0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

High Short-term Mortality in Hospitalized Patients With Advanced Dementia:  Lack of Benefit of Tube Feeding FREE

Diane E. Meier, MD; Judith C. Ahronheim, MD; Jane Morris, RN; Shari Baskin-Lyons, MPH; R. Sean Morrison, MD
[+] Author Affiliations

From the Department of Geriatrics and Adult Development, the Lilian and Benjamin Hertzberg Palliative Care Institute, Mount Sinai School of Medicine (Drs Meier and Morrison and Mss Morris and Baskin-Lyon), the Eileen E. Anderson Section of Geriatrics, St Vincent's Hospital and Medical Center (Dr Ahronheim), and the New York Medical College (Dr Ahronheim), New York, NY.


Arch Intern Med. 2001;161(4):594-599. doi:10.1001/archinte.161.4.594.
Text Size: A A A
Published online

Background  The influence of tube feeding on survival in hospitalized patients with advanced dementia is controversial.

Objective  To assess long-term survival in an inception cohort, incident tube feeding placement during the index hospitalization, and the influence of tube feeding on survival in this group of patients.

Subjects and Methods  Ninety-nine hospitalized patients with advanced dementia and an available surrogate decision maker were followed up through and after the index hospitalization for mortality and placement of a feeding tube. Other variables measured included advance directive status, presence of a long-term primary care physician, level of involvement of the surrogate decision maker, admitting diagnosis, prior hospitalizations, comorbidities, and diagnosis related group diagnostic category.

Results  A new feeding tube was placed in 50% (51/99) of the study patients during the index hospitalization, 31% (31/99) left the hospital without a feeding tube, and 17% (17/99) were admitted with a feeding tube already in place. By stepwise logistic regression analysis, predictors of new feeding tube placement included African American ethnicity (odds ratio, 9.43; 95% confidence interval, 2.1-43.2) and residence in a nursing home (odds ratio, 4.9; 95% confidence interval, 1.02-2.5). Median survival of the 99 patients was 175 days. Eighty-five (85%) survived the index hospitalization, and 28 (28%) were still alive at last follow-up, a range of 1.3 to 4.2 years after enrollment in the study. Tube feeding was not associated with survival (P = .90). An admitting diagnosis of infection was associated with higher mortality (odds ratio, 1.9; 95% confidence interval, 1.01-3.6).

Conclusions  In this cohort of hospitalized patients with advanced dementia, risk of receiving a new feeding tube is high, associated with African American ethnicity, and prior residence in a nursing home, and has no measurable influence on survival. With or without a feeding tube, these patients have a 50% six-month median mortality.

Figures in this Article

ALZHEIMER DISEASE and related dementing illnesses are incurable, progressive disorders leading gradually to complete loss of cognitive function and subsequent death. By the year 2040, the prevalence of Alzheimer disease in the United States is estimated to rise to more than 9 million affected individuals.1,2 Costs of care increase with severity of the dementing illness with an annual US estimate of more than $100 billion in 1993 alone, a figure that is expected to double by 2040.2

While the setting and type of care provided to persons with advanced dementia and acute superimposed illness is highly variable,313 hospitalization is a frequent sequela of acute illness in advanced dementia.3 This practice occurs despite the fact that hospitalization is a known hazard for frail elderly persons14,15 and its use in advanced dementia has not been demonstrated to improve clinical outcomes.1618 Similarly, the characteristics and predictors of decisions to use a feeding tube when oral intake declines are not well described.19,20 Although a recent systematic review of tube feeding in the care of patients with advanced dementia found little evidentiary basis for (or against) the practice,20,21 placement of a feeding tube is a common intervention in this population.2224

In the context of an acute illness superimposed on a late-stage dementia, those charged with decisions about whether to hospitalize and whether to place a feeding tube must not only consider the purposes and goals of medical intervention and care for such a patient, but also must weigh the benefits and risks of hospitalization and tube feeding per se under this clinical circumstance. Knowledge of the likely outcomes of hospitalization, and the often associated decision to place a feeding tube, in terms of its influence on long-term survival, is critical to informed decision making on behalf of patients with advanced dementia. To this end, in the context of a study evaluating the influence of palliative care consultation for hospitalized persons with advanced dementia,12,25 we assessed long-term survival in an inception cohort, incident feeding tube placement during the index hospitalization, and the influence of tube feeding on survival in this group of patients.

