Background Dementia is a leading cause of death in the United States but is underrecognized as a terminal illness. The clinical course of nursing home residents with advanced dementia has not been well described. Methods We followed 323 nursing home residents with advanced dementia and their health care proxies for 18 months in 22 nursing homes. Data were collected to characterize the residents’ survival, clinical complications, symptoms, and treatments and to determine the proxies’ understanding of the residents’ prognosis and the clinical complications expected in patients with advanced dementia. Results Over a period of 18 months, 54.8% of the residents died. The probability of pneumonia was 41.1%; a febrile episode, 52.6%; and an eating problem, 85.8%. After adjustment for age, sex, and disease duration, the 6-month mortality rate for residents who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%. Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last 3 months of life, 40.7% of residents underwent at least one burdensome intervention (hospitalization, emergency room visit, parenteral therapy, or tube feeding). Residents whose proxies had an understanding of the poor prognosis and clinical complications expected in advanced dementia were much less likely to have burdensome interventions in the last 3 months of life than were residents whose proxies did not have this understanding (adjusted odds ratio, 0.12; 95% confidence interval, 0.04 to 0.37). Conclusions Pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are also common among such patients. Patients with health care proxies who have an understanding of the prognosis and clinical course are likely to receive less aggressive care near the end of life.

Nursing home residents dying with advanced dementia are not perceived as having a terminal condition, and most do not receive optimal palliative care. Management and educational strategies are needed to improve end-of-life care in advanced dementia.

Delirium can accelerate the trajectory of cognitive decline in patients with Alzheimer disease (AD). The information from this study provides the foundation for future randomized intervention studies to determine whether prevention of delirium might ameliorate or delay cognitive decline in patients with AD.

These findings identified muscle power to be a more influential proximal determinant of physical performance than impairments in strength and emphasized muscle power as an important determinant of mobility skills in older adults.

Context Survival varies for patients with advanced dementia, and accurate prognostic tools have not been developed. A small proportion of patients admitted to hospice have dementia, in part because of the difficulty in predicting survival.

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HE CHALLENGE OF ACCURATELYestimating life expectancy in advanced dementia is a barrier to providing palliative care to the more than 5 million individuals in the United States with this condition. [1][2][3][4][5][6][7][8] Hospice has been shown to benefit residents dying with dementia. [9][10][11][12] Although trends indicate that hospice enrollment of patients with dementia is gradually increasing, in 2008, the National Hospice and Palliative Care Organization reported that only 11% of hospice admissions had a primary diagnosis of dementia. 13 Hospice professionals cite prognostication as the main hindrance to enrolling patients with dementia. 1 Medicare hospice eligibility requires an estimated survival of less than 6 months and, for dementia, is guided by 2 criteria 14 : stage 7c on the Functional Assessment Staging (FAST) scale 15 and the occurrence of least 1 of 6 specified medical conditions in the prior year. Earlier studies suggest these guidelines do not accurately predict survival, but these studies are limited by retrospective designs, 3,4,8,16 small sample sizes, 3 testing of only the FAST component, 3,4 and simulation of hospice eligibility using the minimum data set (MDS). 4,16,17 The prognostic accuracy of hospice guidelines for dementia has not been evaluated in a large prospective study.To date and to our knowledge, rigorous research efforts to create prognostic models for advanced stage de-

OBJECTIVES To investigate the relationships between uncontrolled and controlled hypertension, orthostatic hypotension (OH), and falls in participants of the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study (N = 722, mean age 78.1). DESIGN Prospective population-based study. SETTING Community. PARTICIPANTS Seven hundred twenty-two adults aged 70 and older living within a 5-mile radius of the study headquarters at Hebrew Rehabilitation Center in Boston. MEASUREMENTS Blood pressure (BP) was measured at baseline in the supine position and after 1 and 3 minutes of standing. Systolic OH (SOH) and diastolic OH at 1 and 3 minutes were defined as a 20-mmHg decline in systolic BP and a 10-mmHg decline in diastolic BP upon standing. Hypertension was defined as BP of 140/90 mmHg or greater or receiving antihypertensive medications (controlled if BP < 140/90 mmHg and uncontrolled if ≥140/90 mmHg). Falls data were prospectively collected using monthly calendars. Fallers were defined as those with at least two falls within 1 year of follow-up. RESULTS OH was highest in participants with uncontrolled hypertension; SOH at 1 minute was 19% in participants with uncontrolled hypertension, 5% in those with controlled hypertension, and 2% in those without hypertension (P≤.001)). Participants with SOH at 1 minute and uncontrolled hypertension were at greater risk of falls (hazard ratio = 2.5, 95% confidence interval = 1.3–5.0) than those with uncontrolled hypertension without OH. OH by itself was not associated with falls. CONCLUSION Older adults with uncontrolled hypertension and SOH at 1 minute are at greater risk for falling within 1 year. Hypertension control, with or without OH, is not associated with greater risk of falls in older community-dwelling adults.