Abstract
Clinical decision-making is usually difficult in older people due to the presence of a greater number of comorbidities and functional and cognitive or social problems that could worsen prognosis. All these factors could create relevant problems in terms of the correct diagnostic or therapeutic approach to these individuals. Frail individuals are particularly susceptible to adverse drug reactions, and frailty may result in reduced treatment efficacy by physicians. Thus, life expectancy should be included in clinical decisions to better assess the pros and the cons of different treatment approaches in advanced age. Mortality prognostic tools might help clinical decision-making in diagnostics and therapeutics, suggesting appropriate intervention for older patients since it is likely that the effectiveness of drug treatments may be significantly different in older patients with different risk of mortality. In this chapter, we will discuss the importance of prognosis in clinical decision-making and the use of the multidimensional prognostic index (MPI) in defining the most appropriate intervention for older frail subjects.
References
Clegg A, Relton C, Young J, Witham M (2015) Improving recruitment of older people to clinical trials: use of the cohort multiple randomised controlled trial design. Age Ageing 44:547–550. doi:10.1093/ageing/afv044
Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K (2013) Frailty in elderly people. Lancet (London, England) 381:752–762. doi:10.1016/S0140-6736(12)62167-9
Santos-Eggimann B, Cuénoud P, Spagnoli J, Junod J (2009) Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. J Gerontol Ser A Biol Sci Med Sci 64:675–681. doi:10.1093/gerona/glp012
Kojima G (2015) Prevalence of frailty in nursing homes: a systematic review and meta-analysis. J Am Med Dir Assoc 16:940–945. doi:10.1016/j.jamda.2015.06.025
Mangoni AA (2012) Predicting and detecting adverse drug reactions in old age: challenges and opportunities. Expert Opin Drug Metab Toxicol 8:527–530. doi:10.1517/17425255.2012.665874
Muller M, Smulders YM, de Leeuw PW, Stehouwer CD (2014) Treatment of hypertension in the oldest old: a critical role for frailty? Hypertension 63:433–441. doi:10.1161/HYPERTENSIONAHA.113.00911
Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV et al (2015) A randomized trial of intensive versus standard blood pressure control. N Engl J Med 373:2103–2116. doi:10.1056/NEJMoa1511939
Gill TM (2012) The central role of prognosis in clinical decision making. JAMA 307:199–200. doi:10.1001/jama.2011.1992
Schoenborn NL, Bowman TL 2nd, Cayea D, Pollack CE, Feeser S, Boyd C (2016) Primary care practitioners' views on incorporating long-term prognosis in the care of older adults. JAMA Intern Med 176:671–678. doi:10.1001/jamainternmed.2016.0670
Siontis GC, Tzoulaki I, Siontis KC, Ioannidis JP (2012) Comparisons of established risk prediction models for cardiovascular disease: systematic review. BMJ 344:e3318. doi:10.1136/bmj.e3318
Gill TM, Gahbauer EA, Han L, Allore HG (2010) Trajectories of disability in the last year of life. N Engl J Med 362:1173–1180. doi:10.1056/NEJMoa0909087
Jones DM, Song X, Rockwood K (2004) Operationalizing a frailty index from a standardized comprehensive geriatric assessment. J Am Geriatr Soc 52:1929–1933. doi:10.1111/j.1532-5415.2004.52521.x
Pilotto A, Ferrucci L, Franceschi M, D’Ambrosio LP, Scarcelli C, Cascavilla L et al (2008) Development and validation of a multidimensional prognostic index for one-year mortality from comprehensive geriatric assessment in hospitalized older patients. Rejuvenation Res 11:151–161. doi:10.1089/rej.2007.0569
Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK (2012) Prognostic indices for older adults: a systematic review. JAMA 307:182–192. doi:10.1001/jama.2011.1966
Pilotto A, Rengo F, Marchionni N, Sancarlo D, Fontana A, Panza F, Ferrucci L (2012) Comparing the prognostic accuracy for all-cause mortality of frailty instruments: a multicentre 1-year follow-up in hospitalized older patients. PLoS One 7:e29090. doi:10.1371/journal.pone.0029090
Sancarlo D, D’Onofrio G, Franceschi M, Scarcelli C, Niro V, Addante F et al (2011) Validation of a modified-multidimensional prognostic index (m-MPI) including the mini nutritional assessment short-form (MNA-SF) for the prediction of one-year mortality in hospitalized elderly patients. J Nutr Health Aging 15:169–173
