Abstract
Objective
Difficulties with prognostication prevent more patients with advanced dementia from
receiving timely palliative support. The aim of this study is to develop and validate
a prognostic model for 6-month and 1-year mortality in home-dwelling patients with
advanced dementia.
Design
Prospective cohort study.
Setting and Participants
The data set of 555 home-dwelling patients with dementia at Functional Assessment
Staging Test stage 7 was split into derivation (n = 275) and validation (n = 280)
cohorts.
Methods
Cox proportional hazards regression modeled survival in the derivation cohort using
prognostic variables identified in univariate analysis. The model was validated internally
and using 10-fold cross-validation. Area under the receiver operating characteristic
curve measured the accuracy of the final model.
Results
Four hundred nineteen (75.5%) patients died with a median follow-up of 47 days [interquartile
range (IQR) 161]. Prognostic variables in the multivariate model included serum albumin
level, dementia etiology, number of homecare admission criteria fulfilled, presence
of moderate to severe chronic kidney disease, peripheral vascular disease, quality
of life in late-stage dementia scores, housing type, and the Australian National Sub-Acute
and Non-Acute Patient palliative care phase.
The model was refined into a parsimonious 6-variable model [Palliative Support DEMentia
Model (PalS-DEM)] consisting of age, dementia etiology, Functional Assessment Staging
Test stage, Charlson Comorbidity Index scores, Australian National Sub-Acute and Non-Acute
Patient palliative care phase, and 30-day readmission frequency for the prediction
of 1-year mortality. The area under the receiver operating characteristic curve was
0.65 (95% confidence interval 0.59–0.70). Risk scores categorized patients into 3
prognostic groups, with a median survival of 175 days (IQR 365), 104 days (IQR 246),
and 19 days (IQR 88) for the low-risk (0‒1 points), moderate-risk (2‒4), and high-risk
(≥5) groups, respectively.
Conclusions and Implications
The PalS-DEM identifies patients at high risk of death in the next 1 year. The model
produced consistent survival results across the derivation, validation, and cross-validation
cohorts and will help healthcare providers identify patients with advanced dementia
earlier for palliative care.
Keywords
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Article info
Publication history
Published online: December 14, 2020
Footnotes
Allyn Hum MRCP and Pradeep Paul George PhD are co first authors.
This study was supported by Temasek Foundation Cares (Grant TC-APP-3-39).
The sponsor has no role in the study design, methods, participant recruitment, data collection, analysis, and preparation of this report.
The authors declare no conflicts of interest.
Identification
Copyright
© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
