An interactive talk on prognosis / frailty assessment tools, the commonalities and key factors, and misconceptions about assessing prognosis in elderly people. Relies heavily on ePrognosis.org - a great site!

1. Prognosticating
Dr Colin Mitchell

2. 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

3. Inpatient Mortality
You have just clerked Mrs McRory
72 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.

4. 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

5. 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)

6. Inpatient Mortality 2
You are about to discharge Mr Khan home
76 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

7. 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

8. 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…

9. Inpatient Mortality 2a
You are about to discharge Mr Khan home
76 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

10. The Walter /
Covinsky
Scale
Mr 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)

11. Community-Dweller Mortality
You have just seen Mr Gordon for clinic F/U
Referred 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

12. 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

13. The Lee /
Covinsky
Scale
Mr 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)

14. Take home messages
You can predict prognosis
or at least odds of dying
There are validated tools
They’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

15. www.ePrognosis.org