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New Standardized Risk Score Better Predicts 6 Month Mortality of Newly Admitted Nursing Home Patients with Advanced Dementia

New Standardized Risk Score Better Predicts 6 Month Mortality of Newly Admitted Nursing Home Patients with Advanced Dementia

Critique date: Wed, 01/12/2005 - 3:21pm
Institution: 
Mount Sinai School of Medicine
   
Article Citation
Citation: 
Mitchell S, Kiely D, Hamel M, Park P, Morris J and Fries B . Estimating Prognosis for Nursing Home Residents with Advanced Dementia. JAMA. 2004;291:2734-2740.
   
Clinical Bottom Lines

A risk score based on 12 variables from the MDS estimates 6-month mortality for nursing home residents with advanced dementia with greater accuracy than existing prognostic guidelines.

   
Methods
Type of Study: 
Clinical Prediction Rule
Study Design: 
Cohort study
Setting: 
Nursing home
Patient Population: 

Derivation Cohort: 6,799 patients >65 years with advanced dementia (> 83 yr: 45.2%; Female: 66.8%; Nonwhite: 20.1%; completely functionally dependent: 25.7%) admitted to New York State nursing homes between June 1, 1994 and December 30, 1998. Validation Cohort: 4,631 like patients admitted to similar facilities in Michigan from October 1, 1998 through July 30, 2000.

 

Inclusions

>65 years; MDS assessment at admission to Medicare or Medicaid licensed nursing home in either NY or Michigan; advanced dementia defined as a diagnosis of dementia and a Cognitive Performance Score of 5 or 6 (severe or very severe impairment with eating problems; corresponds to a Mini-Mental State Examination score of < 5).

Intervention/Exposure: 

Bivariate analysis of multiple demographic, functional status, diagnostic, and other health condition variables from the MDS, not including specific treatments like tube feeding or advance directives. The MDS contains information on each resident's functional, psychologic and social status and are required on admission.

Outcome Measures: 

 Survival time

   
Conclusion
Results: 

6 month mortality: Derivation Cohort -28.3%; Validation Cohort -35.1%

Clinical Prediction Rule: 6 month Mortality

Characteristic

HR*

Points

Score***

 

(95% CI)

 

 

Complete Functional Dependence**

1.9 (1.7-2.1)

1.9

 

Male sex

1.9 (1.7-2.1)

1.9

 

Cancer

1.7 (1.5-1.9)

1.7

 

Oxygen therapy

1.6 (1.4-1.8)

1.6

 

CHF

1.6 (1.4-1.7)

1.6

 

Shortness of breath

1.5 (1.3-1.9)

1.5

 

<25% food eaten

1.5 (1.4-1.7)

1.5

 

Unstable medical conditions

1.5 (1.3-1.6)

1.5

 

Bowel incontinence

1.5 (1.3-1.7)

1.5

 

Bedfast

1.5 (1.3-1.7)

1.5

 

³83 years (median)

1.4 (1.3-1.6)

1.4

 

Not awake most of day

1.4 (1.2-1.6)

1.4

 

Total Risk Score, Rounded to Nearest Integer

Possible Range 0-19

 

*Multivariate Proportional Hazards Model of Characteristics Associated with 6-Month Mortality Among Residents with Advanced Dementia in the Derivation Cohort (n-6799)

**Complete functional dependence in bed mobility, dressing, using the toilet, transfer, eating, grooming, and locomotion

***Column indicates that a provider can compute a total risk score for each patient, which corresponds to a risk estimate of death within 6 months (see table below).

 

If Total Risk Score is...

Risk Estimate of Death with 6 Months

0

8.9%

1 -2

10.8%

3- 5

23.2%

6- 8

40.4%

9- 11

57%

> 12

70%

 
Concerns Regarding Methodology, Applicability to Older Adults, etc.: 
  • As per authors:
    • The prognostic model was derived in a population of older persons with advanced dementia who were recently admitted to a nursing home. Therefore, the risk score may not be generalizable to residents who have lived in nursing homes for longer periods or for those living in the community.
    • By using admission data to predict death within 6 months, changes in health status during the interim period that may influence survival could not be accounted for.
    • There may not have been adequate power to demonstrate statistically significant associations between uncommon conditions (eg, septicemia) and 6-month mortality.
    • The risk score was derived and validated with data collected retrospectively. Prospective validation would be helpful to further assess the usefulness of the risk score in clinical practice.
  • Treatment decisions that could affect survival, such as advance directives or tube feeding, were not considered as variables.
Funding Source and Role: 
Hebrew Rehabilitation Center for the Aged (HRCA) Research and Training Institute, Teaching Nursing Home Award and the Harvard Older American Independence Center Grant from the National Institute on Aging. No role in design, conduct of study; collection, analysis, interpretation of the data; preparation, review or approval of the manuscript.
Created By: 
Rengena Chan-Ting, Second-Year Fellow, Mt. Sinai School of Medicine
This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.