STUDY SUBJECTS

Patients with advanced cognitive impairment admitted to Mount Sinai Hospital (a 1000-bed tertiary care teaching hospital) in New York City during a 3-year period (August 1994-June 1997) were identified by daily rounds conducted by one of us (J.M.). Eligibility criteria included hospitalization for an acute illness; advanced dementia defined as Functional Assessment Staging Tool (FAST)26 stage 6d or greater with a stable neurological deficit for at least 1 month. Thus, patients with acute or subacute declines in mental status associated with delirium were excluded from the study. Reisberg stages 6d and below include patients incontinent of bladder (6d), and bowel (6e), with speech limited to fewer than 6 words (7a) or a single word (7b), inability to walk (7c), and sit (7d) without assistance, and inability to hold the head up without assistance (7f).26 Stage was determined by the best observable mental status prior to hospitalization, based on medical history obtained from family or other caregivers and health professionals familiar with the patient's baseline condition.

Permission to approach surrogate decision makers for participation in the study was initially obtained from the patient's attending physician. Informed consent was obtained from the designated surrogate decision maker (ie, duly appointed guardian, health care agent, or next of kin). The study was approved by the Mount Sinai School of Medicine Institutional Review Board.

Initial assessment consisted of a complete medical history and physical examination by a physician member (D.E.M. or J.C.A.) of the study team. Subjects were then randomized to an intervention or a control (usual care) group for a prospective randomized trial of inpatient palliative care consultation, described elsewhere.12,25 The intervention consisted of consultative recommendations designed to maximize comfort and minimize painful and nonpalliative procedures; as well as extensive consultation and discussion with family, other surrogate decision makers, and the primary medical team about the goals of care. The intervention25 had no effect on any measurable outcome except for a slight increase in the numbers of subjects discharged from the hospital with a palliative care plan documented in their medical record. Of 182 subjects initially identified as eligible for study participation and whose primary attending physician gave permission to approach the surrogate decision maker, consent was obtained in 99 cases, largely because of incapacity, unavailability, or unwillingness of surrogates to endorse their relative's participation, as previously reported (Table 1).12 The study subjects consisted of the 99 patients eligible for inclusion for whom both the primary attending physician and a surrogate decision maker were available and willing to give consent for their participation.

Table Graphic Jump LocationTable 1. Enrollment of 192 Eligible Subjects Who Were Hospitalized With Advanced Dementia*

A research assistant (S.B.L.) blinded to the randomization status of the subjects gathered medical record information on demographics; preadmission medical history of prior hospitalizations or pneumonia; presence of an advance directive; residence of surrogate (local vs out of town); availability of a long-term primary care physician; comorbidities; and diagnosis related group diagnostic category. Main outcome measures included mortality both during and after the index hospitalization, site of discharge, length of hospital stay, do-not-resuscitate orders, and attempts at cardiopulmonary resuscitation and feeding tube placement before or during the index hospitalization. These outcome measures were determined from the date of admission during the index hospitalization until discharge or in-hospital death. The number of hospitalizations in the year preceding and after the index hospitalization were determined from surrogate interviews and review of hospital databases. Research assistant telephone contact was maintained on a 3-monthly basis through June 1999 with next of kin of study subjects until they were lost to follow up or the subject's death was reported.

STATISTICAL METHODS

Statistical analyses focused on determining factors that predicted placement of percutaneous feeding tubes and on variables that predicted survival. In the first analyses, we used χ2 tests to examine the relationship between independent variables and the placement of a feeding tube on the index hospital admission. Variables that were of borderline significance (P<.15) were entered into a forward stepwise logistic regression model (entry criteria of P<.10 and removal criteria of P>.15). To determine factors that influenced survival, we performed a series of single-variable Cox proportional hazards regression models examining the relationship of the variable of interest to time of death. Variables of borderline significance (P<.15), and variables that have been previously shown to be related to survival in advanced dementia (ie, dementia stage, sex, age, prior hospitalizations, prior pneumonia, degree of involvement of surrogate decision maker, long-term primary care physician, presence of a pressure ulcer, presence of a feeding tube, and residence at home vs nursing home),2732 randomization status, and presence of a feeding tube were entered into the final survival model.

One hundred ninety-two subjects were eligible to participate during the 3-year (August 1994-June 1997) study period. Informed consent could not be obtained from 93 (48%) primarily because there was no available surrogate decision maker or because the surrogate decision maker was unable or unwilling to participate in the informed consent discussion process (Table 1).12 Ninety-nine eligible subjects (52%) had surrogate decision makers who gave informed consent and the subjects were enrolled in the study.

SUBJECT CHARACTERISTICS

Characteristics of study subjects are given in Table 2. The average subject was 84.8 years old (age range, 63-100 years), 80 (81%) were women, 39 (39%) were black, 36 (36%) were white, and 22 (22%) were Hispanic. Twenty-nine subjects (29%) were admitted from home and 69 (70%) were admitted to the hospital from a nursing home. An advance directive (ie, a living will, proxy appointment, or clear oral or written evidence of the patient's wishes) was available for the index admission in 15 (15%) of the subjects. The most common admitting diagnosis was pneumonia (44 [44%] of 99 subjects), followed by other infectious illnesses (14 subjects [14%]) and gastrointestinal disorders (12 subjects [12%]).

