Dr Timothy Dauwalder Medical Director

VNA Hospice & Palliative Care of Southern California

CREDIT, ACKNOWLEDGEMENT, AND GRATITUDE: Terri Maxwell PhD, APRN Vincent Vanston, MD FAAHPM Janet Bull, MD FAAHP (Data, Content, Research, and Professional Generosity

Know the Rules

CMS FY 2014 Rule • Reinforced that all providers should code and report the

principal diagnosis as well as all coexisting and additional diagnoses related to the terminal condition or related conditions.

• Clarified the use of nonspecific, symptom diagnosesRef:

FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform [CMS-1449-P]

CMS Changes Related to Coding

• Codes under the classification, “Symptoms, Signs, and Ill-defined Conditions” (ICD-9 780-799) are not to be used as a principal diagnosis; however, they may be used as other, additional, or coexisting in the additional diagnoses lines on the claims form. o Includes “Debility unspecified” (ICD-9 799.3) &

“Adult Failure to Thrive” (ICD-9 783.4)

• Effective date: October 2014

Changing Regulatory Climate

Why did this CMS take this action • In FY 2012, both “debility” and “adult failure

to thrive” were in the top five hospice diagnoses reported on claims o first and third most common hospice diagnoses,

respectively.

• Trending upward over the past decade

The Changing Regulatory Climate Cont’d

What industry experts are saying: • CMS equates debility with hospices enrolling

chronically ill patients requiring custodial care who are not terminally ill

• Debility patients typically have longer LOS • CMS trying to reign in hospice

expenditures...

Additional Clarifications: Diagnosis Reporting on Hospice Claims

• “All of a patient’s coexisting or additional diagnoses” related to the terminal illness or related conditions should be reported on the hospice claims

Federal Register/ Vol. 77, No. 145/ Friday July 27, 2012

Terminal Trajectory?

Topic of Discussion: ‘Debility’ and ‘FTT’ ...what are we really diagnosing…? AND…...

…. this ppt presentation...

…. individually, they have little impact…. BUT…..

TOGETHER

… WE HAVE TERMINAL SEDATION!!! PPT + BORING SUBJECT MATTER = A TERMINAL TRAJECTORY (Code: 666.66)

SERIOUSLY

-BE DISEASE SPECIFIC AND ACCURATE -NAME ALL DISEASES….. -CODE SPECIFICALLY -SUPPORT THE PROGNOSIS WITH QUANTIFIABLE DATA AND QUALITY OPINION.

Diagnosis Reporting: CMS’ Position...

• Hospice patients at the end-of-life are elderly and likely have multiple co-morbidities.

• Claims that report only one diagnosis are “not providing an accurate description of the patients’ conditions.”

• After doing a comprehensive assessment “providers should code and report coexisting or additional diagnoses to more fully describe the Medicare patients they are treating.”

• Will provide data needed for hospice payment reform.

Why have Hospices used Debility as a Default Diagnosis?

• Usually chosen when a patient does not meet the Local Coverage Determination (LCD) guidelines for a more specific diagnosis, but has a 6-month prognosis.

• Palmetto has a LCD for “adult failure to thrive” and

MACs have not discouraged the use of these diagnoses.

• Some patients have no other definitive diagnosis, or co-

morbid to choose from.

ICD-9-CM Guidelines for Coding and Reporting

• Requires reporting of all additional or co-existing diagnoses.

• Adherence to these guidelines

when assigning ICD-9-CM diagnosis and procedure codes is required under HIPAA

• Imperative that hospice providers

follow ICD-9 coding guidelines and sequencing rules for all diagnoses.

Implications for Coverage Are hospice agencies responsible for all of the care,

medications, and equipment for all of the diagnoses listed on the claim form?

