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Prediction of Mortality in Community-Living Frail Elderly People with Long-Term Care Needs

Authors

  • Elise C. Carey MD,

    1. From the *Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MinnesotaDivision of Geriatrics, University of California at San Francisco, San Francisco, CaliforniaSan Francisco Veterans Affairs Medical Center, San Francisco, California§Research Institute of California Pacific Medical Center, San Francisco, CaliforniaOn Lok Senior Health Services, San Francisco, California#Purdue University School of Nursing, Center for Healthcare Engineering, Center for Aging and the Life Course, West Lafayette, Indiana.
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  • Kenneth E. Covinsky MD, MPH,

    1. From the *Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MinnesotaDivision of Geriatrics, University of California at San Francisco, San Francisco, CaliforniaSan Francisco Veterans Affairs Medical Center, San Francisco, California§Research Institute of California Pacific Medical Center, San Francisco, CaliforniaOn Lok Senior Health Services, San Francisco, California#Purdue University School of Nursing, Center for Healthcare Engineering, Center for Aging and the Life Course, West Lafayette, Indiana.
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  • Li-Yung Lui MA, MS,

    1. From the *Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MinnesotaDivision of Geriatrics, University of California at San Francisco, San Francisco, CaliforniaSan Francisco Veterans Affairs Medical Center, San Francisco, California§Research Institute of California Pacific Medical Center, San Francisco, CaliforniaOn Lok Senior Health Services, San Francisco, California#Purdue University School of Nursing, Center for Healthcare Engineering, Center for Aging and the Life Course, West Lafayette, Indiana.
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  • Catherine Eng MD,

    1. From the *Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MinnesotaDivision of Geriatrics, University of California at San Francisco, San Francisco, CaliforniaSan Francisco Veterans Affairs Medical Center, San Francisco, California§Research Institute of California Pacific Medical Center, San Francisco, CaliforniaOn Lok Senior Health Services, San Francisco, California#Purdue University School of Nursing, Center for Healthcare Engineering, Center for Aging and the Life Course, West Lafayette, Indiana.
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  • Laura P. Sands PhD,

    1. From the *Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MinnesotaDivision of Geriatrics, University of California at San Francisco, San Francisco, CaliforniaSan Francisco Veterans Affairs Medical Center, San Francisco, California§Research Institute of California Pacific Medical Center, San Francisco, CaliforniaOn Lok Senior Health Services, San Francisco, California#Purdue University School of Nursing, Center for Healthcare Engineering, Center for Aging and the Life Course, West Lafayette, Indiana.
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  • Louise C. Walter MD

    1. From the *Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MinnesotaDivision of Geriatrics, University of California at San Francisco, San Francisco, CaliforniaSan Francisco Veterans Affairs Medical Center, San Francisco, California§Research Institute of California Pacific Medical Center, San Francisco, CaliforniaOn Lok Senior Health Services, San Francisco, California#Purdue University School of Nursing, Center for Healthcare Engineering, Center for Aging and the Life Course, West Lafayette, Indiana.
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  • An abstract of this study was presented at the annual meeting of the Society of General Internal Medicine, May 2004.

Address correspondence to Louise C. Walter, MD, VA Medical Center 181G, 4150 Clement Street, San Francisco, CA 94121. E-mail: Louise.Walter@ucsf.edu

Abstract

OBJECTIVES: To develop and validate a prognostic index for mortality in community-living, frail elderly people.

DESIGN: Cohort study of Program of All-Inclusive Care for the Elderly (PACE) participants enrolled between 1988 and 1996.

SETTING: Eleven PACE sites, a community-based long-term care program that cares for frail, chronically ill elderly people who meet criteria for nursing home placement.

PARTICIPANTS: Three thousand eight hundred ninety-nine PACE enrollees. The index was developed in 2,232 participants and validated in 1,667.

MEASUREMENTS: Time to death was predicted using risk factors obtained from a geriatric assessment performed by the PACE interdisciplinary team at the time of enrollment. Risk factors included demographic characteristics, comorbid conditions, and functional status.

RESULTS: The development cohort had a mean age of 79 (68% female, 40% white). The validation cohort had a mean age of 79 (76% female, 65% white). In the development cohort, eight independent risk factors of mortality were identified and weighted, using Cox regression, to create a risk score: male sex, 2 points; age (75–79, 2 points; 80–84, 2 points; ≥85, 3 points); dependence in toileting, 1 point; dependence in dressing (partial dependence, 1 point; full dependence, 3 points); malignant neoplasm, 2 points; congestive heart failure, 3 points; chronic obstructive pulmonary disease, 1 point; and renal insufficiency, 3 points. In the development cohort, respective 1- and 3-year mortality rates were 6% and 21% in the lowest-risk group (0–3 points), 12% and 36% in the middle-risk group (4–5 points), and 21% and 54% in the highest-risk group (>5 points). In the validation cohort, respective 1- and 3-year mortality rates were 7% and 18% in the lowest-risk group, 11% and 36% in the middle-risk group, and 22% and 55% in the highest-risk group. The area under the receiver operating characteristic curve for the point score was 0.66 and 0.69 in the development and validation cohorts, respectively.

CONCLUSION: A multidimensional prognostic index was developed and validated using age, sex, functional status, and comorbidities that effectively stratifies frail, community-living elderly people into groups at varying risk of mortality.

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