Table Graphic Jump LocationTable 2. Characteristics of 99 Subjects Hospitalized With Advanced Dementia
FEEDING TUBES

A feeding tube was present on admission in 17 subjects (17%). Of the 99 study subjects, 80 (80%) did not have a feeding tube on admission and were not admitted to the hospital specifically for this purpose. Two subjects (2%) were brought into the hospital specifically for the purpose of placing a feeding tube. Of the 82 subjects without a feeding tube on admission, 51 (62%) had a percutaneous endoscopic gastrostomy tube placed during the index hospitalization. Thirty-one (31%) of the 99 subjects left the index hospitalization without a feeding tube. The regression model examining predictors of feeding tube placement is given in Table 3. In the logistic regression analysis African American ethnicity (odds ratio [OR], 9.43; 95% confidence interval [95% CI], 2.1-43.2) and residence in a nursing home (OR, 4.9; 95% CI, 1.02-2.5) were significantly associated with receiving a new feeding tube during the index hospitalization.

Table Graphic Jump LocationTable 3. Multiple Logistic Regression Model for Placement of a New Feeding Tube During the Index Admission*
SURVIVAL

Median survival of the 99 enrolled subjects was 175 days (198 days in the intervention group and 147 days in the control or usual care group [P = .41]) (Figure 1). The hazard model is given in Table 4. Admitting diagnosis of infection (ie, pneumonia or urosepsis) was associated with mortality (OR, 1.9; 95% CI, 1.01-3.6). Eighty-five subjects (85%) survived the index hospitalization. Twenty-eight (28%) were still alive at the time of last follow-up contact (June 1, 1999), a range of 465 to 1502 days (ie, 1.3-4.2 years) after study enrollment. Median survival following admission in subjects receiving a feeding tube during the index hospitalization was 195 days (range, 21-1405 days) as compared with 189 days among subjects who did not receive a feeding tube (range, 4-1502 days). Tube feeding was not associated with survival (P = .9) (Table 4).

Place holder to copy figure label and caption

Survival for 99 subjects with end-stage dementia.

Graphic Jump Location
Table Graphic Jump LocationTable 4. Cox Proportional Hazards Regression Model for Mortality After Index Hospitalization in 99 Subjects With Advanced Dementia

In this cohort of acutely ill and hospitalized patients with advanced dementia, median survival was 6 months despite hospitalization and use of life-sustaining measures including the administration of parenteral fluids, antibiotic agents, and artificial nutrition. Prior studies in hospital,33 long-term care,34 and hospice35 settings have all found similarly high mortality rates in persons with advanced dementia, of a magnitude comparable to the prognosis observed in chronic end-stage liver disease or multiorgan system failure with sepsis36,37 and some metastatic cancers.38 Despite the high risk of death associated with advanced dementia, it is generally not perceived by family and health care providers to be a terminal illness, owing, at least in part, to the variability in individual life expectancy demonstrated in this and other studies.39,40

The prevalence of hospitalization for acute illness in severe dementia is unknown since the discharge diagnosis and claims associated with the illness usually reflect the primary reason for admission, such as pneumonia. Studies of hospitalization rates of nursing home residents with pneumonia vary by a factor of 5.3 Propensity to hospitalize has been shown to be related both to clinical factors3,57,9,10 and to the number of hospital beds per capita.4 As we have previously reported,12 over one third of the eligible subjects for this study could not be randomized because they lacked an available or functional surrogate decision maker: the absence of a functional surrogate decision maker may also be a risk factor for hospitalization as there is no family member to advocate for continued care at home or in the nursing home during a supervening illness.5,6,8,1012,41 Since decisions to hospitalize for acute illness should be based on expectation of benefit in terms of articulated goals of care for a given individual—whether the goals are primarily focused on maximal possible prolongation of life or on the relief of symptom distress, or both—the fact that mortality rates are high and seem to be similar independent of venue suggests that hospitalization may not be the best way to achieve either goal.42 Randomized trials of home or nursing home care vs hospital care in acute illness superimposed on advanced dementia are needed to address this question.

