Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines.
BACKGROUND
Estimating life expectancy is challenging in advanced dementia, potentially limiting the use of hospice care in these patients.


OBJECTIVE
To prospectively validate and compare the performance of the Advanced Dementia Prognostic Tool (ADEPT) and hospice eligibility guidelines to estimate 6-month survival in nursing home residents with advanced dementia.


METHODS
A prospective cohort study conducted in 21 nursing homes in Boston, Massachusetts, of 606 residents with advanced dementia who were recruited between November 1, 2007, and July 30, 2009. Data were ascertained at baseline to determine the residents' ADEPT score (range, 1.0-32.5; higher scores indicate worse prognosis) and whether they met Medicare hospice eligibility guidelines. Survival was followed up to 6 months.


METHODS
Assessment and comparison of the performance of the ADEPT score and hospice guidelines to predict 6-month survival using sensitivity, specificity, and the area under the receiver operating characteristic (AUROC) curve.


RESULTS
At baseline, the residents' mean (SD) ADEPT score was 10.1 (3.1) points and 65 residents (10.7%) met hospice eligibility guidelines. Over 6 months, 111 residents (18.3%) died. The AUROC for the ADEPT score's prediction of 6-month mortality as a continuous variable was 0.67 (95% confidence interval [CI], 0.62-0.72). The AUROC for Medicare hospice eligibility guidelines was 0.55 (95% CI, 0.51-0.59), the specificity was 0.89 (95% CI, 0.86-0.92), and the sensitivity was 0.20 (95% CI, 0.13-0.28). Using a cutoff of 13.5 on the ADEPT score, which also had specificity of 0.89, the AUROC was 0.58 (95% CI, 0.54-0.63) and the sensitivity was 0.27 (95% CI, 0.19-0.36).


CONCLUSIONS
When prospectively validated at the bedside and used as a continuous measure, the ability of the ADEPT score to identify nursing home residents with advanced dementia at high risk of death within 6 months was modest, albeit better than hospice eligibility guidelines. Care provided to these residents should be guided by their goals of care rather than estimated life expectancy.
The Hebrew Senior Life, Institute for Aging Research, Boston, Massachusetts, USA.
Susan L
SL
Mitchell
Susan C
SC
Miller
Joan M
JM
Teno
Dan K
DK
Kiely
Roger B
RB
Davis
Michele L
ML
Shaffer
D000368:Aged; D000369:Aged, 80 and over; D003704:Dementia / Q000145:classification* / Q000401:mortality*; D004608:Eligibility Determination; D005260:Female; D017408:Guidelines as Topic; D017051:Hospice Care; D006801:Humans; D008017:Life Expectancy; D008297:Male; D006278:Medicare; D009735:Nursing Homes; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D012306:Risk; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D016019:Survival Analysis; D014481:United States