[Show abstract][Hide abstract] ABSTRACT: Objectives
To evaluate the relationship between intervening illnesses and injuries leading to hospitalization and restricted activity, respectively, and prolongation of disability in four essential activities of daily living in newly disabled older persons.DesignProspective cohort study.SettingGreater New Haven, Connecticut.ParticipantsCommunity-living persons aged 70 and older who had at least one episode of disability from March 1998 to June 2013 (N = 632).MeasurementsDisability and exposure to intervening illesses and injuries leading to hospitalization and restricted activity, respectively, were assessed every month. Prolongation of disability was operationalized in two complementary ways: as a dichotomous outcome, based on the persistence of any disability, and as a count of the number of disabled activities.ResultsDuring a median follow-up of 114 months, the 632 participants experienced 2,764 disability episodes. The mean exposure rates for hospitalization and restricted activity were 80.7 (95% confidence interval (CI) = 73.7–88.4) and 173.6 (95% CI = 162.5–185.5), respectively, per 1,000 person-months. After adjustment for multiple disability risk factors, the likelihood of disability prolongation was 2.5 times as great (odds ratio (OR) 2.54, 95% CI = 2.05–3.15) for hospitalization and 1.2 times as great (1.21, 95% CI = 1.06–1.40) for restricted activity as for no hospitalization or restricted activity, and the mean number of disabilities was 35% (risk ratio (RR) = 1.35, 95% CI = 1.30–1.39) greater in the setting of hospitalization and 7% (1.07, 95% CI = 1.05–1.09) greater in the setting of restricted activity.Conclusion
Intervening illnesses and injuries leading to hospitalization and restricted activity, respectively, are strongly associated with prolongation of disability in newly disabled older adults. Efforts to prevent and more-aggressively manage these intervening events have the potential to break the cycle of disability in older persons.
Journal of the American Geriatrics Society 03/2015; 63(3). DOI:10.1111/jgs.13319 · 4.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Little is known about functional trajectories of older persons in the year before and after admission to the intensive care unit (ICU) or how pre-ICU functional trajectories affect post-ICU functional trajectories and death.
To characterize functional trajectories in the year before and after ICU admission and to evaluate the associations among pre-ICU functional trajectories and post-ICU functional trajectories, short-term mortality, and long-term mortality.
Prospective cohort study of 754 community-dwelling persons 70 years or older, conducted between March 23, 1998, and December 31, 2012, in greater New Haven, Connecticut. The analytic sample included 291 participants who had at least 1 admission to an ICU through December 2011.
Functional trajectories in the year before and after an ICU admission based on 13 basic, instrumental, and mobility activities. Additional outcomes included short-term (30 day) and long-term (1 year) mortality.
The mean (SD) age of participants was 83.7 (5.5) years. Three distinct pre-ICU functional trajectories identified were minimal disability (29.6%), mild to moderate disability (44.0%), and severe disability (26.5%). Seventy participants (24.1%) experienced early death, defined as death in the hospital (50 participants [17.2%]) or death after hospital discharge but within 30 days of admission (20 participants [6.9%]). Among the remaining 221 participants, 3 distinct post-ICU functional trajectories identified were minimal disability (20.8%), mild to moderate disability (28.1%), and severe disability (51.1%). More than half of the participants (53.4%) experienced functional decline or early death after critical illness. The pre-ICU functional trajectories of mild to moderate disability and severe disability were associated with more than double (adjusted hazard ratio [HR], 2.41; 95% CI, 1.29-4.50) and triple (adjusted HR, 3.84; 95% CI, 1.84-8.03) the risk of death within 1 year of ICU admission, respectively. Other factors associated with 1-year mortality included ICU length of stay (adjusted HR, 1.03; 95% CI, 1.00-1.05), mechanical ventilation (adjusted HR, 2.89; 95% CI, 1.91-4.37), and shock (adjusted HR, 2.68; 95% CI, 1.63-4.38).
Among older persons with critical illness, more than half died within 1 month or experienced significant functional decline over the following year, with particularly poor outcomes in those who had high levels of premorbid disability. These results may help to inform discussions about prognosis and goals of care before and during critical illness.
JAMA Internal Medicine 02/2015; 175(4). DOI:10.1001/jamainternmed.2014.7889 · 13.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Increasing evidence suggests that illnesses and injuries leading to restricted activity have adverse functional consequences, but whether the two components of restricted activity have comparable effects is unknown. We evaluated whether an illness/injury leading to bed rest represents a more potent exposure than one leading to cutting down on one's usual activities without bed rest.
We prospectively evaluated 754 community-living persons, 70+ years. Telephone interviews were completed monthly for >15 years to assess disability in four basic, five instrumental, and four mobility activities and to ascertain exposure to illnesses/injuries leading to cut down activities and bed rest, respectively. For each of the three functional domains, transitions between no disability, mild disability, and severe disability were evaluated each month.
