cognition [34].”
BackgroundSelf-citationDoran, D. I., Hirdes, J. P., Blais, R., Baker, G. R., Poss, J. W., Li, X., Dill, D., Gruneir, A., Heckman, G. A., Lacroix, H., et al. (2013) · Healthcare policy · doi:10.12927/hcpol.2013.23468 · Cited by 17
Self-citationCai, S., Miller, S. C., & Mukamel, D. B. (2016) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14284 · Cited by 21
“The CHESS score (range 0–5, higher scores indicating greater probability of death) is a measure of stability in health and reflects an individual’s frailty level.(28) Hospice enrollment during the last 30 day of life was also accounted for because hospice enrollment could affect the risk of EOL hospitalizations.”
Backgroundde Medeiros, P. A., Fortunato, A. R., Viscardi, A. A. D. F., Sperandio, F. F., & Mazo, G. Z. (2016) · Ciência & Saúde Coletiva · doi:10.1590/1413-812320152111.09912015 · Cited by 17
Egbujie, B. A., Turcotte, L., Heckman, G. A., & Hirdes, J. P. (2024) · Age and Ageing · doi:10.1093/ageing/afae264 · Cited by 16
Self-citationCognitive and Functional Decline Among Long-Term Care Residents
Hakimjavadi, R., Yin, C. Y., Scott, M., Talarico, R., Ramsay, T., Webber, C., Manuel, D. G., Moledina, A., Hsu, A. T., Fung, C., et al. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.5635 · Cited by 16
Qureshi, D., Schumacher, C., Talarico, R., Lapenskie, J., Tanuseputro, P., Scott, M., & Hsu, A. T. (2020) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2020.07.018 · Cited by 16
Stock, K. J., Hogan, D. B., Lapane, K. L., Amuah, J. E., Tyas, S. L., Bronskill, S. E., Morris, A. M., Bell, C. M., Jeffs, L. P., & Maxwell, C. J. (2017) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2017.02.013 · Cited by 16
Risk Factors Associated with Skin Tear Development in the Canadian Long-term Care Population
LeBlanc, K. A., Woo, K. Y., VanDenKerkhof, E. G., & Woodbury, M. G. (2020) · Advances in Skin & Wound Care · doi:10.1097/01.asw.0000717232.03041.69 · Cited by 16
Guthrie, D. M., Thériault, É. R., & Davidson, J. G. S. (2015) · Home Health Care Management & Practice · doi:10.1177/1084822315591812 · Cited by 16
“The Changes in Health, End-Stage Disease and Signs and Symptoms (CHESS) scale identifies clients who are at risk of health instability and has been found to be a significant predictor of mortality.(41) A cut-point of 2+ was chosen because this indicated that the client had at least two health conditions that would con…”
Background
Metadata
- Authors
- Hirdes, J. P., Frijters, D. H., & Teare, G. F.
- Affiliations
- University of Waterloo (CA)
- Vrije Universiteit Amsterdam (NL)
- University of Toronto (CA)
- Corresponding author
- Hirdes, John P.
- Venue
- Journal of the American Geriatrics Society
- Publisher
- Wiley
- Published
- 2003-01
- Volume
- 51
- Issue
- 1
- Pages
- 96-100
- ISSN
- 0002-8614 (ISSN-L)
- 1532-5415
- OpenAlex
- W1997637125
- Cited by
- 477
- References
- 20
- Citations by year
- 2026: 22 · 2025: 22 · 2024: 32 · 2023: 18 · 2022: 22 · 2021: 24 · 2020: 41 · 2019: 23 · 2018: 24 · 2017: 26 · 2016: 29 · 2015: 23 · 2014: 28 · 2013: 26 · 2012: 17
- FWCI
- 4.44
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of the American Geriatrics Society (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Geriatrics and Gerontology › Geriatric Care and Nursing Homes
- Keywords
- mortality prediction, frailty, institutionalized elderly, end-stage disease, symptoms and signs, activities of daily living, do-not-resuscitate orders, pain, nursing assessment
- MeSH terms
- Activities of Daily Living, Aged, Aged, 80 and over, Canada, Chronic Disease, Female, Humans, Institutionalization, Male, Middle Aged, Mortality, Severity of Illness Index, Geriatric Assessment, Comorbidity, Proportional Hazards Models, Frail Elderly
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