Modify hospice eligibility for dementia patients, says Institute for Aging Research study

The system for hospice admissions for patients with advanced dementia, which is a terminal illness, should be guided by patient and family preference for comfort, not estimated life expectancy, says a new study published in the Nov. 3 Journal of the American Medical Association by the Institute for Aging Research at Hebrew SeniorLife, an affiliate of Harvard Medical School.

Currently, patients requesting hospice services must be certified by their physician to have six months or less to live, and must sign a statement choosing comfort care services in lieu of curative treatments.

"Whether a patient with advanced dementia lives one month, six months or longer," says lead author Susan L. Mitchell, M.D., M.P.H., a senior scientist at the Institute for Aging Research, "they should get high-quality palliative [comfort] care if that is their wish. Because we can't predict with a high level of accuracy who will die within six months, hospice eligibility should be guided by a desire for comfort care, not by how long a patient is expected to live."

Hospice has been shown to benefit patients dying with dementia, but hospice has traditionally under-served dementia patients. Only about 10 percent of hospice patients have a diagnosis of dementia and only an estimated one out of 10 people dying with dementia gets hospice care. Hospice professionals cite estimating life expectancy as the main hindrance to enrolling patients.

Earlier this year, Dr. Mitchell and her colleagues created a new tool to assess mortality risk in advanced dementia patients. The 12-item Advanced Dementia Prognostic Tool (ADEPT) scores such measures as age, shortness of breath, bowel incontinence, and weight loss to estimate a dementia patient's estimated risk of death within six months. The higher the score, the higher the risk of death. The tool was designed using rigorous statistical models and a nationwide database of nursing home residents with advanced dementia.
vThe Institute for Aging Research study then compared the ability of the ADEPT score to current Medicare hospice guidelines to predict six-month survival in a cohort of 606 Greater Boston-area nursing home residents with end-stage dementia.

Medicare hospice eligibility guidelines use two criteria to estimate life expectancy for dementia patients: a score of at least 7c on the Functional Assessment Staging scale (inability to dress, bathe or toilet; bowel incontinence; speech limited to less than 5 words; and non-ambulatory) and the presence of at least one of six serious medical conditions in the past year. How well these criteria actually predict six-month survival had not been previously known.

Dr. Mitchell found that 67 percent of the time the ADEPT score correctly classified residents who died and those who did not die over six months. In comparison, current hospice criteria correctly classified those who died and those who survived only 55 percent of the time, or slightly better than chance.