For each domain, cut down activities and bed rest were significantly associated with at least one transition. The associations were consistently stronger, however, for bed rest than for cut down activities. Bed rest was a particularly potent exposure for transitions from no disability to severe disability, with hazard ratios as high as 8.94 (95% CI, 5.69-14.1) for the mobility activities, and for all transitions from severe disability (representing recovery), with hazard ratios as low as 0.25 (0.12-0.54) for the transition to no disability for the basic activities.
In the setting of an illness/injury, bed rest was more strongly associated with a set of clinically meaningful transitions in functional status than cut down activities. Prompt medical attention may be warranted when an older person takes to bed because of an illness/injury.
The Journals of Gerontology Series A Biological Sciences and Medical Sciences 11/2014; 70(7). DOI:10.1093/gerona/glu203 · 5.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to describe the rates of residential relocations over the course of 10.5 years and evaluate differences in these relocation rates according to gender and decedent status.
Prospective, longitudinal study with monthly telephone follow-up for up to 126 months.
Greater New Haven, CT.
There were 754 participants, aged 70 years or older, who were initially community-living and nondisabled in their basic activities of daily living.
Residential location was assessed during monthly interviews and included community, assisted living facility, and nursing home. A residential relocation was defined as a change of residential location for at least 1 week and included relocations within (eg, community-community) or between (community- assisted living) locations. We calculated the rates of relocations per 1000 patient-months and evaluated differences by gender and decedent status.
Sixty-six percent of participants had at least one residential relocation (range 0-12). Women had lower rates of relocations from nursing home to community (rate ratio [RR] 0.59, P = .02); otherwise, there were no gender differences. Decedents had higher rates of relocation from community to assisted living (RR 1.71, P = .002), from community to nursing home (RR 3.64, P < .001), between assisted living facilities (RR 3.65, P < .001), and from assisted living to nursing home (RR 2.5, P < .001). In decedents, relocations from community to nursing home (RR 3.58, P < .001) and from assisted living to nursing home (RR 3.3, P < .001) were most often observed in the last year of life.
Most older people relocated at least once during 10.5 years of follow-up. Women had lower rates of relocation from nursing home to community. Decedents were more likely to relocate to a residential location providing a higher level of assistance, compared with nondecedents. Residential relocations were most common in the last year of life.
Journal of the American Medical Directors Association 04/2014; 15(7). DOI:10.1016/j.jamda.2014.03.013 · 4.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The frailty index (FI) is used to measure the health status of ageing individuals. An FI is constructed as the proportion of deficits present in an individual out of the total number of age-related health variables considered. The purpose of this study was to systematically assess whether dichotomizing deficits included in an FI affects the information value of the whole index.
Secondary analysis of three population-based longitudinal studies of community dwelling individuals: Nova Scotia Health Survey (NSHS, n = 3227 aged 18+), Survey of Health, Ageing and Retirement in Europe (SHARE, n = 37546 aged 50+), and Yale Precipitating Events Project (Yale-PEP, n = 754 aged 70+). For each dataset, we constructed two FIs from baseline data using the deficit accumulation approach. In each dataset, both FIs included the same variables (23 in NSHS, 70 in SHARE, 33 in Yale-PEP). One FI was constructed with only dichotomous values (marking presence or absence of a deficit); in the other FI, as many variables as possible were coded as ordinal (graded severity of a deficit). Participants in each study were followed for different durations (NSHS: 10 years, SHARE: 5 years, Yale PEP: 12 years).
Within each dataset, the difference in mean scores between the ordinal and dichotomous-only FIs ranged from 0 to 1.5 deficits. Their ability to predict mortality was identical; their absolute difference in area under the ROC curve ranged from 0.00 to 0.02, and their absolute difference between Cox Hazard Ratios ranged from 0.001 to 0.009.
Analyses from three diverse datasets suggest that variables included in an FI can be coded either as dichotomous or ordinal, with negligible impact on the performance of the index in predicting mortality.
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE Although a serious fall injury is often a devastating event, little is known about the course of disability (ie, functional trajectories) before a serious fall injury or the relationship between these trajectories and those that follow the fall. OBJECTIVES To identify distinct sets of functional trajectories in the year immediately before and after a serious fall injury, to evaluate the relationship between the prefall and postfall trajectories, and to determine whether these results differed based on the type of injury. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study conducted in greater New Haven, Connecticut, from March 16, 1998, to June 30, 2012, in 754 community-living persons aged 70 years or older who were initially nondisabled in their basic activities of daily living. Of the 130 participants who subsequently sustained a serious fall injury, 62 had a hip fracture and 68 had another fall-related injury leading to hospitalization. MAIN OUTCOMES AND MEASURES Functional trajectories, based on 13 basic, instrumental, and mobility activities assessed during monthly interviews, were identified in the year before and the year after the serious fall injury. RESULTS Before the fall, 5 distinct trajectories were identified: no disability in 16 participants (12.3%), mild disability in 34 (26.2%), moderate disability in 34 (26.2%), progressive disability in 23 (17.7%), and severe disability in 23 (17.7%). After the fall, 4 distinct trajectories were identified: rapid recovery in 12 participants (9.2%), gradual recovery in 35 (26.9%), little recovery in 26 (20.0%), and no recovery in 57 (43.8%). For both hip fractures and other serious fall injuries, the probabilities of the postfall trajectories were greatly influenced by the prefall trajectories, such that rapid recovery was observed only among persons who had no disability or mild disability, and a substantive recovery, defined as rapid or gradual, was highly unlikely among those who had progressive or severe disability. The postfall trajectories were consistently worse for hip fractures than for the other serious injuries. CONCLUSIONS AND RELEVANCE The functional trajectories before and after a serious fall injury are quite varied but highly interconnected, suggesting that the likelihood of recovery is greatly constrained by the prefall trajectory.
