The Hebrew Senior Life, Institute for Aging Research, Boston, Massachusetts, USA.
JAMA. 2010 Nov 3;304(17):1929-35. doi: 10.1001/jama.2010.1572.
Estimating life expectancy is challenging in advanced dementia, potentially limiting the use of hospice care in these patients.
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.
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.
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).
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.
在晚期痴呆症中，估计预期寿命具有挑战性，这可能限制了这些患者接受临终关怀的使用。
前瞻性验证和比较高级痴呆预后工具（ADEPT）和临终关怀资格指南，以估计患有晚期痴呆症的养老院居民的 6 个月生存率。
设计、地点和参与者：前瞻性队列研究，在马萨诸塞州波士顿的 21 家养老院进行，共招募了 606 名患有晚期痴呆症的居民，他们于 2007 年 11 月 1 日至 2009 年 7 月 30 日期间入组。在基线时确定居民的 ADEPT 评分（范围为 1.0-32.5；分数越高表示预后越差）和他们是否符合医疗保险临终关怀资格标准。对生存情况进行了 6 个月的随访。
使用灵敏度、特异性和接收者操作特征（ROC）曲线下面积（AUROC）评估 ADEPT 评分和临终关怀指南预测 6 个月生存率的性能，并进行比较。
在基线时，居民的平均（SD）ADEPT 评分为 10.1（3.1）分，65 名居民（10.7%）符合临终关怀资格标准。在 6 个月内，有 111 名居民（18.3%）死亡。ADEPT 评分作为连续变量预测 6 个月死亡率的 AUROC 为 0.67（95%置信区间[CI]，0.62-0.72）。医疗保险临终关怀资格标准的 AUROC 为 0.55（95%CI，0.51-0.59），特异性为 0.89（95%CI，0.86-0.92），敏感性为 0.20（95%CI，0.13-0.28）。使用 ADEPT 评分的截断值为 13.5，特异性也为 0.89，AUROC 为 0.58（95%CI，0.54-0.63），敏感性为 0.27（95%CI，0.19-0.36）。
当在床边前瞻性验证并作为连续测量使用时，ADEPT 评分识别 6 个月内死亡风险高的养老院晚期痴呆症患者的能力适度，尽管优于临终关怀资格标准。应为这些患者提供符合其护理目标而非预计寿命的护理。