In our advanced dementia cohort, there was no survival advantage among subjects who received a feeding tube during the index hospitalization as compared with those discharged from the hospital without a feeding tube. By multiple regression analysis, African American ethnicity and residence in a nursing home were associated with a higher risk of receiving a new feeding tube. A large study of Medicare claims data also found a higher frequency of feeding tube placement in African American, as opposed to white, patients.23 Reasons for the racial difference in propensity to receive a feeding tube are unknown, but the finding persists after adjustment for the higher likelihood of residence in a nursing home in our African American subjects. Further, the racial disparity in feeding tube placement could not be explained by the surrogate decision maker's geographic proximity to the hospital, by the absence of a long-term primary care physician, or by the prevalence of advance directives in the different ethnic groups. As suggested by a recent report,43 the economic hardship associated with care of a relative with chronic advanced illness4446 may have contributed both to a higher risk of nursing home placement and in decisions to use tube feeding among our African American subjects. We were unable to adjust for educational and socioeconomic variables among subjects and their surrogate decision makers that might have accounted for this ethnic difference both in nursing home residence and in decisions to use tube feeding. Other investigations of the influence of ethnicity on medical decision making have suggested that mistrust, associated fears of undertreatment, and differing cultural evaluations of the benefits and risks of artificial nutrition and hydration, may contribute to decisions to use life-sustaining technologies, including tube feeding.4750

The decision to use a feeding tube when oral intake cannot be easily sustained may be related to the variable and uncertain prognosis of advanced dementias and the desire of family and physicians to prevent the anticipated burdens of malnutrition and dehydration. Despite data suggesting that among cognitively intact patients refusal of food and water in the context of terminal illness is not painful51 and the common observation of aversive feeding behaviors in advanced dementia52 (ie, refusing to eat or swallow, spitting out food, or holding food in the mouth), inadequate intake of food and water is often thought to lead to distressing hunger, thirst, and hastened death. Similarly, tube feeding is believed to prevent aspiration pneumonia and other infections, improve function, promote physical comfort, and prolong life. As was recently reviewed,1921 evidence does not exist to support (or refute) these assumptions. Data from the study reported here suggest that tube feeding has no measurable influence on survival, at least in this cohort of severely demented patients hospitalized with acute comorbid illness. Multiple other observational studies have confirmed both high short-term mortality rates and lack of survival advantage to tube feeding in the context of advanced dementia.1921,53,54

Limitations of this study include bias in the sample related to its conduct in a tertiary care teaching hospital in New York City. The high evidentiary standard for decisions to forego artificial nutrition and hydration under New York state law55 could lead to a higher prevalence of tube feeding among patients lacking decisional capacity and advance directives. Other socioeconomic factors typical of patients cared for in an urban teaching hospital may be associated with the lesser ability of families to care for patients at home as well as limited availability of long-term primary care physicians. However, frail nursing home patients with advanced dementia are commonly transferred to acute care hospitals for treatment of intercurrent illness27,56 and the high risk of feeding tube placement and mortality observed is consistent with data from a wide range of clinical and geographic settings. Second, these data apply only to persons with advanced dementia who have a surrogate decision maker able to participate in medical decision making. The high proportion of otherwise eligible subjects who could not be included in this study because they had no functional surrogate decision maker represent a growing population of patients for whom there is no current societal consensus on a mechanism for medical decisions.41 There is, however, no evidentiary basis to suggest that the group of patients with dementia without surrogate decision makers is at any different risk of gastrostomy or death than those who do have involved family members. Finally, small sample size may have limited our ability to identify additional predictors of feeding tube placement and mortality in this cohort.

In a cohort of hospitalized patients with acute illness and advanced dementia, the risk of receiving a new feeding tube is high. With or without tube feeding, these patients have a 50% six-month median mortality, similar to that observed in a wide range of reports from other clinical settings. These data have implications for the development of evidence-based standards of medical care for the growing population of persons with advanced dementia.

Accepted for publication August 22, 2000.

This work was supported by grants from The Greenwall Foundation, and The Kornfeld Foundation, New York, NY. Dr Meier is the recipient of the National Institute on Aging Academic Career Leadership Award (K07AG00903). Dr Morrison is the recipient of a Mentored Clinical Scientist Development Award (K08AG00833) from the National Institute on Aging, Bethesda, Md.

Drs Meier, Morrison, and Ahronheim and Ms Morris are Open Society Institute Faculty Scholars of the Project on Death in America, New York. Dr Morrison is a Brookdale National Fellow.

Corresponding author: Diane E. Meier, MD, Box 1070, Mount Sinai School of Medicine, New York, NY 10029 (e-mail: diane.meier@mssm.edu).

