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An overview of the clinical course of advanced dementia with emphasis on predictors of mortality. Geared toward the office-based physician.
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The Clinical Course of Advanced Dementia
KP Edmonds MDJournal Club Presentation
The ArticleMitchell, SL et al (2009). The Clinical Course of Advanced Dementia. NEJM. 361 (16). 1529-1538.
Objectives
Identify the clinical features of end-stage dementia.
Understand the concept of dementia as a terminal illness.
Describe the odds ratio in regards to medical statistics.
The Background
17-25 million worldwide
5 million US (13 million by 2050)
5% of those >65yo 20% of those >80yo
26% women 21% men
50% Alzheimer type
The Question
Prospective look at the clinical course: Complications Physical suffering Burdensome
interventions What are the realistic
expectations for patient, family, provider?
The Authors
9 identified authors
6 academic institutions
No reported conflicts
Funding Grant (NIA) Mid-career Award
The Study Type
18 month Prospective Case-control Multi-center Data culled from the
CASCADE study
The Study Participants
22 facilities with >60 beds
Within 60 miles of Boston
Initial factors Age 60+ Cognitive
Performance Scale Score
Length of stay >30 days
The Study Participants
Secondary factors Cognitive impairment Global Deterioration
Scale score = 7 English-speaking
health care proxy
The Study Data
Via Chart reviews Interviews of nurses Quarterly physical
exams SES Health Status Clinical Complications Distressing symptoms Intervention Use of hospice
The Results: Participant Characteristics
The Results:Participant Course
55% died 94% of deaths
were in nursing home
Probabilities: 25% death within 6
mos 41% pneumonia 53% febrile episode 86% eating problem
Figure 1
The Results:Survival Probability
Figure 2a
The Results:Survival Probability
Figure 2b
The Results:Survival Probability
Figure 2c
The Results:Problems in the Last 3 Months
Pneumonia in 37% Fever in 32% Eating problems in
90%
The Results:Symptoms in the Last 3 Months
Figure 3
The Results:Interventions in the Last 3 Months
40% received one “burdensome” intervention 29% received
parenteral therapy 12% hospitalized 3% taken to ED 7% tube fed
The Results:Hospice in the Last 3 Months
30% referred 26% at 0-7 days
before death 26% at >181 days
before death
The Results:Health Care Proxy Perspective
96% believed comfort to be the primary goal
20% believed patient had <6 months
18% reported receiving prognosis info from a physician
32% had been counseled by a physician about expected course
The Results:Proxy Beliefs and the Last 3 Months
If proxies: Believed life
expectancy < 6 months
Understood clinical course of dementia
Then patients less likely to undergo “burdensome” intervention
Odds Ratio 0.12 (95% CI 0.04-0.37)
Mandatory Tangent:The Odds Ratio
Compares the probability of an event between two groups 1 = same odds >1 greater odds in group
1 <1 greater odds in group
2 Ours is 0.12 so:
< 1 Greater odds of
intervention in group where proxies less aware
Limitations
Geographically restricted
Relatively large institutions
Possible documentation inaccuracy
Not an inception cohort
The Upshot
Dementia is a terminal illness 25% 6 month mortality
at end-stage 1.3 year median
survival Most deaths not due
to acute events (such as MI)
We must counsel our patients on what to expect!
The Questions…
References
Melzer D, Ely M, Brayne C. Cognitive impairment in elderly people: population based estimated of future in England, Scotland, Wales. BMJ 1997; 315:462.
Mitchell SL, Kiely DK, Jones RN, Prigerson H, Volicer L, Teno JM. Advanced dementia research in the nursing home: the CASCADE study. Alzheimer Dis Assoc Disord 2006;20:166-75.
Mitchell, SL et al (2009). The Clinical Course of Advanced Dementia. NEJM. 361 (16). 1529-1538.