Pilotto A, Gallina P, Fontana A, Sancarlo D, Bazzano S, Copetti M et al (2013) Development and validation of a multidimensional prognostic index for mortality based on a standardized multidimensional assessment schedule (MPI-SVaMA) in community-dwelling older subjects. J Am Med Dir Assoc 14:287–292. doi:10.1016/j.jamda.2013.01.005
Pilotto A, Addante F, Ferrucci L, Leandro G, D’Onofrio G, Corritore M et al (2009) The multidimensional prognostic index predicts short- and long-term mortality in hospitalized geriatric patients with pneumonia. J Gerontol Ser A Biol Sci Med Sci 64:880–887. doi:10.1093/gerona/glp031
Sancarlo D, Pilotto A, Panza F, Copetti M, Longo MG, D’Ambrosio LP et al (2012) A multidimensional prognostic index (MPI) based on a comprehensive geriatric assessment predicts short- and long-term all-cause mortality in older hospitalized patients with transient ischemic attack. J Neurol 259:670–678. doi:10.1007/s00415-011-6241-4
Pilotto A, Addante F, D’Onofrio G, Sancarlo D, Ferrucci L (2009) The comprehensive geriatric assessment and the multidimensional approach. A new look at the older patient with gastroenterological disorders. Best Pract Res Clin Gastroenterol 23:829–837. doi:10.1016/j.bpg.2009.10.001
Pilotto A, Sancarlo D, Panza F, Paris F, D’Onofrio G, Cascavilla L et al (2009) The multidimensional prognostic index (MPI), based on a comprehensive geriatric assessment predicts short- and long-term mortality in hospitalized older patients with dementia. J Alzheimers Dis 18:191–199. doi:10.3233/JAD-2009-1139
Gallucci M, Battistella G, Bergamelli C, Spagnolo P, Mazzucco S, Carlini A et al (2014) Multidimensional prognostic index in a cognitive impairment outpatient setting: mortality and hospitalizations. The Treviso dementia (TREDEM) study. J Alzheimer’s Dis (JAD) 42:1461–1468. doi:10.3233/jad-140516
Pilotto A, Addante F, Franceschi M, Leandro G, Rengo G, D’Ambrosio LP et al (2010) Multidimensional prognostic index based on a comprehensive geriatric assessment predicts short-term mortality in older patients with heart failure. Circ Heart Fail 3:191–199
Pilotto A, Sancarlo D, Franceschi M, Aucella F, D’Ambrosio P, Scarcelli C, Ferrucci L (2010) A multidimensional approach to the geriatric patient with chronic kidney disease. J Nephrol 23(Suppl 15):S5–10
Pilotto A, Sancarlo D, Aucella F, Fontana A, Addante F, Copetti M et al (2012) Addition of the multidimensional prognostic index to the estimated glomerular filtration rate improves prediction of long-term all-cause mortality in older patients with chronic kidney disease. Rejuvenation Res 15:82–88. doi:10.1089/rej.2011.1210
Giantin V, Valentini E, Iasevoli M, Falci C, Siviero P, De Luca E et al (2013) Does the multidimensional prognostic index (MPI), based on a comprehensive geriatric assessment (CGA), predict mortality in cancer patients? Results of a prospective observational trial. J Geriat Oncol 4:208–217. doi:10.1016/j.jgo.2013.04.008
Volpato S, Bazzano S, Fontana A, Ferrucci L, Pilotto A (2015) Multidimensional prognostic index predicts mortality and length of stay during hospitalization in the older patients: a multicenter prospective study. J Gerontol Ser A Biol Sci Med Sci 70:325–331. doi:10.1093/gerona/glu167
Angleman SB, Santoni G, Pilotto A, Fratiglioni L, Welmer AK (2015) Multidimensional prognostic index in association with future mortality and number of hospital days in a population-based sample of older adults: results of the EU funded MPI_AGE project. PLoS One 10:e0133789. doi:10.1371/journal.pone.0133789
Brunello A, Fontana A, Zafferri V, Panza F, Fiduccia P, Basso U et al (2016) Development of an oncological-multidimensional prognostic index (Onco-MPI) for mortality prediction in older cancer patients. J Cancer Res Clin Oncol 142:1069–1077. doi:10.1007/s00432-015-2088-x
Giantin V, Falci C, De Luca E, Valentini E, Iasevoli M, Siviero P et al (2016) Performance of the multidimensional geriatric assessment and multidimensional prognostic index in predicting negative outcomes in older adults with cancer. Eur J Cancer Care (Engl). doi:10.1111/ecc.12585
Jung HW, Kim JW, Han JW, Kim K, Kim JH, Kim KI et al (2016) Multidimensional geriatric prognostic index, based on a geriatric assessment, for long-term survival in older adults in Korea. PLoS One 11:e0147032. doi:10.1371/journal.pone.0147032