YES

Implications for Coverage cont’d

CMS reiterated what was stated in the original Conditions of Participation (1983):

...“hospices are required to provide virtually all of the care that is needed by

terminally ill patients”. (48 FR 56010-56011). CMS states “Therefore, unless there is clear evidence that a condition is

unrelated to the terminal prognosis, all services would be considered related. It is also the responsibility of the hospice physician to document why a patient's medical need(s) would be unrelated to the to the terminal prognosis. ...determination of what is related versus unrelated to the terminal prognosis remains within the clinical expertise and judgement of the hospice medical director in collaboration with the IDG.”

Definition of “Other Diagnoses”

• “Other diagnoses” - additional conditions that affect patient care in terms of requiring: o clinical evaluation; or

o therapeutic treatment; or

o diagnostic procedures; or

o extended length of hospital stay; or

o increased nursing care and/or monitoring. CMS ICD 9 Coding Manual

Diagnosis Reporting Requirements On Claim Form

• List the primary hospice diagnosis • List all related “other” diagnoses • Do not list unrelated co-morbidities

o But be sure to list them in the clinical record

• The hospice claim includes a field for the patient’s principal hospice diagnosis, and allows for up to 17 additional diagnoses on the paper UB-04 claim, and up to 24 additional diagnoses on the 837I 5010 electronic claim

Rules for Reporting Diagnosis Codes on the Claim

• Use the ICD-9-CM code that describes the patient’s diagnosis, symptom, complaint, condition or problem. Do not code suspected diagnosis.

• Use the ICD-9-CM code that is chiefly responsible for the item or service provided

• Assign codes to the highest level of specificity. Use the fourth and fifth digits where applicable.

• Code all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions that no longer exist.) Chapter 23 Claims Processing Manual

ICD-9 Codes to Avoid using as the Terminal Diagnosis: 780-799

• 783.21 Abnormal weight loss • 783.41 Failure to thrive • 783.7 Malaise and fatigue • 799.3 Debility unspecified • 799.4 Cachexia • 799.89 Other ill-defined conditions • 799.9 Other unknown & unsuspected cause of

morbidity or mortality Along with any other code in the 780 through 799 range but they may be listed as RELATED conditions

Relatedness • Medicare Hospice Benefit requires hospice to cover “all

palliative care related to the terminal illness and related conditions”

• All services considered related unless… o Hospice physician documents why a patient’s medical needs would be

unrelated to the terminal prognosis. “Patient’s nasal allergies are not contributing to the patient’s

expected death from his pancreatic cancer.” “HTN involves a different organ system than dementia, and is not

contributing to the terminal prognosis.”

• Determination of “relatedness” o Clinical expertise and judgement of the hospice medical director. o Collaboration with the IDG

Additional Coding Convention: Manifestation Codes

• Manifestations are characteristics, signs or symptoms of an illness. When one disease or condition causes another disease or condition, the one that caused it is the etiology and the resulting second condition is the manifestation.

• According to coding guidelines, manifestations must be preceded by the code for the underlying condition or etiology.

Ex: 1. Diabetes (the etiology) 250.7 2. End stage renal disease (the manifestation) 585.6

Action Steps Coding Diagnoses

1. Do not use debility or adult failure to thrive (AFTT) as primary diagnosis.

2. Look for clues to identify the primary diagnosis most contributory to the patient’s terminal disease trajectory.

3. Identify the reason for admission (e.g., sign, symptom, diagnosis, condition to be coded).

4. Code the underlying disease first-don’t use manifestation codes. 5. If symptoms are present but a definitive diagnosis has not been

determined, code the symptoms. Do not code conditions that are referred to as “rule out” “suspected,” “probable,” or “questionable.”

Action Steps: Coding Diagnosis Cont’d

6. Where possible, use other conditions to support a 6-month prognosis 7. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.

8. For primary diagnosis, consider using the one a physician would list as cause of death on the death certificate.

Determining the Diagnosis: Role of the Physician

• CMS recognizes that diagnosing and determining prognosis is not a perfect science.

• Certifying physicians should use their “best clinical judgment” when determining the principal diagnosis and related conditions.

• There MUST be a basis for the hospice certification and supported by clinical information and documentation that provide a basis for certification.