Katzman  RKawas  C The epidemiology of dementia and Alzheimer disease. Terry  RDKatzman  RBick  KLeds.Alzheimer Disease New York, NY Raven Press Ltd1994;105- 122
Rice  DPFox  PJMax  WWebber  PA  et al.  The economic burden of Alzheimer's disease care. Health Aff (Millwood). 1993;12164- 176
Link to Article
Muder  RR Management of nursing home-acquired pneumonia: unresolved issues and priorities for future investigation. J Am Geriatr Soc. 2000;4895- 96
Pritchard  RSFisher  ESTeno  JM  et al. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), Influence of patient preferences and local health system characteristics on the place of death. J Am Geriatr Soc. 1998;461242- 1250
Intrator  OCastle  NGMor  V Facility characteristics associated with hospitalization of nursing home residents: results of a national study. Med Care. 1999;37228- 237
Link to Article
Cohen  CAGold  DPShulman  KIWortley  JTMcDonald  GWargon  M Factors determining the decision to institutionalize dementing individuals: a prospective study. Gerontologist. 1993;33714- 720
Link to Article
Collins  COgle  K Patterns of predeath service use by dementia patients with a family caregiver. J Am Geriatr Soc. 1994;42719- 722
Jette  AMBranch  LGSleeper  LAFeldman  HSullivan  LM High-risk profiles for nursing home admission. Gerontologist. 1992;32634- 640
Link to Article
Kliebsch  USiebert  HBrenner  H Extent and determinants of hospitalization in a cohort of older disabled people. J Am Geriatr Soc. 2000;48289- 294
Mittelman  MSFerris  SHShulman  ESteinberg  GLevin  B A family intervention to delay nursing home placement of patients with Alzheimer disease: a randomized controlled trial. JAMA. 1996;2761725- 1731
Link to Article
Mohide  EAPringle  DMStreiner  DLGilbert  JRMuir  GTew  M A randomized trial of family caregiver support in the home management of dementia. J Am Geriatr Soc. 1990;38446- 454
Baskin  SAMorris  JAhronheim  JCMeier  DEMorrison  RS Barriers to obtaining consent in dementia research: implications for surrogate decision-making. J Am Geriatr Soc. 1998;46287- 290
Olichney  JMHofstetter  CRGalasko  DThal  LJKatzman  R Death certificate reporting of dementia and mortality in an Alzheimer's disease research center cohort. J Am Geriatr Soc. 1995;43890- 893
Creditor  MC Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118219- 223
Link to Article
Kohn  LTCorrigan  JMDonaldson  MS To Err Is Human: Building a Safer Health System.  Washington, DC National Academy Press2000;26- 48
Fried  TRGillick  MRLipsitz  LA Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer. J Am Geriatr Soc. 1997;45302- 306
Fried  TRGillick  MRLipsitz  LA Whether to transfer? factors associated with hospitalization and outcome of elderly long-term care patients and pneumonia. J Gen Intern Med. 1995;10246- 250
Link to Article
Thompson  RSHall  NKSzpiech  M Hospitalization and mortality rates for nursing home acquired pneumonia. J Fam Pract. 1999;48291- 293
Finucane  TBynum  JP Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996;3481421- 1424
Link to Article
Finucane  TETravis  KChristmas  C Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999;2821365- 1370
Link to Article
Gillick  MR Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000;342206- 210
Link to Article
Callahan  CMHaag  KMBuchanan  NNNisi  R Decision making for percutaneous endoscopic gastrostomy among older adults in a community setting. J Am Geriatr Soc. 1999;471105- 1109
Grant  MDRudberg  MABrody  JA Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA. 1998;2791973- 1976
Link to Article
Rabeneck  LWray  NPPetersen  NJ Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. J Gen Intern Med. 1996;11287- 293
Link to Article
Ahronheim  JCMorrison  RSMorris  JBaskin-Lyons  SMeier  DE Palliative care in advanced dementia: a randomized controlled trial and descriptive analysis. J Palliat Med. 2000;3265- 273
Link to Article
Reisberg  B Functional assessment staging (FAST). Psychopharmacol Bull. 1988;24653- 659
Fried  TRMor  V Frailty and hospitalization of long-term stay nursing home residents. J Am Geriatr Soc. 1997;45265- 269
Stern  YTang  MXAlbert  MS  et al.  Predicting time to nursing home care and death in individuals with Alzheimer disease. JAMA. 1997;277806- 812
Link to Article
Muder  RRBrennen  CSwenson  DLWagener  M Pneumonia in a long-term care facility: a prospective study of outcome. Arch Intern Med. 1996;1562365- 2370
Link to Article
Fabiszewski  KJVolicer  BVolicer  L Effect of antibiotic treatment on outcome of fevers in institutionalized Alzheimer patients. JAMA. 1990;2633168- 3172
