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prognosis for patients with dementia

Indications: - mortality predictions may help inform conversations between clinicians, patients, & families regarding advance care planning & clinical decisions [12] * estimates the time horizon for making life decisions Etiology: Risk factors for progression of Alzheimer's disease (AD) - psychosis, agitation/aggression, affective symptoms [10] - cognitive decline is the strongest predictor of shorter life expectancy [11] - older age, male, white, motor symptoms, functional impairment, & neuropsychiatric symptoms also predict shorter life expectancy [11] Risk factors for 6 month mortality from Minimum Data Set (MDS) - activities of daily living - male sex - cancer - congestive heart failure - oxygen therapy needed in past 14 days - shortness of breath - loss of appetite (eats < 25% of food) - unstable medical condition - bowel incontinence - bedridden - age > 83 years - sleeps most of day * Score: 0-19 * MDS allegedly better than functional assessment staging (FAST) * ADEPT is marginally better than MDS [4] non-healing pressure ulcers in a setting of good supportive care most predictive of terminal stage [9] Epidemiology: Prognosis: - mean survival time after onset of dementia: - men: 4.1 years, - women: 4.6 years, - combined: 4.5 years (all ages) - onset 65-69 years of age: 10.7 years - onset >= 90 years of age: 3.8 years - advanced dementia & poor functional status: 1.3 years [6] Complications: - pneumonia is common cause of mortality - antibiotics do have survival benefit (HR=0.2-0.26), but do not improve symptoms or comfort [7] - advanced dementia is consistently associated with severe disablity [5] Management: - feeding tubes do not prolong survival in patients with advanced dementia [8] Notes: . telomere lenth? - increased mortality in patients with dementia correlates with lesser telomere length in peripheral blood leukocytes [4] (it is difficult to envision a mechanism)

Related

dementia; Alzheimer's disease & related dementias (ADRD) life expectancy

Specific

hospice guidelines for determining prognosis, dementia

General

prognosis

References

  1. Journal Watch 24(14):113-114, 2004 Mitchell SL, Kiely DK, Hamel MB, Park PS, Morris JN, Fries BE. Estimating prognosis for nursing home residents with advanced dementia. JAMA. 2004 Jun 9;291(22):2734-40. PMID: 15187055
  2. Honig LS et al, Shorter telomeres are associated with mortality in those with APOE epsilon4 and dementia. Ann Neurol 2006, 60:181 PMID: 16807921
  3. Xie J et al, Survival times in people with dementia. Analysis from population based cohort study with 14 year follow-up. BMJ 2008, Jan 10 PMID: 18187696
  4. Mitchell SL et al. Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA 2010 Nov 3; 304:1929 PMID: 21045099
  5. Gill TM, Gahbauer EA, Han L, Allore HG. Trajectories of disability in the last year of life. N Engl J Med 2010 Apr 1; 362(13):1173-1180. PMID: 20357280
  6. Mitchell SL et al The Clinical Course of Advanced Dementia N Engl J Med 2009, 361:1529 PMID: 19828530 http://content.nejm.org/cgi/content/short/361/16/1529 - Sachs GA Dying from Dementia N Engl J Med 2009, 361:1595 PMID: 19828537 http://content.nejm.org/cgi/content/extract/361/16/1595
  7. Givens JL, Jones RN, Shaffer ML, et al. Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med 2010; 170(13):1102-1107. PMID: 20625013 - Chang A, Walter LC. Invited Commentary: Recognizing dementia as a terminal illness in nursing home residents: Comment on "Survival and Comfort after Treatment of Pneumonia in Advanced Dementia." Arch Intern Med 2010; 170(13):1107-1109. PMID: 20625014
  8. Teno JM et al Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc. 2012 Oct;60(10):1918-21. PMID: 23002947
  9. Mitchell SL, Black BS, Ersek M, et al. Advanced dementia: State of the art and priorities for the next decade. Ann Intern Med 3 January 2012; 156(1 Part 1):45-51 PMID: 22213494
  10. Peters ME et al. Neuropsychiatric symptoms as predictors of progression to severe Alzheimer's dementia and death: The Cache County Dementia Progression Study. Am J Psychiatry 2015 Jan 13 PMID: 25585033 http://psychiatryonline.org/doi/abs/10.1176/appi.ajp.2014.14040480
  11. Schaffert J, LoBue C, Hynan LS et al Predictors of Life Expectancy in Autopsy-Confirmed Alzheimer's Disease. Journal of Alzheimer's Disease 2022;86(1)271-281 PMID: 35034898 https://content.iospress.com/articles/journal-of-alzheimers-disease/jad215200
  12. Deardorff WJ et al. Development and external validation of a mortality prediction model for community-dwelling older adults with dementia. JAMA Intern Med 2022 Sep 26; [e-pub] https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2796662