Role of Physician cont’d • Hospice Medical Director determines the terminal

diagnosis, based on similar sources as for determining prognosis. o Records review o Input from IDT o Discussions with referral sources/attending

physician o Clinical judgement o Examination of patient (if applicable)

The Hospice Medical Director should also document why an unrelated diagnosis is not related. Develop a process for this

Steps to an Alternate Diagnosis

To Establish a primary dx, consider the following: What dx is most likely leading to demise? What made the patient have debility/ failure to thrive? Is

there an LCD for that condition? What are the comorbid conditions?

Steps to an Alternate Diagnosis cont’d

Cont’d: What medications is patient on?

What is the nature of decline? Do you believe it is more likely than not that the patient

will have terminal event in next 6 months? Do they also suffer from debility?

What are we really trying to avoid?

??????????

THE 6 LETTER WORD…..

ZOMBIE APOCALYPSE

‘Z.O.R.T’ ZPICs ( (Zone Program Integrity Contractors)

Case Study Initial certification narrative: 84yr old F w mild COPD, mild dementia. On recent CXR, she was found to have an enlarging lung mass for which w/u was declined. She has had increased weakness, decreased appetite with weight loss in 3 months from 130 to 125 lbs, and 1 episode of hemoptysis, all attributed to presumptive lung CA. Patient recently seen by primary care MD who noted weight loss, risk for sudden decline, and her belief that more likely than not that patient will have terminal event in the next 6 months…

(narrative continued on next slide).

Case Study cont’d Initial certification narrative cont’d: Pt is DNR/DNH/CMO, clear in her wish for no interventions to prolong her life. Given this patient’s clinical decline, likely lung cancer, weight loss, episodes of hemoptysis, and wish for DNR/CMO, pt is a high risk for massive hemoptysis, respiratory failure, rapid decline. It is my professional judgement that prognosis is less than 6 months.

Case Study cont’d What dx is most likely leading to her demise and

underlying her debility? Presumed lung cancer.

Can you code this as her terminal diagnosis? If not, what diagnosis would you use?

What are her comorbid conditions? COPD, osteoporosis, arthritis, mild dementia

What medications is she on? None

Case Study cont’d • What is the current nature of her decline?

o No further hemoptysis, has lost 4 lbs, and has had very slightly increased weakness. No new symptoms have arisen.

• Do you believe it is more likely than not that she will

have a terminal event in the next 6 months? o Nothing to suggest a terminal decline...

Case Study cont’d • Can use “at high risk of life-threatening hemoptysis and

respiratory failure” when enrolling this patient, but if these do not occur, cannot keep using them for recertification.

• Clinical record needs to demonstrate downward

trajectory. • If none exists, patient is no longer eligible for the

hospice benefit.

Coding “Suspected Cancer”

• 799.3 Unspecified debility (use this 2nd) • 784.2 Swelling, mass, or lump in chest (use this 1st) • 793 Nonspecific abnormal findings on radiological and other exam of body

structure. • Instructional notes: “...(780-799)~this section includes symptoms, signs, abnormal results of

laboratory or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.~ The conditions and signs or symptoms included in categories 780-796 consist of : (a) cases for which no more specific diagnosis can be made even after all facts bearing on the case have been investigated; (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; (c) provisional diagnoses in a patient who failed to return for further investigation or care; (d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases in which a more precise diagnosis was not available for any other reason;...”

Case Study cont’d

6 months later:

Patient now weighs 121 lbs. (loss of 4 lbs). No new symptoms or new medications. No significant change in respiratory status. No further episodes of hemoptysis. Declines further work-up or evaluation.

Case Example cont’d

...Over the next few months, her BMI fell to 17 and her PPS decline to 30%. She progressively declined and easily met the Palmetto LCD for “adult failure to thrive”. No other diagnoses were ever identified.

