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When should you admit a patient with suspected CAP?
When the patient has 2 or more of the following CURB-65 criteria: respiratory rate ≥30, acute confusion, low blood pressure (systolic blood pressure <90 or diastolic BP ≤60 mm Hg), blood urea nitrogen [BUN] >19.6 mg/dL, and age ≥65 years (strength of recommendation [SOR]: B, based on 3 prospective cohort studies). Alternatively, consider hospitalization for patients presenting with a Pneumonia Severity Index (PSI) class of 4 or 5 (SOR: B; 1 prospective cohort study). There are no studies that test whether using these rules improve outcomes over standard care.
What about the homeless man, or the debilitated woman?
Timothy E. Huber, MD
Oroville, Calif
I occasionally work in my community hospital’s emergency room. Clinical decision rules are often very helpful, but they are limited when dealing with special populations, such as patients who are immunosuppressed or pregnant, or those with underlying cardiac or lung disease.
In addition, there are often social factors that must be taken into account when considering admitting a patient. For instance, a homeless man may not be able to purchase his medications; a debilitated woman living alone may not be able to adequately care for herself, despite a low CURB-65 score. Clinical decision rules provide a useful starting point, but they are meant to supplement, not replace, clinical decision-making.
Evidence summary
The CURB-65 criteria: Having ≥2 factors increases mortality
In a split-sample (derivation and validation) analysis1 of 3 prospective studies involving 1068 patients presenting to the hospital with the diagnosis of pneumonia, various clinical features were analyzed for their association with 30-day mortality. The 5 parameters that were most strongly associated with mortality were:
- acute confusion (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.8–13.7)
- BUN >19.6 mg/dL (OR= 5.6; 95% CI, 3.1–10)
- respiratory rate ≥30 (OR=1.7; 95% CI, 1.07–2.8)
- low blood pressure (SBP <90 or DBP ≤60) (OR=2.4; 95% CI, 1.4–3.8)
- age ≥65 years (OR=5.5; 95% CI, 2.8–10.9).
The 30-day mortality estimation using these 5 criteria is called CURB-65 (Confusion, Urea, Respiratory rate, low Blood pressure, and age ≥65).
In patients with 2 or more of these factors, the associated rate of mortality increased significantly compared with patients who had none or only 1 of the factors (TABLE 1). Although albumin <3.0 g/dL was also significantly associated with an increased mortality rate (OR=4.7; 95% CI, 2.5–8.7), it was not included in CURB-65 because it is not a routine lab ordered for patients with pneumonia.
A variation of the CURB-65 score, CRB-65, uses only the clinical parameters without laboratory data (confusion, respiratory rate, blood pressure, and age). Patients with a score of 0 had a 0.9% 30-day mortality rate. However, the rate increased to 8.15% when patients had 1 or 2 of the 4 clinical criteria.
TABLE 1
CURB-65 criteria
Give 1 point for each:
|
| |
| SCORE | 30-DAY MORTALITY | POSSIBLE TREATMENT OPTIONS |
| 0 or 1 | Low (1.5%) | Consider outpatient treatment |
| 2 | Intermediate (9.2%) | Short-stay hospitalization or closely monitored outpatient therapy |
| 3 or more | High (22%) | Hospitalize and consider ICU |
| Source: Lim et al 2003.1 | ||
Pneumonia Severity Index has similar sensitivity to CURB-65
A more detailed assessment using 20 parameters called the Pneumonia Severity Index (PSI) was derived and validated in separate cohorts (TABLE 2).2 When compared with CURB-65 and CRB-65, the PSI has similar sensitivity and specificity in predicting 30-day mortality.3 All 3 predictive rules had high negative predictive values for mortality but a low positive predictive value at all cutoff points.
Larger proportions of patients were identified as low-risk by PSI (47.2%) and CURB-65 (43.3%) than by CRB-65 (12.6%). Therefore PSI and CURB-65 are much more helpful in identifying patients who could be treated in the outpatient setting.
