ContextClinicians have observed various patterns of functional decline at the
end of life, but few empirical data have tested these patterns in large populations.ObjectiveTo determine if functional decline differs among 4 types of illness
trajectories: sudden death, cancer death, death from organ failure, and frailty.Design, Setting, and ParticipantsCohort analysis of data from 4 US regions in the prospective, longitudinal
Established Populations for Epidemiologic Studies of the Elderly (EPESE) study.
Of the 14 456 participants aged 65 years or older who provided interviews
at baseline (1981-1987), 4871 died during the first 6 years of follow-up;
4190 (86%) of these provided interviews within 1 year before dying. These
decedents were evenly distributed in 12 cohorts based on the number of months
between the final interview and death.Main Outcome MeasuresSelf- or proxy-reported physical function (performance of 7 activities
of daily living [ADLs]) within 1 year prior to death; predicted ADL dependency
prior to death.ResultsMean function declined across the 12 cohorts, simulating individual
decline in the final year of life. Sudden death decedents were highly functional
even in the last month before death (mean [95% confidence interval {CI}] numbers
of ADL dependencies: 0.69 [0.19-1.19] at 12 months before death vs 1.22 [0.59-1.85]
at the final month of life, P = .20); cancer decedents
were highly functional early in their final year but markedly more disabled
3 months prior to death (0.77 [0.30-1.24] vs 4.09 [3.37-4.81], P<.001); organ failure decedents experienced a fluctuating pattern
of decline, with substantially poorer function during the last 3 months before
death (2.10 [1.49-2.70] vs 3.66 [2.94-4.38], P<.001);
and frail decedents were relatively more disabled in the final year and especially
dependent during the last month (2.92 [2.24-3.60] vs 5.84 [5.33-6.35], P<.001). After controlling for age, sex, race, education,
marital status, interval between final interview and death, and other demographic
differences, frail decedents were more than 8 times more likely than sudden
death decedents to be ADL dependent (OR, 8.32 [95% CI, 6.46-10.73); cancer
decedents, one and a half times more likely (OR, 1.57 [95% CI, 1.25-1.96]);
and organ failure decedents, 3 times more likely (OR, 3.00 [95% CI, 2.39-3.77]).ConclusionsTrajectories of functional decline at the end of life are quite variable.
Differentiating among expected trajectories and related needs would help shape
tailored strategies and better programs of care prior to death.

https://jamanetwork.com/journals/jama/articlepdf/196538/JOC22440.pdf

Patterns of functional decline at the end of life.

Background: As more and more cancers occur in elderly people, oncologists are increasingly confronted with the necessity of integrating geriatric parameters in the treatment of their patients. Methods: The International Society of Geriatric Oncology (SIOG) created a task force to review the evidence on the use of a comprehensive geriatric assessment (CGA) in cancer patients. A systematic review of the evidence was conducted. Results: Several biological and clinical correlates of aging have been identified. Their relative weight and clinical usefulness is still poorly defined. There is strong evidence that a CGA detects many problems missed by a regular assessment in general geriatric and in cancer patients. There is also strong evidence that a CGA improves function and reduces hospitalization in the elderly. There is heterogeneous evidence that it improves survival and that it is cost-effective. There is corroborative evidence from a few studies conducted in cancer patients. Screening tools exist and were successfully used in settings such as the emergency room, but globally were poorly tested. The article contains recommendations for the use of CGA in research and clinical care for older cancer patients. Conclusions: A CGA, with or without screening, and with follow-up, should be used in older cancer patients, in order to detect unaddressed problems, improve their functional status, and possibly their survival. The task force cannot recommend any specific tool or approach above others at this point and general geriatric experience should be used.

Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG).

The National Healthcare Disparities Report summarizes health care quality and access among various racial, ethnic, and income groups and other priority populations, such as residents of rural areas and people with disabilities.

National Healthcare Disparities Report

Methods We evaluated data on 383 decedents from a longitudinal study involving 754 community-dwelling older persons. None of the subjects had disability in essential activities of daily living at the beginning of the study, and the level of disability was ascertained during monthly interviews for more than 10 years. Information on the conditions leading to death was obtained from death certificates and comprehensive assessments that were completed at 18-month intervals after the baseline assessment. Results In the last year of life, five distinct trajectories were identified, from no disability to the most severe disability: 65 subjects had no disability (17.0%), 76 had catastrophic disability (19.8%), 67 had accelerated disability (17.5%), 91 had progressive disability (23.8%), and 84 had persistently severe disability (21.9%). The most common condition leading to death was frailty (in 107 subjects [27.9%]), followed by organ failure (in 82 subjects [21.4%]), cancer (in 74 subjects [19.3%]), other causes (in 57 subjects [14.9%]), advanced dementia (in 53 subjects [13.8%]), and sudden death (in 10 subjects [2.6%]). When the distribution of the disability trajectories was evaluated according to the conditions leading to death, a predominant trajectory was observed only for subjects who died from advanced dementia (67.9% of these subjects had a trajectory of persistently severe disability) and sudden death (50.0% of these subjects had no disability). For the four other conditions leading to death, no more than 34% of the subjects had any of the disability trajectories. The distribution of disability trajectories was particularly heterogeneous among the subjects with organ failure (from 12.2 to 32.9% of the subjects followed a specific trajectory) and frailty (from 14.0 to 27.1% of the subjects followed a specific trajectory). Conclusions In most of the decedents, the course of disability in the last year of life did not follow a predictable pattern based on the condition leading to death.

/pdf/trajectories-of-disability-in-the-last-year-of-life-4y9t1xfi8t.pdf

Trajectories of Disability in the Last Year of Life

This chapter will examine the current state of research on frailty. A number of competing and complementary models for its development will be described. This will be followed by a working definition of frailty. Finally, criteria for the identification of frailty in older individuals will be discussed. Promising future directions for research will be noted throughout the chapter. The aim is to provide useful background information about frailty for researchers interested in the field. It is an area of inquiry still early in its evolution.

/pdf/models-definitions-and-criteria-of-frailty-39q0wcezdl.pdf

Models, definitions, and criteria of frailty.

OBJECTIVES: To evaluate the usefulness of a clinical scheme to classify older decedents to better understand the issues associated with healthcare use and costs in the last year of life.

DESIGN: We analyzed Medicare claims data for a random sample of 0.1% of all Medicare beneficiaries with expenditures between 1993 and 1998. This sample yielded 7,966 deaths.

SETTING: Medicare claims data.

PARTICIPANTS: Medicare beneficiaries.

MEASUREMENTS: We classified decedents into groups representing four trajectories at the end of life: sudden death, terminal illness, organ failure, and frailty.

RESULTS: Ninety-two percent of decedents were captured by the profiling strategy. The four trajectory groups had distinct patterns of demographics, care delivery, and Medicare expenditures. Frailty was a dominant pattern, with 47% of all decedents, whereas sudden death claimed only 7%; cancer claimed 22%, and organ system failure, 16%.

CONCLUSIONS: The clinical scheme to classify decedents appears to fit most decedents and to form groups with substantial clinical differences. Acknowledging the differences among these groups may be a fruitful way to evaluate expenditures and develop strategies to improve care at the end of life.

Christopher Hogan

Papers

Profiles of Older Medicare Decedents