(Press-News.org) BOSTON—The system for hospice admissions for patients with advanced dementia, which is a terminal illness, should be guided by patient and family preference for comfort, not estimated life expectancy, says a new study published in the Nov. 3 Journal of the American Medical Association by the Institute for Aging Research at Hebrew SeniorLife, an affiliate of Harvard Medical School.
Currently, patients requesting hospice services must be certified by their physician to have six months or less to live, and must sign a statement choosing comfort care services in lieu of curative treatments.
"Whether a patient with advanced dementia lives one month, six months or longer," says lead author Susan L. Mitchell, M.D., M.P.H., a senior scientist at the Institute for Aging Research, "they should get high-quality palliative [comfort] care if that is their wish. Because we can't predict with a high level of accuracy who will die within six months, hospice eligibility should be guided by a desire for comfort care, not by how long a patient is expected to live."
Hospice has been shown to benefit patients dying with dementia, but hospice has traditionally under-served dementia patients. Only about 10 percent of hospice patients have a diagnosis of dementia and only an estimated one out of 10 people dying with dementia gets hospice care. Hospice professionals cite estimating life expectancy as the main hindrance to enrolling patients.
Earlier this year, Dr. Mitchell and her colleagues created a new tool to assess mortality risk in advanced dementia patients. The 12-item Advanced Dementia Prognostic Tool (ADEPT) scores such measures as age, shortness of breath, bowel incontinence, and weight loss to estimate a dementia patient's estimated risk of death within six months. The higher the score, the higher the risk of death. The tool was designed using rigorous statistical models and a nationwide database of nursing home residents with advanced dementia.
vThe Institute for Aging Research study then compared the ability of the ADEPT score to current Medicare hospice guidelines to predict six-month survival in a cohort of 606 Greater Boston-area nursing home residents with end-stage dementia.
Medicare hospice eligibility guidelines use two criteria to estimate life expectancy for dementia patients: a score of at least 7c on the Functional Assessment Staging scale (inability to dress, bathe or toilet; bowel incontinence; speech limited to less than 5 words; and non-ambulatory) and the presence of at least one of six serious medical conditions in the past year. How well these criteria actually predict six-month survival had not been previously known.
Dr. Mitchell found that 67 percent of the time the ADEPT score correctly classified residents who died and those who did not die over six months. In comparison, current hospice criteria correctly classified those who died and those who survived only 55 percent of the time, or slightly better than chance.
The findings show that while the ADEPT score was better than the current Medicare criteria at predicting the death of advanced dementia patients within six months, its predictive ability was not perfect. This underscores the challenge of estimating how long one will live with advanced dementia and suggests, says Dr. Mitchell, that determining eligibility for hospice based on life expectancy for these patients limits their access to hospice services.
"Our study strongly suggests that delivery of palliative care to these patients should be guided by a preference for comfort as the primary goal and not by life-expectancy estimates," says Dr. Mitchell, an associate professor of medicine at Harvard Medical School. "The challenge for health-care professionals is to ensure that high-quality palliative care is accessible to the growing number of individuals dying with dementia in nursing homes, an effort that may necessitate both revisiting the six-month prognosis requirement for hospice and expanding comprehensive palliative care services in the nursing home."
Currently, more than 5 million Americans suffer from dementia, a number that is expected to increase by almost three-fold in the next 40 years. Dementia is a group of symptoms severe enough to interfere with daily functioning, including memory loss, difficulty communicating, personality changes, and an inability to reason. Alzheimer's disease is the most common form of dementia.
A 2009 study by Dr. Mitchell and her colleagues (Oct. 15, 2009 New England Journal of Medicine) was the first to rigorously describe the clinical course of dementia and to label the disease a terminal illness similar to other incurable illnesses, such as cancer.
Scientists at the Institute for Aging Research seek to transform the human experience of aging by conducting research that will ensure a life of health, dignity and productivity into advanced age. The Institute carries out rigorous studies that discover the mechanisms of age-related disease and disability; lead to the prevention, treatment and cure of disease; advance the standard of care for older people; and inform public decision-making.
The Institute has introduced many well regarded assessment tools, including the Minimum Data Set, which helps nursing homes gather information on residents' health, needs and strengths in order to develop the best caregiving plans.
###
Founded in 1903, Hebrew SeniorLife, an affiliate of Harvard Medical School, is a nonprofit, nonsectarian organization devoted to innovative research, health care, education and housing that improves the lives of seniors.