TABLE 2
Pneumonia Severity Index
| CHARACTERISTIC | POINTS ASSIGNED | |
| Demographic factors | ||
| Age, men | Age in years | |
| Age, women | Age in years –10 | |
| Nursing home resident | +10 | |
| Coexisting illnesses | ||
| Neoplastic disease | +30 | |
| Liver disease | +20 | |
| Congestive heart failure | +10 | |
| Cerebrovascular disease | +10 | |
| Renal disease | +10 | |
| Physical examination findings | ||
| Altered mental status | +20 | |
| Respiratory rate ≥30/min | +20 | |
| Systolic blood pressure <90 mm Hg | +20 | |
| Temperature <35°C (95°F) or ≥40°C (104°F) | +15 | |
| Pulse ≥125 beats/min | +10 | |
| Laboratory and radiographic findings | ||
| Arterial blood pH <7.35 | +30 | |
| Blood urea nitrogen level ≥30 mg/dL | +20 | |
| Sodium level <130 mmol/L | +20 | |
| Glucose level ≥250 mg/dL | +10 | |
| Hematocrit <30% | +10 | |
| Partial pressure of arterial O2 <60 mm Hg or O2 saturation <90% on pulse oximetry | +10 | |
| Pleural effusion | +10 | |
| RISK CLASS | POINTS | 30-DAY MORTALITY |
| I | 0–50 | 0.1%–0.4% |
| II | 51–70 | 0.6%–0.7% |
| III | 71–90 | 0.9%–2.8% |
| IV | 91–130 | 8.3%–9.3% |
| V | >130 | 27.0%–31.1% |
| Patients in classes I, II, and III can be managed on an outpatient basis; patients in classes IV and V should be hospitalized. | ||
| Source: Fine et al 1997.2 | ||
Recommendations from others
The 2007 Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS), in their Consensus Guidelines on the Management of Community-Acquired Pneumonia,4 concluded that severity-of-illness scores, such as the CURB-65 or PSI, can be used to identify patients with CAP who may be candidates for outpatient treatment (evidence level I by IDSA/ATS rating).
The guidelines recommend that objective criteria or scores always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. Also, CURB-65 is more suitable than PSI for use in the emergency department because of its simplicity of application and ability to identify low-risk patients (evidence level II).4
1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58:377-382.
2. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-250.
3. Yan Man S, Lee N, Ip M, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax 2007;62:348-353.
4. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27-S72.
When the patient has 2 or more of the following CURB-65 criteria: respiratory rate ≥30, acute confusion, low blood pressure (systolic blood pressure <90 or diastolic BP ≤60 mm Hg), blood urea nitrogen [BUN] >19.6 mg/dL, and age ≥65 years (strength of recommendation [SOR]: B, based on 3 prospective cohort studies). Alternatively, consider hospitalization for patients presenting with a Pneumonia Severity Index (PSI) class of 4 or 5 (SOR: B; 1 prospective cohort study). There are no studies that test whether using these rules improve outcomes over standard care.
What about the homeless man, or the debilitated woman?
Timothy E. Huber, MD
Oroville, Calif
I occasionally work in my community hospital’s emergency room. Clinical decision rules are often very helpful, but they are limited when dealing with special populations, such as patients who are immunosuppressed or pregnant, or those with underlying cardiac or lung disease.
In addition, there are often social factors that must be taken into account when considering admitting a patient. For instance, a homeless man may not be able to purchase his medications; a debilitated woman living alone may not be able to adequately care for herself, despite a low CURB-65 score. Clinical decision rules provide a useful starting point, but they are meant to supplement, not replace, clinical decision-making.
Evidence summary
The CURB-65 criteria: Having ≥2 factors increases mortality
In a split-sample (derivation and validation) analysis1 of 3 prospective studies involving 1068 patients presenting to the hospital with the diagnosis of pneumonia, various clinical features were analyzed for their association with 30-day mortality. The 5 parameters that were most strongly associated with mortality were:
- acute confusion (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.8–13.7)
- BUN >19.6 mg/dL (OR= 5.6; 95% CI, 3.1–10)
- respiratory rate ≥30 (OR=1.7; 95% CI, 1.07–2.8)
- low blood pressure (SBP <90 or DBP ≤60) (OR=2.4; 95% CI, 1.4–3.8)
- age ≥65 years (OR=5.5; 95% CI, 2.8–10.9).
The 30-day mortality estimation using these 5 criteria is called CURB-65 (Confusion, Urea, Respiratory rate, low Blood pressure, and age ≥65).
In patients with 2 or more of these factors, the associated rate of mortality increased significantly compared with patients who had none or only 1 of the factors (TABLE 1). Although albumin <3.0 g/dL was also significantly associated with an increased mortality rate (OR=4.7; 95% CI, 2.5–8.7), it was not included in CURB-65 because it is not a routine lab ordered for patients with pneumonia.
A variation of the CURB-65 score, CRB-65, uses only the clinical parameters without laboratory data (confusion, respiratory rate, blood pressure, and age). Patients with a score of 0 had a 0.9% 30-day mortality rate. However, the rate increased to 8.15% when patients had 1 or 2 of the 4 clinical criteria.
TABLE 1
CURB-65 criteria
Give 1 point for each:
|
| |
| SCORE | 30-DAY MORTALITY | POSSIBLE TREATMENT OPTIONS |
| 0 or 1 | Low (1.5%) | Consider outpatient treatment |
| 2 | Intermediate (9.2%) | Short-stay hospitalization or closely monitored outpatient therapy |
| 3 or more | High (22%) | Hospitalize and consider ICU |
| Source: Lim et al 2003.1 | ||
Pneumonia Severity Index has similar sensitivity to CURB-65
A more detailed assessment using 20 parameters called the Pneumonia Severity Index (PSI) was derived and validated in separate cohorts (TABLE 2).2 When compared with CURB-65 and CRB-65, the PSI has similar sensitivity and specificity in predicting 30-day mortality.3 All 3 predictive rules had high negative predictive values for mortality but a low positive predictive value at all cutoff points.