Link to Article
Volicer  BJHurley  AFabiszewski  KJMontgomery  PVolicer  L Predicting short-term survival for patients with advanced Alzheimer's disease. J Am Geriatr Soc. 1993;41535- 540
Luchins  DJHanrahan  PMurphy  K Criteria for enrolling dementia patients in hospice. J Am Geriatr Soc. 1997;451054- 1059
Morrison  RSSiu  AL Survival in end-stage dementia following acute illness. JAMA. 2000;28447- 52
Link to Article
Aguero-Torres  HFratiglioni  LGuo  ZViitanen  MWinblad  B Prognostic factors in very old demented adults: a seven-year follow-up from a population-based survey in Stockholm. J Am Geriatr Soc. 1998;46444- 452
Hanrahan  PLuchins  DJ Feasible criteria for enrolling end-stage dementia patients in home hospice care. Hosp J. 1995;1047- 54
Knaus  WAHarrell Jr  FELynn  J  et al. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), The SUPPORT prognostic model: objective estimates of survival for seriously ill hospitalized adults. Ann Intern Med. 1995;122191- 203
Link to Article
Standards and Accreditation Committee, Medical Guidelines Task Force, Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases. 2nd ed. Arlington, Va National Hospice Organization1996;
Vigano  ABruera  EJhangri  GSNewman  SCFields  ALSuarez-Almazor  ME Clinical survival predictors in patients with advanced cancer. Arch Intern Med. 2000;160861- 868
Link to Article
Lynn  JTeno  JMHarrell Jr  FE Accurate prognostications of death: opportunities and challenges for clinicians. West J Med. 1995;163250- 257
Lynn  JHarrell Jr  FCohn  FWagner  DConnors Jr  AF Prognoses of seriously ill hospitalized patients on the days before death: implications for patient care and public policy. New Horiz. 1997;556- 61
Meier  DE Voiceless and vulnerable: dementia patients without surrogates in an era of capitation. J Am Geriatr Soc. 1997;45375- 377
Naughton  BJMylotte  JM Treatment guideline for nursing home-acquired pneumonia based on community practice. J Am Geriatr Soc. 2000;4882- 88
Emanuel  EJFairclough  DLSlutsman  JEmanuel  LL Understanding economic and other burdens of terminal illness: the experience of patients and their caregivers. Ann Intern Med. 2000;132451- 459
Link to Article
Covinsky  KEGoldman  LCook  EF  et al. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment, The impact of serious illness on patients' families SUPPORT Investigators. Study to understand Prognoses and Preferences for Outcomes and Risks of Treatment. JAMA. 1994;2721839- 1844
Link to Article
Arno  PSLevine  CMemmott  MM The economic value of informal caregiving. Health Aff (Millwood). 1999;18182- 188
Link to Article
Emanuel  EJFairclough  DLSlutsman  JAlpert  HBaldwin  DEmanuel  LL Assistance from family members, friends, paid care givers and volunteers in the care of terminally ill patients. N Engl J Med. 1999;341956- 963
Link to Article
Freeman  HPPayne  R Racial injustice in health care. N Engl J Med. 2000;3421045- 1046
Link to Article
Tulsky  JACassileth  BRBennett  CL The effect of ethnicity on ICU use and DNR orders in hospitalized AIDS patients. J Clin Ethics. 1997;8150- 157
Phillips  RSHamel  MBTeno  JM  et al. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), Race, resource use, and survival in seriously ill hospitalized adults. J Gen Intern Med. 1996;11387- 396
Link to Article
McKinley  EDGarrett  JMEvans  ATDanis  M Differences in end-of-life decision making among black and white ambulatory cancer patients. J Gen Intern Med. 1996;11651- 656
Link to Article
McCann  RMHall  WJGroth-Juncker  A Comfort care for terminally ill patients: the appropriate use of nutrition and hydration. JAMA. 1994;2721263- 1266
Link to Article
Blandford  GWatkins  LBMulvihill  MN  et al.  Assessing abnormal feeding behavior in dementia: a taxonomy and initial findings. Research and Practice in Alzheimer's Disease. New York, NY Springer Publishing1998;
Mitchell  SLKiely  DKLipsitz  LA The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med. 1997;157327- 332
Link to Article
Mitchell  SLKiely  DKLipsitz  LA Does artificial enteral nutrition prolong the survival of institutionalized elders with chewing and swallowing problems? J Gerontol A Biol Sci Med Sci. 1998;53M207- M213
Link to Article
New York State Task Force on Life and the Law, When Others Must Choose: Deciding for Patients Without Capacity.  New York New York State Task Force on Life and the Law1992;
Weiler  PGLubben  JEChi  I Cognitive impairment and hospital use. Am J Public Health. 1991;811153- 1157
Link to Article

