Mortality prediction model for dementia patients may help guide decisions on end-of-life care

A mortality prediction model for older adults with dementia can help clinicians frame conversations with patients and their families regarding end-of-life care, such as in-home support and nursing homes. Additionally, the model can help clinicians determine whether patients should continue routine cancer screening or discontinue medications, such as insulin for people with type 2 diabetes, interventions that may harm more than help.

In his study, publishing in JAMA Internal Medicine on September 26, 2022, UC San Francisco-led researchers followed 4,267 participants with probable dementia, who were not nursing home residents, in whom 81% had died by the end of the follow-up period.

A prediction model was developed based on an individual’s age, gender, body mass index, chronic conditions, smoking, ability to walk several blocks, and vigorous activity. They also included the ability to perform activities of daily living, such as attending to personal care, eating, and getting in and out of bed, as well as instrumental activities of daily living, such as meal preparation, grocery shopping, medication and money management. . The model proved accurate in determining who lived and who died over a period of up to 10 years in about 75% of cases.

The participants, whose average age was 82, and of whom 12% were African American and 69% women, had been enrolled in the Health and Retirement Study, a nationally representative survey of adults age 50 and older. His diagnosis of probable dementia was determined by a high-precision algorithm. The findings were validated in a separate group of people enrolled in the National Study of Trends in Health and Aging.

The model can generate conversations about financial resources, treatment preferences

The prediction model can help guide discussions about what financial resources are needed to support the person with dementia, said first author W. James Deardorff, MD, a geriatrician at UCSF and the San Francisco VA Health Care System.

“An estimate of an individual’s prognosis can be an important factor in families’ financial planning, particularly as many people with dementia need more support at home and are eventually admitted to nursing homes,” he said, noting that previous studies have shown that the average survival time from the time of diagnosis is between three and 12 years.

Also, people with limited life expectancy may want to focus on quality of life and being comfortable, rather than trying to live as long as possible. This may lead them to forego certain interventions, such as cardiopulmonary resuscitation in the event of cardiac arrest. Information about an individual’s prognosis can help inform discussions about certain medical treatment preferences.”

W. James Deardorff, MD, geriatrician at UCSF

Factors associated with mortality include older age, male sex, body mass index less than 18.5, previous or current smoking, chronic diseases, difficulty walking several blocks, and engaging in recreational activities. daily life and instruments of daily life.

Colonoscopies, insulin may no longer make sense

Of note, the authors suggest the model can help guide conversations between doctors and patients and their families about cancer screening, which can pinpoint slower-growing malignancies that might not be life-threatening during 10 to 15 years.

“For people with limited life expectancy, cancer screening, such as colonoscopy, may cause more harm, such as pain, bleeding, without living long enough to experience a mortality benefit,” Deardorff said.

Patients who also have type 2 diabetes may be advised to reduce or stop insulin, said senior author Sei Lee, MD, professor in the UCSF Division of Geriatrics and senior scholar for the San Francisco VA Quality Scholars. “In younger patients, tight glycemic control reduces the risk of vision loss and kidney failure within 10 years. But in older patients, these benefits may not materialize, and the risks of low levels sugar as a result of too much insulin can be very serious.”

Along with the mortality prediction model, the researchers designed an individualized mortality risk calculator for patients with dementia, available online at ePrognosis. Additional mortality calculators and risk versus benefit cancer screening calculators are available, along with videos to assist clinicians in their discussions with patients about life expectancy and goals of care.

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Magazine reference:

James Deardorff, W. et al. (2022) Development and external validation of a mortality prediction model for older adults with dementia living in the community. JAMA Internal Medicine. doi.org/10.1001/jamainternmed.2022.4326.

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