Larger proportions of patients were identified as low-risk by PSI (47.2%) and CURB-65 (43.3%) than by CRB-65 (12.6%). Therefore PSI and CURB-65 are much more helpful in identifying patients who could be treated in the outpatient setting.
TABLE 2
Pneumonia Severity Index
| CHARACTERISTIC | POINTS ASSIGNED | |
| Demographic factors | ||
| Age, men | Age in years | |
| Age, women | Age in years –10 | |
| Nursing home resident | +10 | |
| Coexisting illnesses | ||
| Neoplastic disease | +30 | |
| Liver disease | +20 | |
| Congestive heart failure | +10 | |
| Cerebrovascular disease | +10 | |
| Renal disease | +10 | |
| Physical examination findings | ||
| Altered mental status | +20 | |
| Respiratory rate ≥30/min | +20 | |
| Systolic blood pressure <90 mm Hg | +20 | |
| Temperature <35°C (95°F) or ≥40°C (104°F) | +15 | |
| Pulse ≥125 beats/min | +10 | |
| Laboratory and radiographic findings | ||
| Arterial blood pH <7.35 | +30 | |
| Blood urea nitrogen level ≥30 mg/dL | +20 | |
| Sodium level <130 mmol/L | +20 | |
| Glucose level ≥250 mg/dL | +10 | |
| Hematocrit <30% | +10 | |
| Partial pressure of arterial O2 <60 mm Hg or O2 saturation <90% on pulse oximetry | +10 | |
| Pleural effusion | +10 | |
| RISK CLASS | POINTS | 30-DAY MORTALITY |
| I | 0–50 | 0.1%–0.4% |
| II | 51–70 | 0.6%–0.7% |
| III | 71–90 | 0.9%–2.8% |
| IV | 91–130 | 8.3%–9.3% |
| V | >130 | 27.0%–31.1% |
| Patients in classes I, II, and III can be managed on an outpatient basis; patients in classes IV and V should be hospitalized. | ||
| Source: Fine et al 1997.2 | ||
Recommendations from others
The 2007 Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS), in their Consensus Guidelines on the Management of Community-Acquired Pneumonia,4 concluded that severity-of-illness scores, such as the CURB-65 or PSI, can be used to identify patients with CAP who may be candidates for outpatient treatment (evidence level I by IDSA/ATS rating).
The guidelines recommend that objective criteria or scores always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. Also, CURB-65 is more suitable than PSI for use in the emergency department because of its simplicity of application and ability to identify low-risk patients (evidence level II).4
When the patient has 2 or more of the following CURB-65 criteria: respiratory rate ≥30, acute confusion, low blood pressure (systolic blood pressure <90 or diastolic BP ≤60 mm Hg), blood urea nitrogen [BUN] >19.6 mg/dL, and age ≥65 years (strength of recommendation [SOR]: B, based on 3 prospective cohort studies). Alternatively, consider hospitalization for patients presenting with a Pneumonia Severity Index (PSI) class of 4 or 5 (SOR: B; 1 prospective cohort study). There are no studies that test whether using these rules improve outcomes over standard care.
What about the homeless man, or the debilitated woman?
Timothy E. Huber, MD
Oroville, Calif
I occasionally work in my community hospital’s emergency room. Clinical decision rules are often very helpful, but they are limited when dealing with special populations, such as patients who are immunosuppressed or pregnant, or those with underlying cardiac or lung disease.
In addition, there are often social factors that must be taken into account when considering admitting a patient. For instance, a homeless man may not be able to purchase his medications; a debilitated woman living alone may not be able to adequately care for herself, despite a low CURB-65 score. Clinical decision rules provide a useful starting point, but they are meant to supplement, not replace, clinical decision-making.
Evidence summary
The CURB-65 criteria: Having ≥2 factors increases mortality
In a split-sample (derivation and validation) analysis1 of 3 prospective studies involving 1068 patients presenting to the hospital with the diagnosis of pneumonia, various clinical features were analyzed for their association with 30-day mortality. The 5 parameters that were most strongly associated with mortality were:
- acute confusion (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.8–13.7)
- BUN >19.6 mg/dL (OR= 5.6; 95% CI, 3.1–10)
- respiratory rate ≥30 (OR=1.7; 95% CI, 1.07–2.8)
- low blood pressure (SBP <90 or DBP ≤60) (OR=2.4; 95% CI, 1.4–3.8)
- age ≥65 years (OR=5.5; 95% CI, 2.8–10.9).
