Which late-stage Alzheimer’s patients should be referred for hospice care?
Morrison and Siu conducted a prospective cohort study of consecutive patients admitted with hip fracture or pneumonia to a single New York hospital over an 18-month period.5 Survival rates of 118 advanced dementia patients, defined by a GDS score of 6 or 7, were compared with survival rates of 98 patients without dementia. At 6 months, 42 (53%) of 80 pneumonia patients with end-stage dementia had died, compared with 5 (13%) of 39 cognitively intact patients with pneumonia (adjusted hazard ratio=4.6 [95% CI, 1.8–11.8]). At 6 months, 21 (55%) of 38 hip fracture patients with end-stage dementia had died, compared with 7 (12%) of 59 cognitively intact patients with hip fracture (adjusted hazard ratio=5.8 [95% CI, 1.7–20.4]). Of note, the end-stage dementia patients with hip fracture or pneumonia were 6 and 4 years older, respectively, than cognitively intact patients. In addition, the dementia patients were more likely to reside in nursing homes (82% vs 5% with hip fracture, 63% vs 5% with pneumonia). A palliative care plan was not identified for any of these patients during the admission.
TABLE
Prognostic factors and accuracy for 6-month survival in Alzheimer’s dementia
| CITATION | PROGNOSTIC FACTOR | PROGNOSTIC ACCURACY |
|---|---|---|
| NHO1,6 (1995) | (Medicare Guidelines) FAST stage 7a*; cannot walk without assistance; incontinence; no meaningful communication; comorbid infection, fever, pressure ulcers, or weight loss | Validity was comparable with clinical assessment by the attending |
| Luchins2 (1997) | FAST stage 7c** | Mean survival=3.2 mo |
| Hanrahan3 (1999) | FAST stage 7c† | Mean survival=4.1 mo 71% died in 6 mo |
| Mitchell4 (2004) | In nursing home residents with Cognitive Performance Score 5 or 6 | 70% risk of death within 6 months |
| Sum of hazard ratios of 12 MDS components≥12 | ||
| Morrison and Siu5 (2000) | GDS stage 6‡ or worse, age>70, hospitalized with hip fracture or pneumonia | ~ 53% died in 6 months |
| NHO, National Hospice Organization; FAST, Functional Assessment Staging Scale; GDS, Global Deterioration Scale. | ||
| *FAST stage 7a: speaks 5–-6 words per day, and still able to ambulate. | ||
| † FAST stage 7c: unable to walk without assistance; reached this stage in ordinal (stepwise) fashion; FAST stage 7b: speech limited to single word per average day; see www.hospice.org/pdf/webdementia.pdf for details about the FAST scale.6 | ||
| ‡ GDS stage 6: dependent in activities of daily living and unaware of recent events and experiences; forgets name of spouse or children. See www.geriatric-resources.com/html/gds.html for more details.7 | ||
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