Here - American Geriatrics Society

P OSTER
A BSTRACTS
The oldest old (age>85yo) are the fastest growing segment of
the US population
About 27% of Medicare’s annual $426 billion budget goes to
care for patients in their final year of life, with acute hospitalizations
being a major cost.
Evidence supports improved clinical and utilization outcomes
with palliative care consults for seriously ill patients and increased
patient and family satisfaction.
The goal of this study was to assess the role of palliative care
consults(PCC)in preventing futile escalation of care in a cohort of seriously
ill oldest old inpatients.
Methods:
A retrospective chart review of palliative care consults in a tertiary
academic medical center between August 2008 and June 2011
yielded 314 patients >85 yo. Charts were reviewed to extract patient
demographics,admitting diagnosis, inpatient mortality and disposition
post PCC including initiation of “Do Not Escalate Care” pathway
and facilitation of Hospice discharge.
Results:
-Of the 314 patients identified, there were 148 males (47%) and
166 females (53%).153 patients (49%) were nonagenarians.
-Admission diagnosis included Cancer: 25% (77), Stroke:15%
(48), Cardiac:15% (47), Dementia: 12% (36), Pulmonary: 6% (8), and
Other (including infection, falls, failure to thrive, Hepatic & Renal
disease): 27% (86)
-36% (113 patients) died during the course of hospitalization.
-PCC resulted in the initiation of the “Do Not Escalate Care”
pathway in 73% (229 patients) during the hospitalization.
-Of the 201 patients who did not die during the hospitalization,hospice
was initiated in 60% (113 patients): 32% home hospice,
22% long term care facility with hospice, 6% inpatient hospice. Non
hospice discharges: 17% SNF and 18% home. No discharge data
available: 5%.
Conclusions:
-Oldest old inpatients had a high (36%) in hospital mortality.
Most deaths were expected and due to serious illnesses including
Cancer, Stroke, end stage cardiac, lung and renal disease.
-PCC resulted in initiation of the “Do Not Escalate Care” pathway
in 73% of the patients, thereby preventing ineffective interventions
(such as CPR, invasive procedures, ICU care) in this seriously ill
population of older adults;
-PCC facilitated discharge to hospice in 60% of the survivors,
thereby promoting comfort and quality of life while avoiding prolonged
hospitalizations.
B148
Predicting Mortality in End Stage Dementia: A Retrospective
comparison of Medicare Guidelines and Mitchell Criteria for
Hospice Referral.
J. Almeida, M. C. Galicia-Castillo. Internal Medicine/Geriatrics,
Eastern Virginia Medical School, Norfolk, VA.
Background: Dementia is the sixth-leading cause of death posing
a significant cost of $183 billion annually(1). The progression of
the disease is variable, with the end stage lasting as long as three
years(2). Current guidelines for predicting six-month mortality have
been under scrutiny; they are not evidenced-based and were never
studied prior to implementation as hospice criteria(3,4). Mitchell et al
derived a mortality risk index for six-month mortality using items
from the minimum data set. The objective of this study was to compare
the Mitchell risk index to Medicare guidelines in predicting sixmonth
mortality in end-stage dementia(3).
Methods: A retrospective chart review of patients who died
from dementia in a nursing home facility from January 2004 through
December of 2009 was performed. Data points from three, six and
twelve months prior to death were collected from the minimum data
set. At each point subjects were coded as eligible or ineligible for hospice
according to Mitchell risk index and Medicare guidelines.
Results: At six months prior to death, out of 24 subjects, the
Mitchell risk index score identified 13 (54%) as eligible for hospice
and Medicare guidelines identified six(25%; p =0.16). Three months
prior to death, out of 24 subjects Mitchell risk index identified 19
(79%); using Medicare guidelines identified nine(37.5%, p=0.118)
Conclusion: Current guidelines for predicting six-month mortality
for appropriate hospice referral for end-stage dementia are inaccurate.
The Mitchell risk index may be a better tool to help clinicians
better prognosticate six-month mortality and employ hospice services
earlier.
References
1 Herbert, LE; Scherr, PA; Bienias, JL; Bennet, DA. Alzheimer
Disease in the U.S. Population: Prevalence Estimates Using the 2000
Census. Archives of Neurology August 2003:60(8)1119-1122.
2 Shuster, J. Palliative Care for Advanced Dementia. Clinics in
Geriatric Medicine 2000: 16(2).
3 Mitchell, SL; Kiely, DK; Hamel, MB; Park, PS; Morriss, JN;
Fries, BE. Estimating Prognosis for Nursing Home Residents with
Advanced Dementia. JAMA2004:291 (22) 2734-2740.
4 Schonwetter RS, Han B, Small BJ, Martin B, Tope K, Haley
WE. Predictors of six-month survival among patients with dementia.
American Journal of Hospice and Palliative Care 2003:(20):105-113.
B149 Encore Presentation
Pain is good for you? Non-cancer pain predicts improved 5-year
survival.
J. Shega, 1 M. Andrew, 2 D. Lau, 3 K. Herr, 4 M. Ersek, 5 D. Weiner, 6
W. Dale. 1 1. Medicine, University of Chicago, Chicago, IL; 2.
Medicine, Dalhousie University, Halifax, NS, Canada; 3. Pharmacy,
University of Illinois, Chicago, IL; 4. Nursing, University of Iowa, Des
Moines, IA; 5. Nursing, University of Pennsylvania, Philidelphia, PA;
6. Medicine, University of Pittsburgh, Pittsburgh, PA.
Supported By: NIA
Background: Non-cancer pain is known to result in significant
morbidity, but little is known about its impact on mortality. We assessed
the relationship of self-reported non-cancer pain at baseline
and subsequent 5-year mortality among community-dwelling older
adults.
Methods: We analyzed data from a large prospective cohort
study, the 1996 wave of the Canadian Study of Health and Aging.
Non-cancer pain was assessed using the 5-point verbal descriptor
scale, dichotomized into “no/very mild” versus “moderate” or greater
pain. Frailty was measured as the sum of self-reported health (1
item), social support (1 item), co-morbidity (17 items), and functional
abilities (14 items) with each item scored from 0 to 1, ranging from 0-
33, with higher scores indicating greater frailty. Cognitive status was
measured using the Modified Mini-Mental Status Exam, ranging
from 0-100, with a score 11
indicating depression. Multivariable logistic regression was used to
analyze the relationship between pain and mortality, controlling for
other factors.
Results: Of the 5,703 participants, 4,694 (82.3%) had complete
data for analysis. Of these, 35.4% reported moderate or greater pain
and 28.6% had died at 5-year follow-up. The 5-year mortality odds
increased by 1.12 (CI: 1.10, 1.13); p