Consider using Codes- 262 Other Severe Protein-Calorie Malnutrition or 263.0 Malnutrition of Moderate Degree

Adapted from NHPCO’s Comment Letter to CMS

Certification of Terminal Illness (CTI) when the Diagnosis Changes

• A new CTI is not required because the principal diagnosis changes, nor do benefit periods or election status change

• Physician documentation (including IDG

documentation) should include: o New terminal diagnosis and why it changed o Why it is causing a 6 month or less prognosis o Evidence of prognostic indicators o Reference to outcomes of symptom assessment

scales as applicable

What if you can’t determine a single hospice diagnosis?

CMS… • States that they expect hospice providers will not discharge

beneficiaries who meet eligibility requirements, even if they can’t determine a single principal diagnosis.

• Recommends listing all related diagnoses, picking the predominant one as the terminal dx

• If the patient meets the eligibility requirements, they will have access to hospice services under the Medicare Hospice Benefit.

Summary

• As of October 1, 2014, failure to thrive or debility can no longer be used as a primary diagnosis.

• Select a diagnosis from the patient’s list of comorbid conditions and document the effects of other significant co-morbids to support eligibility.

• Discharge patient if they no longer meet eligibility requirements and monitor disease trajectories.

• Ensure that your HMD documents why a condition is not related.

• Ensure that your hospice has ICD-9/ICD-10 coding expertise

Biomarkers used to support Prognostication

In addition to Prognostic indicators LCDs (Local Coverage Determinations) and

other tools

General used to support frailty, debility (ill defined

diagnosis)

• BMI < 21 • 5% wt loss < 6 months • Albumin < 3.5 mg/dl • Anemia • High CRP • Cholesterol < 150 mg/dl • Low Lymphocytes

References Zakai, Neil MD, et al, A Prospective Study of Anemia States, Hemogloblin

Concentration, and Mortality in an Elderly Cohort, 2005, Arch Int Med, pp 2214-19

Harris, Tamara, B, MD, MS et al, Association of Interleukin6 and C-Reactive Protein Levels with Mortality in the Elderly, 1999, Am J Med, vol. 106, pp 506-12

Herman MD, MPH, Francois, et al,Serum Albumin Levels on Admission as a Predictor of Death, Length of Stay, and Readmission, 1992, Jan, Arch Intern Med, Vol 152, 125-130

Rudman, Daniel, MD, et al, Relationship of Serum Albumin Concentration to Death Rate in Nursing Home Men, 1987 Journal of enteral and Parenteral Nutrition, vol 11, pp 360-63

Verdery, Rob B, et al, “Hypocholesterolemia as a Predictor of Death; A Prospective Study of 224 Nursing Home Residents,” 1991, Journal of Gerontology, Vol 46,(3), pp M84-M90

Noel, Margaret A MD, et al, “Characteristics and Outcomes of Hospitalized Older Patients Who Develop Hypocholesterolemia,” JAGS, VOL 39, pp455-61

Cardiac Disease

• Hyponatremia • Cr (> 2) - some studies >1.4 • BNP > 480 pg/dl ( 42% 6 mo mortality) • Troponin • BUN > 30 • CRP • Seattle Heart Model • EFFECT Model

References

Palliation in heart failure, Davis, AJHPM 2005: 22, 211 Fast Fact Concept #143 NEJM - 5/2008 Zetheilius Biomarkers in Heart Failure, NEJM, Vol 358; 2148-2159 Bonnie et al., Circ. Heart Fail. 2012; 5: 183-190 JAMA 2OO3: 290(19): 2581-2587 Am J Cardiol 2006; 98:1076-1093 Maisel, B-Type Natriuretic Peptide Levels: Diagnostic and Prognostic in Congestive Heart Failure , Circulation, 2002, 105;2328-2331

Pulmonary Disease

• BODE

• CRP

• Fibrinogen

• High WBC count

References

Respiratory Care January 2004, 48 (1) 90-98 Am J Respir Crit Care Med. 2012 May 15;185(10):1065-72. dol:

10.1164/rccm.201110-1792OC. Epub 2012 Mar 15. Inflammatory biomarkers improve clinical prediction of mortality in chronic obstructive pulmonary disease. Thorax 2008;63;665-666 community acquired pneumonia