Figures

Place holder to copy figure label and caption

Survival for 99 subjects with end-stage dementia.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Enrollment of 192 Eligible Subjects Who Were Hospitalized With Advanced Dementia*
Table Graphic Jump LocationTable 2. Characteristics of 99 Subjects Hospitalized With Advanced Dementia
Table Graphic Jump LocationTable 3. Multiple Logistic Regression Model for Placement of a New Feeding Tube During the Index Admission*
Table Graphic Jump LocationTable 4. Cox Proportional Hazards Regression Model for Mortality After Index Hospitalization in 99 Subjects With Advanced Dementia

References

Katzman  RKawas  C The epidemiology of dementia and Alzheimer disease. Terry  RDKatzman  RBick  KLeds.Alzheimer Disease New York, NY Raven Press Ltd1994;105- 122
Rice  DPFox  PJMax  WWebber  PA  et al.  The economic burden of Alzheimer's disease care. Health Aff (Millwood). 1993;12164- 176
Link to Article
Muder  RR Management of nursing home-acquired pneumonia: unresolved issues and priorities for future investigation. J Am Geriatr Soc. 2000;4895- 96
Pritchard  RSFisher  ESTeno  JM  et al. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), Influence of patient preferences and local health system characteristics on the place of death. J Am Geriatr Soc. 1998;461242- 1250
Intrator  OCastle  NGMor  V Facility characteristics associated with hospitalization of nursing home residents: results of a national study. Med Care. 1999;37228- 237
Link to Article
Cohen  CAGold  DPShulman  KIWortley  JTMcDonald  GWargon  M Factors determining the decision to institutionalize dementing individuals: a prospective study. Gerontologist. 1993;33714- 720
Link to Article
Collins  COgle  K Patterns of predeath service use by dementia patients with a family caregiver. J Am Geriatr Soc. 1994;42719- 722
Jette  AMBranch  LGSleeper  LAFeldman  HSullivan  LM High-risk profiles for nursing home admission. Gerontologist. 1992;32634- 640
Link to Article
Kliebsch  USiebert  HBrenner  H Extent and determinants of hospitalization in a cohort of older disabled people. J Am Geriatr Soc. 2000;48289- 294
Mittelman  MSFerris  SHShulman  ESteinberg  GLevin  B A family intervention to delay nursing home placement of patients with Alzheimer disease: a randomized controlled trial. JAMA. 1996;2761725- 1731
Link to Article
Mohide  EAPringle  DMStreiner  DLGilbert  JRMuir  GTew  M A randomized trial of family caregiver support in the home management of dementia. J Am Geriatr Soc. 1990;38446- 454
Baskin  SAMorris  JAhronheim  JCMeier  DEMorrison  RS Barriers to obtaining consent in dementia research: implications for surrogate decision-making. J Am Geriatr Soc. 1998;46287- 290
Olichney  JMHofstetter  CRGalasko  DThal  LJKatzman  R Death certificate reporting of dementia and mortality in an Alzheimer's disease research center cohort. J Am Geriatr Soc. 1995;43890- 893
Creditor  MC Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118219- 223
Link to Article
Kohn  LTCorrigan  JMDonaldson  MS To Err Is Human: Building a Safer Health System.  Washington, DC National Academy Press2000;26- 48
Fried  TRGillick  MRLipsitz  LA Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer. J Am Geriatr Soc. 1997;45302- 306
Fried  TRGillick  MRLipsitz  LA Whether to transfer? factors associated with hospitalization and outcome of elderly long-term care patients and pneumonia. J Gen Intern Med. 1995;10246- 250
Link to Article
Thompson  RSHall  NKSzpiech  M Hospitalization and mortality rates for nursing home acquired pneumonia. J Fam Pract. 1999;48291- 293
Finucane  TBynum  JP Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996;3481421- 1424
Link to Article
Finucane  TETravis  KChristmas  C Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999;2821365- 1370
Link to Article
Gillick  MR Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000;342206- 210
Link to Article
Callahan  CMHaag  KMBuchanan  NNNisi  R Decision making for percutaneous endoscopic gastrostomy among older adults in a community setting. J Am Geriatr Soc. 1999;471105- 1109
Grant  MDRudberg  MABrody  JA Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA. 1998;2791973- 1976
Link to Article
Rabeneck  LWray  NPPetersen  NJ Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. J Gen Intern Med. 1996;11287- 293
Link to Article
Ahronheim  JCMorrison  RSMorris  JBaskin-Lyons  SMeier  DE Palliative care in advanced dementia: a randomized controlled trial and descriptive analysis. J Palliat Med. 2000;3265- 273
Link to Article
Reisberg  B Functional assessment staging (FAST). Psychopharmacol Bull. 1988;24653- 659
Fried  TRMor  V Frailty and hospitalization of long-term stay nursing home residents. J Am Geriatr Soc. 1997;45265- 269
Stern  YTang  MXAlbert  MS  et al.  Predicting time to nursing home care and death in individuals with Alzheimer disease. JAMA. 1997;277806- 812
Link to Article