The 30-day mortality estimation using these 5 criteria is called CURB-65 (Confusion, Urea, Respiratory rate, low Blood pressure, and age ≥65).
In patients with 2 or more of these factors, the associated rate of mortality increased significantly compared with patients who had none or only 1 of the factors (TABLE 1). Although albumin <3.0 g/dL was also significantly associated with an increased mortality rate (OR=4.7; 95% CI, 2.5–8.7), it was not included in CURB-65 because it is not a routine lab ordered for patients with pneumonia.
A variation of the CURB-65 score, CRB-65, uses only the clinical parameters without laboratory data (confusion, respiratory rate, blood pressure, and age). Patients with a score of 0 had a 0.9% 30-day mortality rate. However, the rate increased to 8.15% when patients had 1 or 2 of the 4 clinical criteria.
TABLE 1
CURB-65 criteria
Give 1 point for each:
|
| |
| SCORE | 30-DAY MORTALITY | POSSIBLE TREATMENT OPTIONS |
| 0 or 1 | Low (1.5%) | Consider outpatient treatment |
| 2 | Intermediate (9.2%) | Short-stay hospitalization or closely monitored outpatient therapy |
| 3 or more | High (22%) | Hospitalize and consider ICU |
| Source: Lim et al 2003.1 | ||
Pneumonia Severity Index has similar sensitivity to CURB-65
A more detailed assessment using 20 parameters called the Pneumonia Severity Index (PSI) was derived and validated in separate cohorts (TABLE 2).2 When compared with CURB-65 and CRB-65, the PSI has similar sensitivity and specificity in predicting 30-day mortality.3 All 3 predictive rules had high negative predictive values for mortality but a low positive predictive value at all cutoff points.
Larger proportions of patients were identified as low-risk by PSI (47.2%) and CURB-65 (43.3%) than by CRB-65 (12.6%). Therefore PSI and CURB-65 are much more helpful in identifying patients who could be treated in the outpatient setting.
TABLE 2
Pneumonia Severity Index
| CHARACTERISTIC | POINTS ASSIGNED | |
| Demographic factors | ||
| Age, men | Age in years | |
| Age, women | Age in years –10 | |
| Nursing home resident | +10 | |
| Coexisting illnesses | ||
| Neoplastic disease | +30 | |
| Liver disease | +20 | |
| Congestive heart failure | +10 | |
| Cerebrovascular disease | +10 | |
| Renal disease | +10 | |
| Physical examination findings | ||
| Altered mental status | +20 | |
| Respiratory rate ≥30/min | +20 | |
| Systolic blood pressure <90 mm Hg | +20 | |
| Temperature <35°C (95°F) or ≥40°C (104°F) | +15 | |
| Pulse ≥125 beats/min | +10 | |
| Laboratory and radiographic findings | ||
| Arterial blood pH <7.35 | +30 | |
| Blood urea nitrogen level ≥30 mg/dL | +20 | |
| Sodium level <130 mmol/L | +20 | |
| Glucose level ≥250 mg/dL | +10 | |
| Hematocrit <30% | +10 | |
| Partial pressure of arterial O2 <60 mm Hg or O2 saturation <90% on pulse oximetry | +10 | |
| Pleural effusion | +10 | |
| RISK CLASS | POINTS | 30-DAY MORTALITY |
| I | 0–50 | 0.1%–0.4% |
| II | 51–70 | 0.6%–0.7% |
| III | 71–90 | 0.9%–2.8% |
| IV | 91–130 | 8.3%–9.3% |
| V | >130 | 27.0%–31.1% |
| Patients in classes I, II, and III can be managed on an outpatient basis; patients in classes IV and V should be hospitalized. | ||
| Source: Fine et al 1997.2 | ||
Recommendations from others
The 2007 Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS), in their Consensus Guidelines on the Management of Community-Acquired Pneumonia,4 concluded that severity-of-illness scores, such as the CURB-65 or PSI, can be used to identify patients with CAP who may be candidates for outpatient treatment (evidence level I by IDSA/ATS rating).
The guidelines recommend that objective criteria or scores always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. Also, CURB-65 is more suitable than PSI for use in the emergency department because of its simplicity of application and ability to identify low-risk patients (evidence level II).4
1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58:377-382.
2. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-250.
3. Yan Man S, Lee N, Ip M, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax 2007;62:348-353.
4. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27-S72.
1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58:377-382.
2. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-250.
3. Yan Man S, Lee N, Ip M, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax 2007;62:348-353.
4. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27-S72.
Evidence-based answers from the Family Physicians Inquiries Network
Which late-stage Alzheimer’s patients should be referred for hospice care?
