Case Presentation: 67-year-old gentleman with medical history significant for alcohol use presented to the Emergency Department (ED) with hallucinations and tremors. His last drink was the day prior. In the ED, he was tremulous, tachycardic, hypertensive and confused. He was admitted and placed on the alcohol withdrawal protocol with diazepam. At discharge, he was evaluated by occupational therapy (OT) using the Saint Louis University Mental Status Examination (SLUMS) with an interpreter in his first language (Oromo). During the evaluation, he was unable to complete the examination. He completed 18 components out of 30, and scored 3 out of the 18 completed. OT recommended 24-hour assist. He declined placement and inpatient chemical dependency treatment. The primary team, using an in-person interpreter, assessed and determined him to have the capacity to make the decision to discharge home. Other team members including care management differed, stating that he did not have capacity due to the low SLUMS score. Psychiatry was consulted for a second opinion, and they re-affirmed that he had capacity. He was discharged home on naltrexone with addiction medicine follow up.
Discussion: This case highlights the use of the SLUMS examination inpatient for discharge decision making and in patients of non-English speaking, immigrant, and low literacy backgrounds. Tools for mental status examinations are used to assess impaired memory and cognition to identify the need for comprehensive testing¹. One such tool is the SLUMS, which tests areas of attention, orientation, memory, and executive function on a 30-point scale with a population study of primarily white males at a VAMC². The primary language of the SLUMS is English and although there are translations, there are many African languages without translations and require an interpreter. There are English words that may not translate into a patient’s native language, despite interpreter use, affecting a patient’s score. As an example, patients are asked to recall details from a story that references a “stockbroker,” Eurocentric names, and a United States (US) city as well as answer a math question involving the word “dozen”. Although the SLUMS score adjusts for less than High School education, there are cultural differences in education in the US versus outside the US that can impact a patient’s score. The patient’s experience was negatively impacted and discharge of this non-English speaking and low literacy African Immigrant patient was delayed due to the suboptimal use of the SLUMS score.
Conclusions: The SLUMS examination is used to screen for dementia and mild neurocognitive disorder and was studied in a primarily white population in an outpatient setting². Its application inpatient and in patients outside of the English speaking, US born patient is limited and should prompt a discussion among the hospital team prior to its use in making capacity and discharge decisions. The goal is to have a tool that accurately measures cognitive impairment with minimal cultural, educational, linguistic, and demographic differences. This case highlights the need to suspect cultural bias when assessing patients of non-English speaking, immigrant, or low literacy backgrounds.