END
In a study examining the factors that play a role in an older adult's transition to disability, intervening illnesses and injuries that led to hospitalization or activity restriction were associated with worsening functional ability, especially among those who were physically frail, according to a study in the November 3 issue of JAMA, a theme issue on aging.
Thomas M. Gill, M.D., of the Yale University School of Medicine, New Haven, Conn., presented the findings of the study at a JAMA media briefing at the National Press Club.
Among older persons, disability in essential ...
Use of a fall prevention tool kit, which included a fall risk assessment, patient-specific prevention plan, an educational handout and a poster for over the patient's hospital bed reduced the number of older patients with falls in hospitals, according to a study in the November 3 issue of JAMA, a theme issue on aging.
Patricia C. Dykes, R.N., D.N.Sc., of Partners HealthCare System, Brigham and Women's Hospital and Harvard Medical School, Boston, presented the findings of the study at a JAMA media briefing at the National Press Club.
"Falls are a public health problem ...
In a review of comprehensive primary care programs for older adults with multiple chronic conditions, authors identified three models that appear to have the greatest potential for improving quality of care and life for these patients, while reducing or not increasing the costs of their health care, according to an article in the November 3 issue of JAMA, a theme issue on aging.
Chad Boult, M.D., M.P.H., M.B.A., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, presented the findings of the study at a JAMA media briefing at the National Press Club.
"Older ...
Patients with mild to moderate Alzheimer's disease (AD) who received supplementation with the omega-3 fatty acid docosahexaenoic acid (DHA), believed to possibly reduce the risk of AD, did not experience a reduction in the rate of cognitive and functional decline, compared to patients who received placebo, according to a study in the November 3 issue of JAMA, a theme issue on aging.
Joseph F. Quinn, M.D., of Oregon Health and Science University and the Portland VA Medical Center, Portland, Ore., presented the findings of the study at a JAMA media briefing at the National ...
VIDEO:
Researchers show that obesity-induced heart disease can be prevented by reducing the activity of TOR, a nutrient-sensing protein that regulates molecular circuits involved in growth, metabolism and lifespan.
Click here for more information.
LA JOLLA, Calif., November 2, 2010 – It's no secret that obesity is hard on the heart. More than 30 percent of Americans are obese, and many of them are also at increased risk for cancer, diabetes and heart disease. However, there ...
Survival for colorectal cancer patients with MUTYH-associated polyposis was statistically significantly better than for patients with colorectal cancer from the general population, according to a recent study published online November 2 in The Journal of the National Cancer Institute.
People who inherit a mutation in the MUTYH gene have nearly a 100% risk for developing colon cancer at some point in their lifetimes. But it is unknown whether specific histological and molecular genetic features of cancer associated with this genotype influence tumor behavior and survival. ...
A team led by researchers at the National Human Genome Research Institute (NHGRI), part of the National Institutes of Health, has captured the most comprehensive snapshot to date of DNA regions that regulate genes in human pancreatic islet cells, a subset of which produces insulin.
The study highlights the importance of genome regulatory sequences in human health and disease, particularly type 2 diabetes, which affects more than 20 million people in the United States and 200 million people worldwide. The findings appear Nov. 3 in Cell Metabolism.
"This study applies ...
The nature-nurture debate is a "giant step" closer to being resolved after scientists studying bees documented how environmental inputs can modify our genetic hardware. The researchers uncovered extensive molecular differences in the brains of worker bees and queen bees which develop along very different paths when put on different diets The research was led by Professor Ryszard Maleszka of The Australian National University's College of Medicine, Biology and Environment, working with colleagues from the German Cancer Institute in Heidelberg, Germany and will be published ...
Immune cells known as microglia, long thought to be activated in the brain only when fighting infection or injury, are constantly active and likely play a central role in one of the most basic, central phenomena in the brain – the creation and elimination of synapses. The findings, publishing next week in the online, open access journal PLoS Biology, catapult the humble microglia cell from its well-recognized duty of protecting the brain to direct involvement in creating the cellular networks at the core of brain behavior. Its apparent role as an architect of synapses – ...
Scientists, in collaboration with researchers at the universities of Southampton and Calgary, used finger ratios from fossilised skeletal remains of early apes and extinct hominins, as indicators of the levels of exposure species had to prenatal androgens – a group of hormones that is important in the development of masculine characteristics such as aggression and promiscuity.
It is thought that androgens, such as testosterone, affect finger length during development in the womb. High levels of the hormones increase the length of the fourth finger in comparison to the ...