Medicare guidelines are used to determine eligibility for hospice care (strength of recommendation [SOR]: C, based on expert opinion), but they correlate with 6-month mortality no better than an experienced clinician’s judgment (SOR: B, based on 1 cohort study). Recent studies, however, have identified additional criteria that may better predict survival in select populations. These prognostic criteria include stepwise progression to Functional Assessment Staging Scale (FAST) stage 7c (inability to walk without assistance) (SOR: A, based on 2 small prospective cohort studies) and criteria derived from the Minimum Data Set (MDS) which include: dependency for activities of daily living, bedbound status, bowel incontinence, comorbid conditions (specifically cancer, congestive heart failure, oxygen dependence, or dyspnea), medical instability, eating<25% of meals, sleeping most of the day, male gender, and age>83 years (SOR: B, based on a large retrospective cohort study).
Combination of factors helps to estimate prognosis for patients with late-stage Alzheimer’s
Krupa Shah, MD
Baylor College of Medicine, Houston, Tex
Medicare beneficiaries must have an estimated life expectancy of less than 6 months to be eligible for hospice in the US. Predicting the life expectancy of patients with Alzheimer’s disease is difficult, but those with advanced age, impaired nutritional status, increased functional impairment, and comorbid conditions have shorter survival times with greater 6-month mortality rates. These variables should be used in addition to the current Medicare guidelines in discussing a patient’s prognosis with family members and determining when a hospice referral is appropriate.
Physicians should identify opportunities to introduce hospice as an option within the early care continuum of an Alzheimer’s patient and in end-of-life discussions. A sensitive discussion about hospice care can ease the suffering and confusion of patient and family in making this difficult decision. In my experience, deferring discussions about hospice may deprive patients and family of comprehensive care at home, emotional support, spiritual resolution, and financial protection.
Evidence summary
Medicare adapted the National Hospice Organization guidelines to determine patients’ eligibility for hospice care.1 Recent studies, however, have identified additional prognostic criteria that may better predict survival of less than 6 months in select populations (TABLE).
Schonwetter and colleagues1 conducted a retrospective chart audit of 165 patients, and a subsequent prospective cohort study of 80 patients at comparable stages of progressive dementia who were consecutively admitted to a community-based hospice program. These patients had estimated life expectancy of less than 6 months, as certified by the attending and the hospice medical director, without use of explicit guidelines. The survival curves for patients who, in retrospect, did and did not meet Medicare guidelines were similarie, the Medicare guidelines were not statistically better at predicting 6-month survival than the clinical impressions of the attending and hospice medical director.
In the 139 patients from the retrospective cohort included in the Cox regression analysis, 108 patients died within 6 months. Of those, 83 (77%) met Medicare criteria and 25 (23%) did not. Of the 31 who lived longer than 6 months, 22 (71%) met Medicare criteria and 9 (29%) did not. In the prospective cohort, of the 61 patients who died within 6 months, 39 (64%) met Medicare criteria and 22 (36%) did not; of the 18 who lived longer than 6 months, 9 met Medicare criteria (50%) and 9 did not.1
More recent studies have looked at the FAST, MDS, and Global Deterioration Scale (GDS) to identify criteria for predicting 6-month mortality. The FAST rating is based on the lowest level of function on a scale ranging from 1 (normal) to 7f (unable to hold up head). The GDS is similar to the FAST, and also ranges from 1 to 7. A rating of 5 is given to people with moderately severe cognitive decline; 6 is severe cognitive decline.
Two prospective cohort studies followed 47 and 45 patients enrolled in hospice over 2 years; these studies demonstrated that patients who reach FAST stage 7c (inability to walk without assistance) in an stepwise fashion are likely to live less than 6 months.2,3 In 1 of the 2 studies, patients who reached stage 7c ordinally had a mean survival time of 4.1 months; 71% died within 6 months of enrollment. For the large subset of patients who met 7c but not in an ordinal fashion (ie, they met criteria for 7c, but perhaps not 7a or 7b), only 30% died within 6 months, with median survival time 10.7 months.
Use of antibiotics did not make a statistically significant difference in survival, and use of Foley catheters was associated with shorter survival times (3.6 months vs 9 months; P<.03.)3 In the other study, however, less aggressive care plans resulted in shorter survival times (P<.01).2
In a retrospective cohort study of 11,430 nursing home residents with advanced dementia (defined as a score of 5 or 6 on the Cognitive Performance Score, which is itself based on MDS data, a prognostic summary score was developed using 12 variables from the MDS, a federally mandated assessment completed by nursing home staff at the time of admission.4 A high score predicted 6-month mortality more accurately than using an MDS correlate of FAST stage 7c. In the derivation cohort (n=6799), 28.3% (n=1922) died within 6 months; in the validation cohort (n=4631), 35.1% (n=1626) died within 6 months. The FAST 7c correlate was found to have a positive predictive value of only 38.5% and a sensitivity of 22% in predicting death within 6 months in this population. In contrast, using the MDS variables, a higher threshold for the prognostic summary score resulted in a positive predictive value of 80%, negative predictive value of 73%, specificity of 99%, but sensitivity of only 6%. A lower cutoff yielded better sensitivity (23%), and still had good specificity (96%) and negative predictive value (76%), though the positive predictive value was slightly lower (67%).