Muder  RRBrennen  CSwenson  DLWagener  M Pneumonia in a long-term care facility: a prospective study of outcome. Arch Intern Med. 1996;1562365- 2370
Link to Article
Fabiszewski  KJVolicer  BVolicer  L Effect of antibiotic treatment on outcome of fevers in institutionalized Alzheimer patients. JAMA. 1990;2633168- 3172
Link to Article
Volicer  BJHurley  AFabiszewski  KJMontgomery  PVolicer  L Predicting short-term survival for patients with advanced Alzheimer's disease. J Am Geriatr Soc. 1993;41535- 540
Luchins  DJHanrahan  PMurphy  K Criteria for enrolling dementia patients in hospice. J Am Geriatr Soc. 1997;451054- 1059
Morrison  RSSiu  AL Survival in end-stage dementia following acute illness. JAMA. 2000;28447- 52
Link to Article
Aguero-Torres  HFratiglioni  LGuo  ZViitanen  MWinblad  B Prognostic factors in very old demented adults: a seven-year follow-up from a population-based survey in Stockholm. J Am Geriatr Soc. 1998;46444- 452
Hanrahan  PLuchins  DJ Feasible criteria for enrolling end-stage dementia patients in home hospice care. Hosp J. 1995;1047- 54
Knaus  WAHarrell Jr  FELynn  J  et al. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), The SUPPORT prognostic model: objective estimates of survival for seriously ill hospitalized adults. Ann Intern Med. 1995;122191- 203
Link to Article
Standards and Accreditation Committee, Medical Guidelines Task Force, Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases. 2nd ed. Arlington, Va National Hospice Organization1996;
Vigano  ABruera  EJhangri  GSNewman  SCFields  ALSuarez-Almazor  ME Clinical survival predictors in patients with advanced cancer. Arch Intern Med. 2000;160861- 868
Link to Article
Lynn  JTeno  JMHarrell Jr  FE Accurate prognostications of death: opportunities and challenges for clinicians. West J Med. 1995;163250- 257
Lynn  JHarrell Jr  FCohn  FWagner  DConnors Jr  AF Prognoses of seriously ill hospitalized patients on the days before death: implications for patient care and public policy. New Horiz. 1997;556- 61
Meier  DE Voiceless and vulnerable: dementia patients without surrogates in an era of capitation. J Am Geriatr Soc. 1997;45375- 377
Naughton  BJMylotte  JM Treatment guideline for nursing home-acquired pneumonia based on community practice. J Am Geriatr Soc. 2000;4882- 88
Emanuel  EJFairclough  DLSlutsman  JEmanuel  LL Understanding economic and other burdens of terminal illness: the experience of patients and their caregivers. Ann Intern Med. 2000;132451- 459
Link to Article
Covinsky  KEGoldman  LCook  EF  et al. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment, The impact of serious illness on patients' families SUPPORT Investigators. Study to understand Prognoses and Preferences for Outcomes and Risks of Treatment. JAMA. 1994;2721839- 1844
Link to Article
Arno  PSLevine  CMemmott  MM The economic value of informal caregiving. Health Aff (Millwood). 1999;18182- 188
Link to Article
Emanuel  EJFairclough  DLSlutsman  JAlpert  HBaldwin  DEmanuel  LL Assistance from family members, friends, paid care givers and volunteers in the care of terminally ill patients. N Engl J Med. 1999;341956- 963
Link to Article
Freeman  HPPayne  R Racial injustice in health care. N Engl J Med. 2000;3421045- 1046
Link to Article
Tulsky  JACassileth  BRBennett  CL The effect of ethnicity on ICU use and DNR orders in hospitalized AIDS patients. J Clin Ethics. 1997;8150- 157
Phillips  RSHamel  MBTeno  JM  et al. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), Race, resource use, and survival in seriously ill hospitalized adults. J Gen Intern Med. 1996;11387- 396
Link to Article
McKinley  EDGarrett  JMEvans  ATDanis  M Differences in end-of-life decision making among black and white ambulatory cancer patients. J Gen Intern Med. 1996;11651- 656
Link to Article
McCann  RMHall  WJGroth-Juncker  A Comfort care for terminally ill patients: the appropriate use of nutrition and hydration. JAMA. 1994;2721263- 1266
Link to Article
Blandford  GWatkins  LBMulvihill  MN  et al.  Assessing abnormal feeding behavior in dementia: a taxonomy and initial findings. Research and Practice in Alzheimer's Disease. New York, NY Springer Publishing1998;
Mitchell  SLKiely  DKLipsitz  LA The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med. 1997;157327- 332
Link to Article
Mitchell  SLKiely  DKLipsitz  LA Does artificial enteral nutrition prolong the survival of institutionalized elders with chewing and swallowing problems? J Gerontol A Biol Sci Med Sci. 1998;53M207- M213
Link to Article
New York State Task Force on Life and the Law, When Others Must Choose: Deciding for Patients Without Capacity.  New York New York State Task Force on Life and the Law1992;
Weiler  PGLubben  JEChi  I Cognitive impairment and hospital use. Am J Public Health. 1991;811153- 1157
Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 100

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Clinical Resolution

Users' Guides to the Medical Literature
Clinical Scenario