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The long clinical course of advanced dementia makes estimating an accurate short-term prognosis difficult. Individuals with advanced disease may survive for long periods of time with severe functional and cognitive impairments. They are also at risk of sudden, life-threatening complications of advanced dementia, such as pneumonias and urinary tract infections. These complications can serve as a marker of a very poor short-term survival. In one prospective study of advanced dementia residing in a nursing home, the 6-month mortality rates after the development of pneumonia, a febrile episode, or eating problems, were 47%, 45%, and 39%, respectively. Short-term survival rates are similar for individuals with advanced dementia who are admitted to the hospital with either pneumonia or a hip fracture, with 6-month mortality rates exceeding 50%.
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Several validated indices have been developed to predict survival in advanced dementia; however, their ability to predict the risk of death within 6 months is poor. An example of a mortality index that can be used in nursing home residents with advanced dementia is the Advanced Dementia Prognostic Tool (ADEPT). The ADEPT can help identify nursing home residents with advanced dementia who are at high risk of death within 6 months, although only marginally better than current hospice eligibility guidelines.
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Congestive Heart Failure
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The majority of deaths from advanced heart failure are preceded by a period of worsening symptoms, functional decline, and repeated hospitalizations as a result of progressive pump failure. Despite significant advances in the treatment of heart failure, the prognosis in patients who have been hospitalized for heart failure remains poor, with a 1-year mortality rates ranging from 20% to 47% after discharge. The prognosis only worsens for those with multiple hospitalizations. In one prospective study, the median survival after the first, second, third, and fourth hospitalization was 2.4, 1.4, 1.0, and 0.6 years, respectively. Advanced age also worsens prognosis as the median survival decreases to 1 year for 85-year olds after 1 hospitalization and approximately 6 months after 2 hospitalizations.
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Other indicators of a poor prognosis in heart failure include patient demographic factors, heart failure severity, comorbid diseases, physical examination findings, and laboratory values. Heart-failure-specific prognostic indices often combine many of these factors to help identify patients who are have a high short-term mortality. The Seattle Heart Failure Model is a well-validated index composed of 14 continuous and 10 categorical variables that provides accurate estimates on 1-, 2-, and 5-year mortality, as well as mean life expectancy both pre- and postintervention. An online calculator is available at http://depts.washington.edu/shfm/.
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Chronic Obstructive Pulmonary Disease
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Severity of disease, comorbidities, and, to a lesser degree, acute exacerbations influence prognosis in chronic obstructive pulmonary disease (COPD). The most widely studied mortality index in COPD is the BODE index (Table 3–3). It includes 4 variables known to influence mortality in COPD: weight (body mass index [BMI]), airway obstruction (forced expiratory volume at 1 second [FEV1]), dyspnea (Medical Research Council dyspnea score), and exercise capacity (6-minute walk distance). The BODE index has been shown to be more accurate than mortality predications based solely on FEV1. However, the BODE index is not useful in predicting short-term life expectancy (in weeks to months).
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Prognosis for earlier stage cancer is primarily based on tumor type, disease burden, and aggressiveness suggested by clinical, imaging, laboratory, pathologic, and molecular characteristics. Tumor-specific factors tend to lose prognostic significance for patients with very advanced cancer. For these advanced cancers, patient-related factors, such as performance status and clinical symptoms, have increasing significance in regards to short-term mortality. Performance status has consistently been found to be a strong predictor of survival in cancer patients. Several different measures of performance status have been developed, including the Eastern Cooperative Oncology Group (ECOG) (Table 3–4) and the Karnofsky Performance Status Score (KPS) (Table 3–5). High performance status score does not necessarily predict long survival, although low or decreasing prognostic scores have been shown to be reliable in predicting a poor short-term prognosis. Symptoms that are associated with a poor short-term prognosis in advanced cancer include dyspnea, dysphagia, weight loss, xerostomia, anorexia, and cognitive impairment. The Palliative Prognostic Index (PPI) is an example of a tool that predicts short-term survival of advanced cancer patients in the palliative care setting by combining functional status with presence of symptoms of edema, delirium, dyspnea at rest, and oral intake.
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