A validated risk score to estimate mortality risk in patients with dementia and pneumonia: barriers to clinical impact

Int Psychogeriatr. 2011 Feb;23(1):31-43. doi: 10.1017/S1041610210001079. Epub 2010 Jul 26.


Background: The clinical impact of risk score use in end-of-life settings is unknown, with reports limited to technical properties.

Methods: We conducted a mixed-methods study to evaluate clinical impact of a validated mortality risk score aimed at informing prognosis and supporting clinicians in decision-making in dementia patients with pneumonia. We performed a trial (n = 69) with physician-reported outcomes referring to the score's aims. Subsequently, physician focus group discussions were planned to better understand barriers to clinical impact, and we surveyed families (n = 50) and nurses practicing in nursing homes (n = 29). We finally consulted with experts and key persons for implementation.

Results: Most (71%) physicians who used the score considered it useful, but mainly for its learning effects. Families were never informed of numerical risk estimates. Two focus group discussions revealed a reluctance to use a numerical approach, and physicians found that outcomes conditional on antibiotic treatment were inadequate to support decision-making. Nurses varied in their perceived role in informing families. Most families (88%) wished to be informed, preferring a numerical (43%), verbalized (35%), or other approach (18%) or had no preference (5%). Revising the score, we added an ethical framework for decision-making to acknowledge its complexity, an explanatory note addressing barriers related to physicians' attitudes, and a nurses' form.

Conclusion: The combined quantitative and qualitative studies elicited: substantial barriers to a numerical approach to physicians' end-of-life decision-making; crucial information for revisions and further score development; and a need for implementation strategies that focus on education.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Validation Study

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Anti-Bacterial Agents / therapeutic use
  • Decision Making
  • Dementia / complications
  • Dementia / mortality*
  • Female
  • Homes for the Aged*
  • Humans
  • Male
  • Middle Aged
  • Nurses
  • Nursing Homes*
  • Physicians
  • Pneumonia / complications
  • Pneumonia / drug therapy
  • Pneumonia / mortality*
  • Prognosis
  • Risk Assessment*
  • Severity of Illness Index
  • Terminal Care


  • Anti-Bacterial Agents