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To the Editor: I have several concerns about the patient selection in the study by Dr Mitchell and colleagues¹ and the implications for who should be considered for a palliative care program.

First, the patients in the study had Cognitive Performance Scores of 5 or 6, equivalent to a Mini-Mental State Examination score of 5 or lower. Although these patients can be considered to have severe dementia, I do not agree that a patient with a Mini-Mental State Examination score of 5 necessarily has "advanced" dementia, assuming advanced to imply the terminal stages of a disease.

Second, the study included patients with infections, severe organ failure, and even associated cancer. However, it is not clear whether the functional evaluation was undertaken during a period of clinical stability or instability. This might mistakenly lead to a prognostic factor from an associated disease being considered a prognostic factor for terminal dementia.

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Baldomero Álvarez-Fernández, MD, PhD

balvarez@geriatrianet.com
Grupo de Demencias de la Sociedad Andaluza de Geriatría y Gerontología
Unidad de Geriatría
Hospital Universitario Carlos Haya
Málaga, Spain

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