Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines

Abstract

Context: Estimating life expectancy is challenging in advanced dementia, potentially limiting the use of hospice care in these patients.

Objective: To prospectively validate and compare the performance of the Advanced Dementia Prognostic Tool (ADEPT) and hospice eligibility guidelines to estimate 6-month survival in nursing home residents with advanced dementia.

Design, setting, and participants: A prospective cohort study conducted in 21 nursing homes in Boston, Massachusetts, of 606 residents with advanced dementia who were recruited between November 1, 2007, and July 30, 2009. Data were ascertained at baseline to determine the residents' ADEPT score (range, 1.0-32.5; higher scores indicate worse prognosis) and whether they met Medicare hospice eligibility guidelines. Survival was followed up to 6 months.

Main outcome measures: Assessment and comparison of the performance of the ADEPT score and hospice guidelines to predict 6-month survival using sensitivity, specificity, and the area under the receiver operating characteristic (AUROC) curve.

Results: At baseline, the residents' mean (SD) ADEPT score was 10.1 (3.1) points and 65 residents (10.7%) met hospice eligibility guidelines. Over 6 months, 111 residents (18.3%) died. The AUROC for the ADEPT score's prediction of 6-month mortality as a continuous variable was 0.67 (95% confidence interval [CI], 0.62-0.72). The AUROC for Medicare hospice eligibility guidelines was 0.55 (95% CI, 0.51-0.59), the specificity was 0.89 (95% CI, 0.86-0.92), and the sensitivity was 0.20 (95% CI, 0.13-0.28). Using a cutoff of 13.5 on the ADEPT score, which also had specificity of 0.89, the AUROC was 0.58 (95% CI, 0.54-0.63) and the sensitivity was 0.27 (95% CI, 0.19-0.36).

Conclusions: When prospectively validated at the bedside and used as a continuous measure, the ability of the ADEPT score to identify nursing home residents with advanced dementia at high risk of death within 6 months was modest, albeit better than hospice eligibility guidelines. Care provided to these residents should be guided by their goals of care rather than estimated life expectancy.

Figure 1

Area Under the Receiver Operating Characteristic (AUROC) Curves for the ADEPT and Hospice Eligibility Guidelines’ Prediction of 6-Month Survival Among Nursing Home Residents With Advanced Dementia (N=606) ADEPT indicates Advanced Dementia Prognostic Tool. The AUROC for the ADEPT score used as a continuous measure was 0.67 (95% confidence interval [CI], 0.62-0.72); for the ADEPT score using a cutoff of more than 13.5 points, 0.58 (95% CI, 0.54-0.63); and for hospice eligibility, 0.55 (95% CI, 0.51-0.59). The 45 degree dotted line represents chance.

Figure 2

Survival Curves for the Entire Cohort of Nursing Home Residents With Advanced Dementia, Those With ADEPT Scores of 13.5 or Less and ADEPT Scores of More Than 13.5, and Those Not Meeting and Meeting Hospice Eligibility Guidelines ADEPT indicates Advanced Dementia Prognostic Tool. P<.001 for the comparison of ADEPT score of 13.5 or less and ADEPT score of more than 13.5. P=.003 for the comparison of not hospice eligible and hospice eligible.