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 | ||
Recommendations from others
Guidelines for Medicare reimbursement for hospice care of demented patients is outlined in the see first row of the TABLE.6
1. Schonwetter RS, Han B, Small BJ, Martin B, Tope K, Haley WE. Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliat Care 2003;20:105-113.
2. Luchins DJ, Hanrahan P, Murphy K. Criteria for enrolling dementia patients into hospice. J Am Geriatr Soc 1997;45:1054-1059.
3. Hanrahan P, Raymond M, McGowan E, Luchins D. Criteria for enrolling dementia patients in hospice: a replication. Am J Hosp Palliat Care 1999;16:395-400.
4. Mitchell SJ, Kiely DK, Hamel MB, Park PS, Morris JN, Fries BE. Estimating prognosis for nursing home residents with advanced dementia. JAMA 2004;291:2734-2740.
5. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA 2000;284:47-52.
6. Hospice of Southern Illinois, Inc web site. Criteria for dementia/Alzheimer’s disease. Available at: www.hospice.org/pdf/webdementia.pdf. Accessed on October 11, 2005.
7. Geriatric Resources, Inc. web site. Global deterioration scale. Available at: www.geriatric-resources.com/html/gds.html. Accessed on October 11, 2005.
Medicare guidelines are used to determine eligibility for hospice care (strength of recommendation [SOR]: C, based on expert opinion), but they correlate with 6-month mortality no better than an experienced clinician’s judgment (SOR: B, based on 1 cohort study). Recent studies, however, have identified additional criteria that may better predict survival in select populations. These prognostic criteria include stepwise progression to Functional Assessment Staging Scale (FAST) stage 7c (inability to walk without assistance) (SOR: A, based on 2 small prospective cohort studies) and criteria derived from the Minimum Data Set (MDS) which include: dependency for activities of daily living, bedbound status, bowel incontinence, comorbid conditions (specifically cancer, congestive heart failure, oxygen dependence, or dyspnea), medical instability, eating<25% of meals, sleeping most of the day, male gender, and age>83 years (SOR: B, based on a large retrospective cohort study).
Combination of factors helps to estimate prognosis for patients with late-stage Alzheimer’s
Krupa Shah, MD
Baylor College of Medicine, Houston, Tex
Medicare beneficiaries must have an estimated life expectancy of less than 6 months to be eligible for hospice in the US. Predicting the life expectancy of patients with Alzheimer’s disease is difficult, but those with advanced age, impaired nutritional status, increased functional impairment, and comorbid conditions have shorter survival times with greater 6-month mortality rates. These variables should be used in addition to the current Medicare guidelines in discussing a patient’s prognosis with family members and determining when a hospice referral is appropriate.
Physicians should identify opportunities to introduce hospice as an option within the early care continuum of an Alzheimer’s patient and in end-of-life discussions. A sensitive discussion about hospice care can ease the suffering and confusion of patient and family in making this difficult decision. In my experience, deferring discussions about hospice may deprive patients and family of comprehensive care at home, emotional support, spiritual resolution, and financial protection.
Evidence summary
Medicare adapted the National Hospice Organization guidelines to determine patients’ eligibility for hospice care.1 Recent studies, however, have identified additional prognostic criteria that may better predict survival of less than 6 months in select populations (TABLE).
Schonwetter and colleagues1 conducted a retrospective chart audit of 165 patients, and a subsequent prospective cohort study of 80 patients at comparable stages of progressive dementia who were consecutively admitted to a community-based hospice program. These patients had estimated life expectancy of less than 6 months, as certified by the attending and the hospice medical director, without use of explicit guidelines. The survival curves for patients who, in retrospect, did and did not meet Medicare guidelines were similarie, the Medicare guidelines were not statistically better at predicting 6-month survival than the clinical impressions of the attending and hospice medical director.
In the 139 patients from the retrospective cohort included in the Cox regression analysis, 108 patients died within 6 months. Of those, 83 (77%) met Medicare criteria and 25 (23%) did not. Of the 31 who lived longer than 6 months, 22 (71%) met Medicare criteria and 9 (29%) did not. In the prospective cohort, of the 61 patients who died within 6 months, 39 (64%) met Medicare criteria and 22 (36%) did not; of the 18 who lived longer than 6 months, 9 met Medicare criteria (50%) and 9 did not.1
More recent studies have looked at the FAST, MDS, and Global Deterioration Scale (GDS) to identify criteria for predicting 6-month mortality. The FAST rating is based on the lowest level of function on a scale ranging from 1 (normal) to 7f (unable to hold up head). The GDS is similar to the FAST, and also ranges from 1 to 7. A rating of 5 is given to people with moderately severe cognitive decline; 6 is severe cognitive decline.
