This is the eleventh in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).
Mr. Z is a 87 year old with advanced dementia living in a nursing home. At baseline he cannot recognize family members, is dependent on all ADLs (dressing, toileting, bathing) but does not have urinary or fecal incontinence. He speaks about 1-2 intelligible words per day and he has had progressive loss of ability to ambulate. He is now admitted to the hospital after sustaining a hip fracture from a fall.
When discussing treatment options for his hip fracture, his wife asks you how long he likely has to live.
Given his current state of health, what would be the most appropriate answer:
a) Given that he does not meet FAST 7C criteria his prognosis is likely greater than 6 months
b) He meets NHPCO Guidelines for hospice eligibility which means he likely has less than a 6 month prognosis
c) Given his advanced dementia and recent hip fracture, his 6 month mortality risk exceeds 50%
d) As with most individuals with advanced dementia, his life expectancy is likely weeks to months
Discussion: Correct answer is (c)
a) The FAST scale measures functional status in dementia and consists of 7 major stages split into 16 different sub-stages. Hospice eligibility criteria for dementia are based largely on whether a patient meets or exceeds Stage 7c on the FAST and whether they have at least one complication from their dementia. Unfortunately, these criteria do not accurately predict 6-month survival.
b) The current National Hospice and Palliative Care Organization (NHPCO) guidelines for hospice eligibility are of limited accuracy in predicting death within 6 months. In addition, NHPCO guidelines relies on the FAST staging, which fails to account for the observation that dementia often does not progress in a sequential pattern. The patient is dependent on ADLs (dressing, toileting, bathing) but does not have urinary or fecal incontinence (FAST Stage 6d and 6e). His speech has declined from less than 6 intelligible words per day (7a) to one or less (7b), and he has had progressive loss of ability to ambulate (7C), however since he does not have 6d and 6e, Mr. Z is not considered Fast Stage 7c, rather he is Fast 6C.
c) Is the correct answer: Individuals with advanced dementia that are either hospitalized for either pneumonia or for hip fracture have a very poor prognosis. In one study, six-month mortality for patients with end-stage dementia and hip fracture was 55% compared with 12% for cognitively intact patients.
d) Advanced dementia is a terminal condition; however estimating prognosis is difficult due to the prolonged period of severe functional and cognitive impairment that occurs prior to death. For those with advanced disease who reside in a nursing home, the 6-month mortality rate is 25% with a median survival in one study of only 478 days.
- Mitchell SL, Miller SC, Teno JM, Kiely DK, Davis RB, Shaffer ML. Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA. Nov 3 2010;304(17):1929-1935.
- Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. Jama. Jul 5 2000;284(1):47-52.
- Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. Oct 15 2009;361(16):1529-1538.
(For email readers - click here for the answer and discussion)