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Am Fam Physician. 2003;68(8):1639-1643

Alzheimer's disease accounts for approximately 7 percent of all deaths in the United States. Hospice programs are established to assist persons with life-limiting illnesses and provide a care option for patients with endstage dementia. The National Hospice Organization (NHO) developed hospice eligibility guidelines for patients with noncancer diseases, including end-stage dementia. However, when these guidelines were developed, there was minimal information on the six-month survival of patients with dementia, and the guidelines were not tested before their release. Medicare developed more recent regional guidelines based on guidelines of the NHO. Predicting the life expectancy of patients with Alzheimer's dementia is difficult because some patients can survive for extended periods, especially if they have no comorbidities. Schonwetter and colleagues performed this study to determine if the Medicare hospice guidelines for patients with dementia were valid and to identify the prognostic factors that could accurately identify dementia patients with a life expectancy of fewer than six months.

The study was a retrospective chart audit of patients admitted to a community-based hospice program with the diagnosis of dementia. Before patients are admitted, the attending physician and hospice medical director must have certified that the patient's life expectancy was less than six months. Patients were excluded from the study if they had other dementia illnesses that are not progressive, such as dementia secondary to trauma or substance abuse, or if they had a diagnosis of stroke. The 165 patients who were included in the study were separated into two groups: those who died within six months (126 patients) and those who died after six months (39 patients). Data collected on admission included demographic and clinical information, the Karnofsky Performance Scale, the Functional Assessment Staging Scale (FAST), and the Charlson Comorbidity Index. In addition, scales assessing appetite, nourishment, mobility, and pain were completed. Re searchers also recorded information on care provided and outcomes during the hospice stay. The length of survival was calculated from the date of admission to hospice until the date of death. The criteria for eligibility for Medicare Hospice Benefit at the time of the study are listed in (see accompanying table).

The results of the study found no correlation between the Medicare guidelines or any component of the guidelines and estimation of six-month survival. Patients with dementia who met the Medicare guidelines and those who did not meet the criteria had similar survival curves. When multivariate analysis was performed, the variables that were significant in predicting shorter survival times included increased age, anorexia, and a poorer functional status as defined by the Karnofsky Performance Scale. In addition, the combination of anorexia and greater functional impairment was a significant predictor of shorter survival.

Stage 7 or beyond according to the FAST scale
Unable to ambulate without assistance
Unable to dress without assistance
Unable to bathe without assistance
Urinary or fecal incontinence, intermittent or constant
No meaningful verbal communication, stereotypical phrases only, or ability to speak limited to six or fewer intelligible words
Plus one of the following within the past 12 months:
Aspiration pneumonia
Pyelonephritis or other upper UTI
Multiple stage 3 or 4 decubitus ulcers
Fever that recurs after antibiotic therapy
Inability to maintain sufficient fluid and calorie intake, with 10 percent weight loss during the previous six months or serum albumin level less than 2.5 g per dL (25 g per L)

The authors conclude that the current Medicare guidelines are not valid predictors of life expectancy in patients with dementia. Patients with advanced age, impaired nutritional status, and greater functional impairment have shorter survival times. The authors add that these variables should be used in addition to the Medicare guidelines to provide physicians with a more accurate method of predicting life expectancy in patients with dementia.

editor's note: One of the most challenging aspects of end-of-life care is predicting life expectancy in patients with noncancer diagnoses. This is particularly true in patients who have Alzheimer's disease. Despite the devastating effect of this dementia on cognitive function, it has little impact on other organ systems until it begins to negatively affect nutritional status. The study by Schonwetter and colleagues provides better guidelines for predicting life expectancy in patients with Alzheimer's disease. These guidelines could help physicians in discussing a patient's prognosis with family members. In addition, they will assist physicians in determining when a hospice referral is appropriate. Family members benefit from multidisciplinary team support from health care workers during the final stages of a loved one's life.—k.e.m.

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