CHEST 2010; 138(3):559-567 ARDS Crit C Med. 2008;36(7):2061-2069 ICU ventilation N Engl J Med 2010;363:266-74. Pulm embolism Am J Respir Crit Care Med Vol 182. pp 1178-1183, 2010 Pulm embolism

Dementia

Mortality Risk Index • MRI - Mitchell, JAMA 2004: 291:2734-2740 • Coexisting Fracture or Pneumonia - Morrison RS JAMA

2000; 264:47-52

Liver Disease

• MELD score - INR, Bilirubin, CR • Sodium - (hepatocellular carcinoma-use MELD- Na

score) References Kamath, Hepatology 2001 Feb 33; A464-70 A model to predict survival in patients with end-stage liver disease

Renal Disease

• Albumin < 3.5 • BNP, NT - Pro BNP, Troponin, CRP References Friedman, JACN JASN February 1, 2010 vol. 21 2 223-230 Reassessment of Albumin as a Nutritional Marker in Kidney Disease Fast Fact #191 Chaykovska L, Clin. Lab. 2011;57:455-467 Biomarkers for the prediction of

mortality and morbidity in patients with renal replacement therapy. Cohen, J Palliat Med. 2006;996):977-992. Predicting Six-Month Mortality for

Patients Who Are on Maintenance Hemodialysis

Stroke

• BNP, CRP References LaBorde Expert Rev Proteomics. 2012;9(4):437-449. Potential Blood Biomarkers for Stroke

JAMA 2007’297 Mitka Hemorrhagic stoke guidelines issued Stroke 2008;39:2304-2309

Sacco et al, Stroke 2009;40:394

HIV and HAART

References http://www.art-cohort-collaboration.org Other Resources Pallipedia.org http://www.eprognosis.org http://www.victoriahospice.org/health-professionals/clinical-tools#

PPS version 2 • See handout

Ten Steps to Better Prognostication • See handout

Prognosis - Clinical Skill

• Lack of Training • Lower Research Priority • Difficult discussion, emotions, superstitions • Tendency to be overoptimistic Christakis et al. BMJ 2000;320: 467-473

Glare et al. Journal of Palliative Medicine 2008, Vol.11: 1: 84 - 183

General Concepts • Accurate estimates of prognosis for a population with a

specific disease • Increased “noise” as we attempt to estimate the

prognosis for an individual • Further confounding factors of multiple co-morbidities • The “median is not the message” Stockler et al. BR J Cancer, 2004:94(2):208-12

NHPCO Guidelines

• Created in 1996 as a GUIDE to be used in conjunction with clinical judgment

• Never intended to be used as public policy • Never validated • Ineffective at predicting prognosis Fox et al, JAMA 1999; 282.1638-1645 Schonwetter, Am JPHM 2003

Performance Status

• Karnofsky Scale o -Normal (100) < ------- > Dead (0) o -50- considerable assistance with frequent medical

care • Eastern Cooperative Oncology Group (ECOG)

o -Normal (0) < ------- > Dead (5) o -3- limited self care / bed or chair > 50% of waking

hours Kamofsky < 40 or ECOG 3 → median survival 3 mos.

FAST FACTS 13, 124, 125

Palliative Performance Scale

• See Handout

Palliative Prognostic Score

• See Handout The Palliative Prognostic Score (PaP) -Dyspnea -Anorexia -KPS -Clinical Prediction/Prognosis -Total WBC -Lymphocyte %

Sobering Data

• Malignant Hypercalcemia 8 weeks • Malignant Pericardial Effusion 8 to 12 weeks • Carcinomatous Meningitis 8 to 12 weeks • Multiple Brain Mets

o Without XRT 4 to 8 weeks o With XRT 12 to 24 weeks

Fast Fact 13

“Predication is very difficult, especially if it is about the future”

Niels Bohr

Question #2 62 yo male with Class IV CHF, COPD, and chronic kidney disease. His EF - 50%, FEV1 -40%, CR - 2.5. BP 90/60 Pulse 100; Weight 160 lbs. Max. meds.

