The Downward Spiral: Predicting Survival For People Over The Age Of 70 And Who Are Admitted To Hospital

Everyone wants to live as long as possible but also as comfortable as possible – clean, dry, pain-free, and well fed.  Years ago most people died fairly quickly:  they were active until they developed pneumonia or some overwhelming infection from an injury.  Now, our drugs and technology can keep people alive for months or years but not necessarily without pain – chronic diseases can produce a “slow death”.

As we age, most of us develop some chronic illnesses and these lead to more frequent hospitalizations.   A major illness requiring admission can produce a lot of anxiety in an elder, worrying about their prognosis – “how much longer do I have”.  Suspecting or knowing that they are beginning to fail – they’ve entered the “downward spiral at the end of life” – people look to their doctor for information to help them make decisions about what interventions will make their remaining time as meaningful as possible – and which ones will only cause unnecessary discomfort and/or expense without improving the quality of life.  This information offers the patient and the family an opportunity to discuss their goals of care with their providers.

Being able to predict someone’s probable remaining time might help everyone make such decisions.  For example, a 78 year old man with mild malnutrition and who is dependent on his children for five ADL’s (Activities of Daily Living), and who is admitted with pneumonia, has only a 32% chance of living another year.  Knowing this, he might choose not to have CPR(CardioPulmonary Resuscitation) or life support, to avoid a proposed heart catheterization for occasional angina, and to not have his hernia fixed; he may prefer Comfort measures rather than invasive interventions which entail some pain and aren’t likely to improve his remaining time. 

Whereas an 80 year old woman who has been living independently and is discharged after treatment for pneumonia has no increased risk of dying compared to the average healthy 80 year old (has a 90% chance of living another year at least).  She may choose to have all the above.

What ADL’s (Activities of Daily Living) are Important:
It’s been found that 1) Eating, 2) Bathing, 3) Toileting, 4) Dressing, and 5) Transfering from bed to a chair, are the most significant Activities of Daily Living. Independent in a specific activity means a person does not require any assistance from another individual,  even if a cane or walker or some other “device” is used. Dependent means another person is needed for assistance.

How to Determine Risk of Dying:
On the reverse side, from the six Risk Factors listed, circle each one that is applicable and write in the appropriate point score; then add the points and write in the total at the bottom (the Index of Risk Score) (there should be no more than 20 points).  Under the Risk of Dying, find the total points scored with the corresponding percentage risk next to it.

Interpreting an Index of Risk Score:
A 68% risk of dying means that out of 100 people with the same score, 68 of them will die within the next year:  in other words, the person has a significantly higher risk of dying than remaining alive.  The higher the risk, the more important it is to determine the potential benefit of an intervention (a surgery, a drug, needing a ventilator, etc.).    There may be little advantage to taking a drug with potential significant side effects and that is expensive if it isn’t likely to add comfort and years to one’s remaining time on earth.

Predicting death is obviously not a precise science.  But, with the studies available now, it is possible to give patients a more accurate estimate of the life they have remaining.  It’s important for a patient, the family, and the physician to discuss this.  For additional help when considering such a difficult issue, read the handouts:  “What is Palliative Care (Comfort Care)”; “Goal Focused Care:  how to choose the most appropriate healthcare while in Hospital”; and “It’s Your Life:  finding the right healthcare goal”.


Predicting Survival for People over age 70 Admitted to Hospital

Step 1.  Identify Your Risk Factors for Dying:
The following are independent risk factors for dying within a year, for people over age 70 who are admitted to hospital, with corresponding points (which, when added together provide an index of risk score).

Circle each factor that applies to you and write in the appropriate points.  Obtain the necessary lab information for #5 and #6 from your doctor.

1. Male (1 pt)    __ points

2. Number of dependent ADL’s 
• 1. Eating
• 2. Bathing
• 3. Toileting
• 4. Dressing
• 5. Transfering from bed to chair

(circle each one that you depend on someone for direct help)
(Dependent in 1-4 ADL’s = 2 pts; Dependent in all 5 ADL’s = 5 pts) __ points

3. CHF (2 pts)    __ points

4. Cancer  (solitary, 3 pts; metastatic, 8 pts)  __ points

5. Creatinine over 3.0mg/dl (2 pts) __ points

6. Albumin 3.0-3.4 gm/dl (1 pt)
< 3.0gm/dl (2pts)   __ points

TOTAL: [Maximum is 20 points.]  __ Points (= Index of Risk Score)

Step 2.  Estimate Your Risk of Dying Within the Next Year:
Take the total points calculated above (Index of Risk Score) and find the corresponding Risk of Dying percentage next to it.

Points  Risk of Dying
0-1      13%

2-3      20%

4-6      37%

>6       68%

What to do With This:

Read the reverse side with its “Interpreting and Index of Risk Score”.  Discuss this with your physician and with your family.  Use the referenced handouts to assist you in your discussion.  Your physician can help you decided the relative benefits and risks of various interventions.