the clinical course of advanced dementia
DESCRIPTION
An overview of the clinical course of advanced dementia with emphasis on predictors of mortality. Geared toward the office-based physician.TRANSCRIPT
![Page 1: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/1.jpg)
The Clinical Course of Advanced Dementia
KP Edmonds MDJournal Club Presentation
![Page 2: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/2.jpg)
The ArticleMitchell, SL et al (2009). The Clinical Course of Advanced Dementia. NEJM. 361 (16). 1529-1538.
![Page 3: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/3.jpg)
Objectives
Identify the clinical features of end-stage dementia.
Understand the concept of dementia as a terminal illness.
Describe the odds ratio in regards to medical statistics.
![Page 4: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/4.jpg)
The Background
17-25 million worldwide
5 million US (13 million by 2050)
5% of those >65yo 20% of those >80yo
26% women 21% men
50% Alzheimer type
![Page 5: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/5.jpg)
The Question
Prospective look at the clinical course: Complications Physical suffering Burdensome
interventions What are the realistic
expectations for patient, family, provider?
![Page 6: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/6.jpg)
The Authors
9 identified authors
6 academic institutions
No reported conflicts
Funding Grant (NIA) Mid-career Award
![Page 7: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/7.jpg)
The Study Type
18 month Prospective Case-control Multi-center Data culled from the
CASCADE study
![Page 8: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/8.jpg)
The Study Participants
22 facilities with >60 beds
Within 60 miles of Boston
Initial factors Age 60+ Cognitive
Performance Scale Score
Length of stay >30 days
![Page 9: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/9.jpg)
The Study Participants
Secondary factors Cognitive impairment Global Deterioration
Scale score = 7 English-speaking
health care proxy
![Page 10: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/10.jpg)
The Study Data
Via Chart reviews Interviews of nurses Quarterly physical
exams SES Health Status Clinical Complications Distressing symptoms Intervention Use of hospice
![Page 11: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/11.jpg)
The Results: Participant Characteristics
![Page 12: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/12.jpg)
The Results:Participant Course
55% died 94% of deaths
were in nursing home
Probabilities: 25% death within 6
mos 41% pneumonia 53% febrile episode 86% eating problem
Figure 1
![Page 13: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/13.jpg)
The Results:Survival Probability
Figure 2a
![Page 14: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/14.jpg)
The Results:Survival Probability
Figure 2b
![Page 15: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/15.jpg)
The Results:Survival Probability
Figure 2c
![Page 16: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/16.jpg)
The Results:Problems in the Last 3 Months
Pneumonia in 37% Fever in 32% Eating problems in
90%
![Page 17: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/17.jpg)
The Results:Symptoms in the Last 3 Months
Figure 3
![Page 18: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/18.jpg)
The Results:Interventions in the Last 3 Months
40% received one “burdensome” intervention 29% received
parenteral therapy 12% hospitalized 3% taken to ED 7% tube fed
![Page 19: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/19.jpg)
The Results:Hospice in the Last 3 Months
30% referred 26% at 0-7 days
before death 26% at >181 days
before death
![Page 20: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/20.jpg)
The Results:Health Care Proxy Perspective
96% believed comfort to be the primary goal
20% believed patient had <6 months
18% reported receiving prognosis info from a physician
32% had been counseled by a physician about expected course
![Page 21: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/21.jpg)
The Results:Proxy Beliefs and the Last 3 Months
If proxies: Believed life
expectancy < 6 months
Understood clinical course of dementia
Then patients less likely to undergo “burdensome” intervention
Odds Ratio 0.12 (95% CI 0.04-0.37)
![Page 22: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/22.jpg)
Mandatory Tangent:The Odds Ratio
Compares the probability of an event between two groups 1 = same odds >1 greater odds in group
1 <1 greater odds in group
2 Ours is 0.12 so:
< 1 Greater odds of
intervention in group where proxies less aware
![Page 23: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/23.jpg)
Limitations
Geographically restricted
Relatively large institutions
Possible documentation inaccuracy
Not an inception cohort
![Page 24: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/24.jpg)
The Upshot
Dementia is a terminal illness 25% 6 month mortality
at end-stage 1.3 year median
survival Most deaths not due
to acute events (such as MI)
We must counsel our patients on what to expect!
![Page 25: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/25.jpg)
The Questions…
![Page 26: The Clinical Course of Advanced Dementia](https://reader035.vdocuments.us/reader035/viewer/2022062702/554b7101b4c90564168b50e1/html5/thumbnails/26.jpg)
References
Melzer D, Ely M, Brayne C. Cognitive impairment in elderly people: population based estimated of future in England, Scotland, Wales. BMJ 1997; 315:462.
Mitchell SL, Kiely DK, Jones RN, Prigerson H, Volicer L, Teno JM. Advanced dementia research in the nursing home: the CASCADE study. Alzheimer Dis Assoc Disord 2006;20:166-75.
Mitchell, SL et al (2009). The Clinical Course of Advanced Dementia. NEJM. 361 (16). 1529-1538.