prognosticating for elderly patients
DESCRIPTION
An interactive talk on prognosis / frailty assessment tools, the commonalities and key factors, and misconceptions about assessing prognosis in elderly people. Relies heavily on ePrognosis.org - a great site!TRANSCRIPT
PrognosticatingDr Colin Mitchell
Prognosis in the Elderly
Truth or Falsehood?Predicting prognosis in frail elderly is a fool’s errand
Comorbidities are the best predictor
Most estimates are based on white Americans
Prognosis correlates with frailty
Inpatient Mortality
You have just clerked Mrs McRory72 years old, admitted with inf exac COPD
History of PMR. Ex smoker. No home nebs/O2
Rx: inhalers, calcium & vit D
Usually mobile with a stick, currently needs A of 1
U&E at baseline, Creat 100. Alb 31.
What is Mrs McRory’s 1yr Mortality?
Please discuss with your immediate neighbour and predict what % chance she has of death in the next year.
Then we’ll compare with the Inouye scale
The Inouye Scale
Mrs McRory’s 1yr mortality would be 32%
She scores a point for:
• Chronic Lung Disease
• Albumin <35
• Unable to mobilise unaided
=3/7
Other points for
• Comorbidities (up to 3)
• Creatinine >135
• Dementia
The Inouye scale is:
Based on ~500 admissions, validated on 1200
77% accurate (ROC curve 0.77)
Inpatient Mortality 2
You are about to discharge Mr Khan home76 years old, admitted with inf exac COPD
Previously living independently, now has once-daily POC for help with washing/dressing
U&E at baseline, Creat 160. Albumin 29
What is Mr Khan’s 1yr Mortality?
Please discuss with your immediate neighbour and predict what % chance he has of death in the next year.
Then we’ll compare with the Walter / Covinsky scale
What is Mr Khan’s 1yr Mortality?
Please discuss with your immediate neighbour and predict what % chance he has of death in the next year.
Then we’ll compare with the Walter / Covinsky scale
Actually, let’s make it a bit different…
Inpatient Mortality 2a
You are about to discharge Mr Khan home76 years old, admitted with inf exac COPD & CRF
Previously living independently, now has once-daily POC for help with washing/dressing
U&E at baseline, Creat 330. Albumin 29
The Walter / Covinsky ScaleMr Khan’s 1yr mortality was 34%
He scores for:
• Help with 2 PADLs (+2)
• Albumin <30 (+2)
• Male sex
=5/17
But add CRF (Creat >300, +2), mortality 64%
Other points for
• Cancer (solitary +3, metastatic +8)
• Heart failure (+2)
The Walter / Covinsky scale is:
Based on ~1500 discharges, validated internally & externally
79% accurate (ROC curve 0.79)
Community-Dweller Mortality
You have just seen Mr Gordon for clinic F/UReferred for investigation of dyspnoea, improved.
80 years old. Ex smoker. BMI 21.
Normal CXR & PFTs. Echo: Mild LVSD
Rx: Enalapril 10mg, Bisoprolol 2.5mg
Largely independent.
Now able to walk 1 mile, can lift boxes
Mild memory problems, son now manages finances. AMT 8/10
What is Mr Gordon’s 4 year mortality?
Please discuss with your immediate neighbour and predict what % chance he has of death in the next 4 years.
Then we’ll compare with the Covinksy / Lee index
The Lee / Covinsky ScaleMr Gordon’s 4yr mortality is 34%
He scores for:
• Age 80 (+5 as baseline is 50 years old)
• Male sex
• BMI <25
• CCF (+2)
• Needs help managing finances (+2)
= 11
Other points for:
Diabetes, Cancer (+2)
Current smoking
Needs help with washing/dressing (+2)
Can’t walk several blocks (+2) or move a chair (+2)
The Lee / Covinsky scale is:
Based on ~12 000 people, validated on 8000
82% accurate (ROC curve 0.82)
Take home messages
You can predict prognosisor at least odds of dying
There are validated toolsThey’re the same tools we use to judge frailty
Key factors:Age (in community dwellers), sex, smoking
Being underweight
Comorbidities, especially CA and cardioresp
Creatinine & albumin
Function & mobility
Admission to hospital
www.ePrognosis.org