prognosticating for elderly patients

PrognosticatingDr Colin Mitchell

Prognosis in the Elderly

Truth or Falsehood?Predicting prognosis in frail elderly is a fool’s errand

Comorbidities are the best predictor

Most estimates are based on white Americans

Prognosis correlates with frailty

Inpatient Mortality

You have just clerked Mrs McRory72 years old, admitted with inf exac COPD

History of PMR. Ex smoker. No home nebs/O2

Rx: inhalers, calcium & vit D

Usually mobile with a stick, currently needs A of 1

U&E at baseline, Creat 100. Alb 31.

What is Mrs McRory’s 1yr Mortality?

Please discuss with your immediate neighbour and predict what % chance she has of death in the next year.

Then we’ll compare with the Inouye scale

The Inouye Scale

Mrs McRory’s 1yr mortality would be 32%

She scores a point for:

• Chronic Lung Disease

• Albumin <35

• Unable to mobilise unaided

=3/7

Other points for

• Comorbidities (up to 3)

• Creatinine >135

• Dementia

The Inouye scale is:

Based on ~500 admissions, validated on 1200

77% accurate (ROC curve 0.77)

Inpatient Mortality 2

You are about to discharge Mr Khan home76 years old, admitted with inf exac COPD

Previously living independently, now has once-daily POC for help with washing/dressing

U&E at baseline, Creat 160. Albumin 29

What is Mr Khan’s 1yr Mortality?

Please discuss with your immediate neighbour and predict what % chance he has of death in the next year.

Then we’ll compare with the Walter / Covinsky scale

What is Mr Khan’s 1yr Mortality?

Please discuss with your immediate neighbour and predict what % chance he has of death in the next year.

Then we’ll compare with the Walter / Covinsky scale

Actually, let’s make it a bit different…

Inpatient Mortality 2a

You are about to discharge Mr Khan home76 years old, admitted with inf exac COPD & CRF

Previously living independently, now has once-daily POC for help with washing/dressing

U&E at baseline, Creat 330. Albumin 29

The Walter / Covinsky ScaleMr Khan’s 1yr mortality was 34%

He scores for:

• Help with 2 PADLs (+2)

• Albumin <30 (+2)

• Male sex

=5/17

But add CRF (Creat >300, +2), mortality 64%

Other points for

• Cancer (solitary +3, metastatic +8)

• Heart failure (+2)

The Walter / Covinsky scale is:

Based on ~1500 discharges, validated internally & externally

79% accurate (ROC curve 0.79)

Community-Dweller Mortality

You have just seen Mr Gordon for clinic F/UReferred for investigation of dyspnoea, improved.

80 years old. Ex smoker. BMI 21.

Normal CXR & PFTs. Echo: Mild LVSD

Rx: Enalapril 10mg, Bisoprolol 2.5mg

Largely independent.

Now able to walk 1 mile, can lift boxes

Mild memory problems, son now manages finances. AMT 8/10

What is Mr Gordon’s 4 year mortality?

Please discuss with your immediate neighbour and predict what % chance he has of death in the next 4 years.

Then we’ll compare with the Covinksy / Lee index

The Lee / Covinsky ScaleMr Gordon’s 4yr mortality is 34%

He scores for:

• Age 80 (+5 as baseline is 50 years old)

• Male sex

• BMI <25

• CCF (+2)

• Needs help managing finances (+2)

= 11

Other points for:

Diabetes, Cancer (+2)

Current smoking

Needs help with washing/dressing (+2)

Can’t walk several blocks (+2) or move a chair (+2)

The Lee / Covinsky scale is:

Based on ~12 000 people, validated on 8000

82% accurate (ROC curve 0.82)

Take home messages

You can predict prognosisor at least odds of dying

There are validated toolsThey’re the same tools we use to judge frailty

Key factors:Age (in community dwellers), sex, smoking

Being underweight

Comorbidities, especially CA and cardioresp

Creatinine & albumin

Function & mobility

Admission to hospital

www.ePrognosis.org