Would you admit this patient to hospice? A. Yes, cardiac disease B. Yes, COPD C. Yes, CKD D. No.

Organic System Failure

• General factors to consider • Prognostication Tools • Would you be surprised if……?

Organ System Failure - General Considerations

• Co-morbid conditions • Rate of Decline • Nutritional Status • Functional Status • Cognitive Status • Number of Hospitalizations • Depression • Social Isolation

CHF - Prognostic Variables

• NYHA Functional Classification

o -Class I - 5% to 10% mortality per year

o -Class IV - 40% to 50% mortality per year

• Recent cardiac hospitalization

• Elevated BUN

• Systolic BP < 100 under/or pulse > 100

• Decreased LVEF

CHF - Prognostic Variables

• Ventricular Dysrhythmias

• Anemia

• Hyponatremia

• Cachexia

• Reduced functional capacity

• Co-morbidities (DM, COPD, CVA etc.)

FAST FACTS #143

CHF - Biomarkers

• C-reactive protein Myeloperoxidase • BNP

Tyrosine Kinase Receptor 1 • Troponin 1 Toll -like

receptor 2 • Creatinine Uric Acid • Multimarker score → 13.7 fold increase in adverse

effects in top tertile • Improved accuracy with Seattle HF Model Bonnie et al., Circ. Heart Fail. 2012; 5 183-190

CHF - Multivariable Models

• Seattle Heart Failure Model o Am J Cardiol 2006; 98: 1076-1082 o www.depts.washington.edu/shfm

• EFFECT Heart Failure Mortality Prediction

o JAMA 2003; 290 (19):2581-2587 o http://www.ccort.ca/Research/CHFRiskModel.aspx

COPD Prognosis

• SUPPORT (30 TO 40% 6 month mortality o Baseline PaCO2 > 45 mm Hg o Presence of Cor Pulmonale o FEV1 < 0.75 liters o Previous episode of respiratory failure in the last six

months

COPD Prognosis

• BODE index (30 to 40% 2 year mortality with a score of 7 or more o BMI < 21 1 point o FEV 1 (36 TO 49%) 2 points o FEV 1 < 35% 3 points o Dyspnea (MMRC) 3 or 4 points o Exercise Capacity 2 or 3 points(six minute walk)

COPD -- Prognosis

• Hansen -- Flaschen Criteria o Best FEV1 < 30% predicted o Increasing dependence on caregivers o Activity limited to a few steps without need to rest o Depression o No spouse o Recurrent hospitalization within the previous year o Associated chronic comorbid illness

Respiratory Care January 2004, 49 (1) 90-98

Acute Ischemic Stroke (85% CVA’s)

• 5% hospital mortality • 17 to 21% 90 day mortality • Medical complications in the hospital increase the

mortality rate • NIHSS and age - strongest predictors

Hemorrhagic Stroke (15% CVA’s)

• 52% 30 day mortality • 90% 30 day mortality if a brainstem bleed • Volume of the bleed

o - < 30 cc’s - 2-% mortality o - 30 to 60 cc’s - 100% with Rankin Score > 4 -

Unable to walk or any ADLs without assistance o - 60 cc’s - 90+% mortality

Mitka, JAMA 2007; 297 (23) 2573

LIfe Expectancy - ESRD Patients

ESRD Patient Population Survival (%)

1-yr for all incident patients, unadjusted 80.4

2-yr for all incident patients, unadjusted 67.8

5-yr for all incident patients, unadjusted 39.8

10-yr for all incident patients, unadjusted 19.9

ESRD Prognosis General Considerations

• Life expectancy - ⅓ to ⅙ as long as non-dialysis patients of the same age and gender

• Five year survivals: o Age 45 to 54 years -60.5% o Age 55 to 64 years -46.3% o Age 64 to 74 years -31.7% o 75 years and older - 19.6%

Albumin < 3.5 → 50% one year survival …. 17% 2 year survival!