Bureau ML, Liuu E, Christiaens L, Pilotto A, Mergy J, Bellarbre F et al (2017) Using a multidimensional prognostic index (MPI) based on comprehensive geriatric assessment (CGA) to predict mortality in elderly undergoing transcatheter aortic valve implantation. Int J Cardiol 236:381–386. doi:10.1016/j.ijcard.2017.02.048
De Luca E, Perissinotto E, Fabris L, Pengo V, Zurlo A, De Toni P et al (2015) Short- and longer-term predictive capacity of the multidimensional prognostic index: the timing of the assessment is of no consequence. Arch Gerontol Geriatr 61:458–463. doi:10.1016/j.archger.2015.07.004
Warnier RM, van Rossum E, van Velthuijsen E, Mulder WJ, Schols JM, Kempen GI (2016) Validity, reliability and feasibility of tools to identify frail older patients in inpatient hospital care: a systematic review. J Nutr Health Aging 20:218–230. doi:10.1007/s12603-015-0567-z
Dent E, Kowal P, Hoogendijk EO (2016) Frailty measurement in research and clinical practice: a review. Eur J Intern Med 31:3–10. doi:10.1016/j.ejim.2016.03.007
Pilotto A, Sancarlo D, Polidori MC, on behalf of the MPI_ AGE Investigators et al (2015) The MPI_AGE european project: using multidimensional prognostic indices (MPI) to improve cost-effectiveness of interventions in multimorbid frail older persons. Background, aim and design. Eur Geriatr Med 6:184–188
Volpato S, Daragjati J, Simonato M, Fontana A, Ferrucci L, Pilotto A (2016) Change in the multidimensional prognostic index score during hospitalization in older patients. Rejuvenation Res 19:244–251. doi:10.1089/rej.2015.1715
Lefebvre MC, St-Onge M, Glazer-Cavanagh M, Bell L, Kha Nguyen JN, Viet-Quoc Nguyen P, Tannenbaum C (2016) The effect of bleeding risk and frailty status on anticoagulation patterns in octogenarians with atrial fibrillation: the FRAIL-AF study. Can J Cardiol 32:169–176. doi:10.1016/j.cjca.2015.05.012
McGrath ER, Go AS, Chang Y, Borowsky LH, Fang MC, Reynolds K, Singer DE (2017) Use of oral anticoagulant therapy in older adults with atrial fibrillation after acute ischemic stroke. J Am Geriatr Soc 65:241–248. doi:10.1111/jgs.14688
Pilotto A, Gallina P, Copetti M et al on behalf of the Multidimensional Prognostic Index_Age Project Investigators (2016) Warfarin treatment and all-cause mortality in community-dwelling older adults with atrial fibrillation: a retrospective observational study. J Am Geriatr Soc 64(7):1416–1424s
Tinetti ME, McAvay G, Trentalange M, Cohen AB, Allore HG (2015) Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study. BMJ 351:h4984. doi:10.1136/bmj.h4984
Strandberg TE, Kolehmainen L, Vuorio A (2014) Evaluation and treatment of older patients with hypercholesterolemia: a clinical review. JAMA 312:1136–1144. doi:10.1001/jama.2014.10924
Pilotto A, Panza F, Copetti M, Simonato M, Sancarlo D, Gallina P, Strandberg T on behalf of the MPI_ AGE Investigators (2015) Statin treatment and mortality in community-dwelling frail older patients with diabetes mellitus: a retrospective observational study. PLoS One 10:e0130946. doi:10.1371/journal.pone.0130946
Pilotto A, Gallina P, Panza F, Copetti M, Cella A, Cruz-Jentoft A et al on behalf of the MPI_Age Project Investigators (2016) Relation of statin use and mortality in community-dwelling frail older patients with coronary artery disease. Am J Cardiol 118(11):1624–1630
D’Onofrio G, Sancarlo D, Addante F, Ciccone F, Cascavilla L, Paris F et al (2015) A pilot randomized controlled trial evaluating an integrated treatment of rivastigmine transdermal patch and cognitive stimulation in patients with Alzheimer’s disease. Int J Geriatr Psych 30:965–975
Anglemyer A, Horvath HT, Bero L (2014) Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials. Cochrane Database Syst Rev 4:MR000034. doi:10.1002/14651858.MR000034.pub2
Cerreta F, Eichler HG, Rasi G (2012) Drug policy for an aging population—the European medicines Agency's geriatric medicines strategy. N Engl J Med 367:1972–1974. doi:10.1056/NEJMp1209034
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG
About this chapter
Cite this chapter
Pilotto, A., Daragjati, J., Veronese, N. (2018). CGA and Clinical Decision-Making: The Multidimensional Prognostic Index. In: Pilotto, A., Martin, F. (eds) Comprehensive Geriatric Assessment. Practical Issues in Geriatrics. Springer, Cham. https://doi.org/10.1007/978-3-319-62503-4_8
Download citation
DOI: https://doi.org/10.1007/978-3-319-62503-4_8
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-62502-7
Online ISBN: 978-3-319-62503-4
eBook Packages: MedicineMedicine (R0)