Two prospective cohort studies followed 47 and 45 patients enrolled in hospice over 2 years; these studies demonstrated that patients who reach FAST stage 7c (inability to walk without assistance) in an stepwise fashion are likely to live less than 6 months.2,3 In 1 of the 2 studies, patients who reached stage 7c ordinally had a mean survival time of 4.1 months; 71% died within 6 months of enrollment. For the large subset of patients who met 7c but not in an ordinal fashion (ie, they met criteria for 7c, but perhaps not 7a or 7b), only 30% died within 6 months, with median survival time 10.7 months.
Use of antibiotics did not make a statistically significant difference in survival, and use of Foley catheters was associated with shorter survival times (3.6 months vs 9 months; P<.03.)3 In the other study, however, less aggressive care plans resulted in shorter survival times (P<.01).2
In a retrospective cohort study of 11,430 nursing home residents with advanced dementia (defined as a score of 5 or 6 on the Cognitive Performance Score, which is itself based on MDS data, a prognostic summary score was developed using 12 variables from the MDS, a federally mandated assessment completed by nursing home staff at the time of admission.4 A high score predicted 6-month mortality more accurately than using an MDS correlate of FAST stage 7c. In the derivation cohort (n=6799), 28.3% (n=1922) died within 6 months; in the validation cohort (n=4631), 35.1% (n=1626) died within 6 months. The FAST 7c correlate was found to have a positive predictive value of only 38.5% and a sensitivity of 22% in predicting death within 6 months in this population. In contrast, using the MDS variables, a higher threshold for the prognostic summary score resulted in a positive predictive value of 80%, negative predictive value of 73%, specificity of 99%, but sensitivity of only 6%. A lower cutoff yielded better sensitivity (23%), and still had good specificity (96%) and negative predictive value (76%), though the positive predictive value was slightly lower (67%).
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 | ||
Recommendations from others
Guidelines for Medicare reimbursement for hospice care of demented patients is outlined in the see first row of the TABLE.6
Medicare guidelines are used to determine eligibility for hospice care (strength of recommendation [SOR]: C, based on expert opinion), but they correlate with 6-month mortality no better than an experienced clinician’s judgment (SOR: B, based on 1 cohort study). Recent studies, however, have identified additional criteria that may better predict survival in select populations. These prognostic criteria include stepwise progression to Functional Assessment Staging Scale (FAST) stage 7c (inability to walk without assistance) (SOR: A, based on 2 small prospective cohort studies) and criteria derived from the Minimum Data Set (MDS) which include: dependency for activities of daily living, bedbound status, bowel incontinence, comorbid conditions (specifically cancer, congestive heart failure, oxygen dependence, or dyspnea), medical instability, eating<25% of meals, sleeping most of the day, male gender, and age>83 years (SOR: B, based on a large retrospective cohort study).
Combination of factors helps to estimate prognosis for patients with late-stage Alzheimer’s
Krupa Shah, MD
Baylor College of Medicine, Houston, Tex
Medicare beneficiaries must have an estimated life expectancy of less than 6 months to be eligible for hospice in the US. Predicting the life expectancy of patients with Alzheimer’s disease is difficult, but those with advanced age, impaired nutritional status, increased functional impairment, and comorbid conditions have shorter survival times with greater 6-month mortality rates. These variables should be used in addition to the current Medicare guidelines in discussing a patient’s prognosis with family members and determining when a hospice referral is appropriate.
Physicians should identify opportunities to introduce hospice as an option within the early care continuum of an Alzheimer’s patient and in end-of-life discussions. A sensitive discussion about hospice care can ease the suffering and confusion of patient and family in making this difficult decision. In my experience, deferring discussions about hospice may deprive patients and family of comprehensive care at home, emotional support, spiritual resolution, and financial protection.
Evidence summary
Medicare adapted the National Hospice Organization guidelines to determine patients’ eligibility for hospice care.1 Recent studies, however, have identified additional prognostic criteria that may better predict survival of less than 6 months in select populations (TABLE).
Schonwetter and colleagues1 conducted a retrospective chart audit of 165 patients, and a subsequent prospective cohort study of 80 patients at comparable stages of progressive dementia who were consecutively admitted to a community-based hospice program. These patients had estimated life expectancy of less than 6 months, as certified by the attending and the hospice medical director, without use of explicit guidelines. The survival curves for patients who, in retrospect, did and did not meet Medicare guidelines were similarie, the Medicare guidelines were not statistically better at predicting 6-month survival than the clinical impressions of the attending and hospice medical director.