The Very Elderly (> 75 years)

• Canadian Data - 1-, 3- and 5- year survival was 69.0%, 36.7% and 20.3%

• Mortality seems to be the highest at the onset of dialysis with North American studies showing-25% mortality in the first 3 months in vulnerable patients

• Kurella et al, - Fewer than half of NH residents survived > 9 months . Functional status preserved in 39% and 13% at 3 months and 12 months.

• Dementia - Very Poor Outcomes

Kurella et al, N Engl J Med., 2009 Oct 15;361(16):1539-47

End-stage Liver Disease The Meld Score

• INR

• Bilirubin

• Creatinine

http://www.mdcalc.com/meld-score-model-for-end-stage-liver-

disease-12-and-older/

….

“Occurrences in this domain are beyond the

reach of exact predictions, because of the

variety of factors in operation, not because of

any lack of order in nature”

Albert Einstein

Question #3

You are asked to evaluate an 85 yo nursing home patient with advanced dementia. She is s/p a recent hospitalization for pneumonia. She has total functional dependence and she is minimally verbal.

Would you admit this patient to hospice?

A. Yes B. No

Dementia and Frailty

• Clinical Course • Staging • Prognostic Indicators • A Better Paradigm

Dementia - The FAST Scale

• FAST 6 - Decrease in ADL’s with Incontinence

• FAST 7: o -A- Speech limited to 6 words o -B- Single word o -C- Loss of ambulation

Poor discrimination. Limited utility

Clinical Course of Advanced Dementia Mitchell S NEJM 361;16: 1529 - 1538

• 323 NH patients with advanced dementia o - Cognitive Performance Scale (5 or 6)

Score of 5 → MMS of 5.1 +/- 5.3 o - Global Deterioration Scale (7)

Inability to recognize family members Minimal verbal communication Total Functional Dependence Incontinence of Urine Inability to Ambulate

Clinical Course of Advanced Dementia Mitchell S NEJM 361;16: 1529 - 1538

Six Month Mortality…. Pneumonia 46.7% A Febrile Episode 44.5% Eating Problem 38.6% Of note, 40.7% underwent at least one “burdensome” intervention in the 3 months before death

A New Paradigm

DEMENTIA is THE DISEASE

Frailty without Dementia

• Vulnerability arising from the dysregulation of multiple physiological systems

The sickest do not necessarily die sooner…

Need for a method of identifying these individuals and quantifying their frailty

Frailty as a Syndrome (3 of 5)

• Reduced Activity

• Slowing of Mobility

• Weight Loss

• Diminished handgrip strength

• Exhaustion

Fried et al; J Gerontol A Biol Sci Med Sci 2001; 56: M146-M156

Frailty as an Accumulation of Deficits

• The Frailty Index • Number of Deficits divided by the number of deficits

considered • Numerical value between 0 and 1 • Strongly correlated with the risk of death • If > 0.5 - close to 100% mortality at 6 months Rockwood K, Miniski A Mech Aging Dev 2006;127; 494-496 Rockwood K et al, J Am Geriatr Soc 2010; 58:316-323

Clinical Frailty Index

1. Very Fit 2. Well 3. Well with treated comorbid disease 4. Apparently vulnerable - “Slowed Up” 5. Mildly frail - Limited dependence 6. Moderately Frail - Help with all ADL’s 7. Severely Frail - Completely dependent upon others Rockwood K et al; (2005) CMAJ 173(5) 489 - 495

GeriPal - www.eprognosis.org

…. Good resource…

Final considerations...

• Prognostication is a critical skill for

physicians

• Our ability to prognosticate accurately is

limited, especially with organ system failure

and frailty

Final considerations...

• Understand the global trajectory of the disease

as you formulate the prognosis and care plan

• Utilize a comprehensive “biopsychosocial”

assessment when formulating prognosis

• Support more research in this area!

Thank You!

… Cure Sometimes, Relieve Often, And Comfort Always… (Unknown)