March 12, 1997

Predicting Time to Nursing Home Care and Death in Individuals With Alzheimer Disease

Author Affiliations

From the Departments of Neurology (Drs Stern, Tang, Jacobs, Bell, Marder, Sano, and S. M. Albert), Psychiatry (Drs Stern and Devanand), and Biostatistics (Dr Tsai), and the Gertrude H. Sergievsky Center and Taub Center for Alzheimer's Disease Research (Drs Stern, Tang, Jacobs, Bell, Marder, Sano, and S. M. Albert), Columbia University College of Physicians and Surgeons, New York, NY; the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Md (Drs Brandt and Bylsma); and the Departments of Psychiatry and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (Dr M. S. Albert).

JAMA. 1997;277(10):806-812. doi:10.1001/jama.1997.03540340040030

Objective.  —To develop and validate an approach that uses clinical features that can be determined in a standard patient visit to estimate the length of time before an individual patient with Alzheimer disease (AD) requires care equivalent to nursing home placement or dies.

Design.  —Prospective cohort study of 236 patients, followed up semiannually for up to 7 years. A second validation cohort of 105 patients was also followed.

Setting.  —Three AD research centers.

Patients.  —All patients met National Institute of Neurological and Communicative Disorders and Stroke—Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria for probable AD and had mild dementia at the initial visit.

Intervention.  —Predictive features, ascertained at the initial visit, were sex, duration of illness, age at onset, modified Mini-Mental State Examination (mMMS) score, and the presence or absence of extrapyramidal signs or psychotic features.

Main Outcome Measures.  —(1) Requiring the equivalent of nursing home placement and (2) death.

Results.  —Prediction algorithms were constructed for the 2 outcomes based on Cox proportional hazard models. For each algorithm, a predictor index is calculated based on the status of each predictive feature at the initial visit. A table that specifies the number of months in which 25%, 50%, and 75% of patients with any specific predictor index value are likely to reach the end point is then consulted.Survival curves for time to need for care equivalent to nursing home placement and for time to death derived from the algorithms for selected predictor indexes fell within the 95% confidence bands of actual survival curves for patients.When the predictor variables from the initial visit for the validation cohort patients were entered into the algorithm, the predicted survival curves for time to death fell within the 95% confidence bands of actual survival curves for the patients.

Conclusions.  —The prediction algorithms are a first but promising step toward providing specific prognoses to patients, families, and practitioners. This approach also has clear implications for the design and interpretation of clinical trials in patients with AD.