The prognosis of older persons discharged from the hospital is worse than that of those living at home and can be estimated by considering gender, comorbid conditions, and function at discharge (Table 4-2).
^ Assessment of Values
Although patients vary in their values and preferences, most frail older patients prioritize maintaining their independence over prolonging survival or relieving pain or other symptoms. Values and preferences are determined by speaking directly with a patient or, when the patient cannot express preferences reliably, with the patient’s surrogate. Values and preferences can be assessed most readily in the context of a specific medical decision. For example, the clinician might ask a patient considering a hip replacement, “How would you like your hip pain and function to be different? Tell me about the risk and discomfort you are willing to go through to achieve that improvement.”
In assessing values and preferences, it is important to keep in mind the following:
1. Patients are experts about their preferences for outcomes and experiences; however, they often do not have adequate information to express informed preferences for specific tests or treatments.
2. Patients’ preferences often change over time. For example, some patients find living with a disability more acceptable than they thought before experiencing it.
^ Assessment of Function
People often lose function in multiple domains as they age, with the results that they may not be able to do some activities as quickly or capably and may need assistance with other activities. Assessment of function improves prognostic estimates (see above). Assessment of function is essential to
Top 25th percentile 50th percentile Lowest 25th percentile
S Figure 4-1. Median life expectancy of older women and men. (Adapted, with permission, from Walter LC et al. Screening for colorectal, breast, and cervical cancer in the elderly: a review of the evidence. Am J Med. 2005 Oct; 118(10):1078-86.) Copyright © Elsevier.
Table 4-1. Prognostic factors, “risk points,” and 4-year mortality rates for older persons living at home.
85 years and older
Comorbid conditions reported by patients
Body mass index
Difficulty handling finances
Difficulty walking several blocks
Sum of Risk Points
4-year Mortality Rate
deciding some kind of individual’s needs in the context of his or her worth also personal preferences, together with the a possibility negative effects of prescribed by doctors cures.