In the 139 patients from the retrospective cohort included in the Cox regression analysis, 108 patients died within 6 months. Of those, 83 (77%) met Medicare criteria and 25 (23%) did not. Of the 31 who lived longer than 6 months, 22 (71%) met Medicare criteria and 9 (29%) did not. In the prospective cohort, of the 61 patients who died within 6 months, 39 (64%) met Medicare criteria and 22 (36%) did not; of the 18 who lived longer than 6 months, 9 met Medicare criteria (50%) and 9 did not.1
More recent studies have looked at the FAST, MDS, and Global Deterioration Scale (GDS) to identify criteria for predicting 6-month mortality. The FAST rating is based on the lowest level of function on a scale ranging from 1 (normal) to 7f (unable to hold up head). The GDS is similar to the FAST, and also ranges from 1 to 7. A rating of 5 is given to people with moderately severe cognitive decline; 6 is severe cognitive decline.
Two prospective cohort studies followed 47 and 45 patients enrolled in hospice over 2 years; these studies demonstrated that patients who reach FAST stage 7c (inability to walk without assistance) in an stepwise fashion are likely to live less than 6 months.2,3 In 1 of the 2 studies, patients who reached stage 7c ordinally had a mean survival time of 4.1 months; 71% died within 6 months of enrollment. For the large subset of patients who met 7c but not in an ordinal fashion (ie, they met criteria for 7c, but perhaps not 7a or 7b), only 30% died within 6 months, with median survival time 10.7 months.
Use of antibiotics did not make a statistically significant difference in survival, and use of Foley catheters was associated with shorter survival times (3.6 months vs 9 months; P<.03.)3 In the other study, however, less aggressive care plans resulted in shorter survival times (P<.01).2
In a retrospective cohort study of 11,430 nursing home residents with advanced dementia (defined as a score of 5 or 6 on the Cognitive Performance Score, which is itself based on MDS data, a prognostic summary score was developed using 12 variables from the MDS, a federally mandated assessment completed by nursing home staff at the time of admission.4 A high score predicted 6-month mortality more accurately than using an MDS correlate of FAST stage 7c. In the derivation cohort (n=6799), 28.3% (n=1922) died within 6 months; in the validation cohort (n=4631), 35.1% (n=1626) died within 6 months. The FAST 7c correlate was found to have a positive predictive value of only 38.5% and a sensitivity of 22% in predicting death within 6 months in this population. In contrast, using the MDS variables, a higher threshold for the prognostic summary score resulted in a positive predictive value of 80%, negative predictive value of 73%, specificity of 99%, but sensitivity of only 6%. A lower cutoff yielded better sensitivity (23%), and still had good specificity (96%) and negative predictive value (76%), though the positive predictive value was slightly lower (67%).
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 | ||
Recommendations from others
Guidelines for Medicare reimbursement for hospice care of demented patients is outlined in the see first row of the TABLE.6
1. Schonwetter RS, Han B, Small BJ, Martin B, Tope K, Haley WE. Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliat Care 2003;20:105-113.
2. Luchins DJ, Hanrahan P, Murphy K. Criteria for enrolling dementia patients into hospice. J Am Geriatr Soc 1997;45:1054-1059.
3. Hanrahan P, Raymond M, McGowan E, Luchins D. Criteria for enrolling dementia patients in hospice: a replication. Am J Hosp Palliat Care 1999;16:395-400.
4. Mitchell SJ, Kiely DK, Hamel MB, Park PS, Morris JN, Fries BE. Estimating prognosis for nursing home residents with advanced dementia. JAMA 2004;291:2734-2740.
5. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA 2000;284:47-52.
6. Hospice of Southern Illinois, Inc web site. Criteria for dementia/Alzheimer’s disease. Available at: www.hospice.org/pdf/webdementia.pdf. Accessed on October 11, 2005.
7. Geriatric Resources, Inc. web site. Global deterioration scale. Available at: www.geriatric-resources.com/html/gds.html. Accessed on October 11, 2005.
1. Schonwetter RS, Han B, Small BJ, Martin B, Tope K, Haley WE. Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliat Care 2003;20:105-113.
2. Luchins DJ, Hanrahan P, Murphy K. Criteria for enrolling dementia patients into hospice. J Am Geriatr Soc 1997;45:1054-1059.
3. Hanrahan P, Raymond M, McGowan E, Luchins D. Criteria for enrolling dementia patients in hospice: a replication. Am J Hosp Palliat Care 1999;16:395-400.
4. Mitchell SJ, Kiely DK, Hamel MB, Park PS, Morris JN, Fries BE. Estimating prognosis for nursing home residents with advanced dementia. JAMA 2004;291:2734-2740.
5. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA 2000;284:47-52.
6. Hospice of Southern Illinois, Inc web site. Criteria for dementia/Alzheimer’s disease. Available at: www.hospice.org/pdf/webdementia.pdf. Accessed on October 11, 2005.
7. Geriatric Resources, Inc. web site. Global deterioration scale. Available at: www.geriatric-resources.com/html/gds.html. Accessed on October 11, 2005.
Evidence-based answers from the Family Physicians Inquiries Network