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Combination of Factors Helps Estimate Prognosis for Patients with Advanced Dementia

CHICAGO A model has been created that can help determine the risk of death within six months for nursing home patients with advanced dementia, according to a study in the June 9 issue of The Journal of the American Medical Association (JAMA).

Accurately estimating the life expectancy of persons with advanced dementia is difficult and hinders palliative care, according to background information in the article. Prognostic information is important in guiding end-of-life decision-making and, in the United States, for determining hospice eligibility. Medicare beneficiaries must have an estimated life expectancy of less than 6 months to be eligible for hospice. A small proportion of patients admitted to hospice have dementia, in part because of the difficulty in predicting survival. Accurate prognostic tools have not been developed.

Susan L. Mitchell, M.D., M.P.H., of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and colleagues identified factors associated with the risk of death in 6 months in newly admitted nursing home residents with advanced dementia and created a practical risk score to predict survival in this population.

The study included all Medicare or Medicaid licensed nursing homes in New York and Michigan. Participants had advanced dementia and were admitted to New York nursing homes between June 1, 1994, and December 30, 1998 (n = 6,799), and to Michigan nursing homes from October 1, 1998, through July 30, 2000 (n = 4,631). The risk score was derived in the New York population and validated in the Michigan population. The patient characteristics that were evaluated are routinely collected in nursing homes in the United States and some other countries as part of the Minimum Data Set.

The variables that were found to have prognostic value and were included in the final model were: Activities of Daily Living score of 28, male sex, cancer, the need for oxygen therapy, congestive heart failure, shortness of breath, no more than 25 percent of food eaten at most meals, an unstable condition, bowel incontinence, bedfast, older than 83 years, and not awake most of the day. Patients that had more of these variables (higher risk score) had a higher risk of death within six months.

" the risk score derived in this study offers a practical approach for estimating with reasonable accuracy the 6-month prognosis of older nursing home residents with advanced dementia," the authors write. "Our risk score offers an improvement over existing prognostic guidelines used in this population because it is based on empiric data, has greater predictive power, and uses standardized, readily available Minimum Data Set assessments."

(JAMA. 2004;291:2734-2740. Available at JAMA.com)

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