Simple tool with ‘good accuracy’ predicts life expectancy in patients with dementia

William Dale, MD, PhD

I want to start by commending Haaksma and colleagues for developing another survival prediction tool to use in patients with dementia. Recently, some of the major creators in this area have been licensing their tools and making it more expensive and difficult to use them clinically, so I’m pleased we will have more options to use in this area. For this reason alone, Haaksma and colleagues’ tool is not as difficult to use as, say, the Montreal Cognitive Assessment (MoCA). I'm also pleased that these researchers focused on creating a tool that primary care physicians can easily use, since that is where the vast majority of patients with dementia are seen.

However, I'm also a little cautious. Any time you try to apply something clinically that's just emerging from research circles, applying it into daily practice can be challenging for several reasons. For example, your patient population can be different than the ones that were studied to develop the tool. One strategy to overcome this challenge is to apply the tool slowly in your practice, in a smaller way, so that you get each aspect of implementation right, and then slowly scale it into your entire practice. Another strategy is to find an office champion who agrees to try the entire tool, perfect its use and then introduce it across the broader practice.

When PCPs discern an older patient’s survival risks using the Haaksma tool (or any similar tool) that indicates a limited prognosis, they may want to do what I do: focus on the health-related items that are the highest on the long list of health concerns. And if we can take care of those highest priorities, we'll keep moving down the list of priorities. Having said that, you also have to be consistently talking to patients about their priorities, since something further down your list of health risks may be very high on theirs. An example of this might be arthritis, which is very rarely life-limiting, but affects quality of life — consider someone with hand arthritis who plays piano or works on the computer. That might be really, really important to them, although not life-threatening. And then tell the patient, well, let's move that one up the list for you and we'll move something else down the list. And if I am able to improve the function and pain, you can try to decrease smoking. By knowing what you and the patient consider highest priorities, you are both working on important things and, at the same time, it helps build the trust and rapport with your patient, something called “shared decision-making.”