JAMA Internal Medicine 08/2013; 173(19). DOI:10.1001/jamainternmed.2013.9063 · 13.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE Freedom from symptoms is an important determinant of a good death, but little is known about symptom occurrence during the last year of life. OBJECTIVE To evaluate the monthly occurrence of physical and psychological symptoms leading to restrictions in daily activities (ie, restricting symptoms) among older persons during the last year of life and to determine the associations of demographic and clinical factors with symptom occurrence. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study. Comprehensive assessments were completed every 18 months, and monthly interviews were conducted to assess the presence of restricting symptoms. Of 1002 nondisabled community-dwelling individuals 70 years or older in greater New Haven, Connecticut, eligible to participate, 754 agreed and were enrolled between 1998 and 1999. MAIN OUTCOMES AND MEASURES The primary outcome was the monthly occurrence of restricting symptoms as a dichotomous outcome. The monthly mean count of restricting symptoms was a secondary outcome. RESULTS Among the 491 participants who died after their first interview and before June 30, 2011, mean age at death was 85.8 years, 61.9% were women, and 9.0% were nonwhite. The mean number of comorbid conditions was 2.4, and 73.1% had multimorbidity. The monthly occurrence of restricting symptoms was fairly constant from 12 months before death (20.4%) until 5 months before death (27.4%), when it began to increase rapidly, reaching 57.2% in the month before death. In multivariable analysis, age younger than 85 years (odds ratio [OR], 1.30 [95% CI, 1.07-1.57]), multimorbidity (OR, 1.38 [95% CI, 1.09-1.75]), and proximity to time of death (OR, 1.14 per month [95% CI, 1.11-1.16]) were significantly associated with the monthly occurrence of restricting symptoms. Participants who died of cancer had higher monthly symptom occurrence (OR, 1.80 [95% CI, 1.03-3.14]) than participants who died of sudden death, although this difference was only marginally significant (P = .04). Symptom burden did not otherwise differ substantially according to condition leading to death. CONCLUSIONS AND RELEVANCE Restricting symptoms are common during the last year of life, increasing substantially approximately 5 months before death. Our results highlight the importance of assessing and managing symptoms in older patients, particularly those with multimorbidity.
JAMA Internal Medicine 07/2013; 173(16). DOI:10.1001/jamainternmed.2013.8732 · 13.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Little is known about the deleterious effects of injurious falls relative to those of other disabling conditions or whether these effects are driven largely by hip fractures. From a cohort of 754 community-living elders of New Haven, Connecticut, we matched 122 hospitalizations for an injurious fall (59 hip-fracture and 63 other fall-related injuries) to 241 non-fall-related hospitalizations. Participants (mean age: 85.7 years) were evaluated monthly for disability in 13 activities and admission to a nursing home from 1998 to 2010. For both hip-fracture and other fall-related injuries, the disability scores were significantly greater during each of the first 6 months after hospitalization than for the non-fall-related admissions, with adjusted risk ratios at 6 months of 1.5 (95% confidence interval (CI): 1.3, 1.7) for hip fracture and 1.4 (95% CI: 1.2, 1.6) for other fall-related injuries. The likelihood of having a long-term nursing home admission was considerably greater after hospitalization for a hip fracture and other fall-related injury than for a non-fall-related reason, with adjusted odds ratios of 3.3 (95% CI: 1.3, 8.3) and 3.2 (95% CI: 1.3, 7.8), respectively. Relative to other conditions leading to hospitalization, hip-fracture and other fall-related injuries are associated with worse disability outcomes and a higher likelihood of long-term nursing home admissions.
American journal of epidemiology 04/2013; 178(3). DOI:10.1093/aje/kws554 · 5.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: Across the life span, women live longer than men but experience higher rates of disability. To more completely evaluate these gender differences, the current study set out to compare the trajectories and burden of disability over an extended period between older men and women. DESIGN: Prospective, longitudinal study with 13.5 years of follow-up. SETTING: Greater New Haven, Connecticut. PARTICIPANTS: Participants were 754 persons, aged 70 years or older, who were initially community-living and nondisabled in their basic activities of daily living. MEASUREMENTS: Disability in 13 basic, instrumental, and mobility activities was assessed during monthly interviews, whereas demographic and clinical covariates were measured during comprehensive assessments every 18 months. RESULTS: Five distinct trajectories were identified over successive 18-month intervals: independent, mild disability, mild to moderate disability, moderate disability, and severe disability. Women were more likely than men to experience the moderate and severe disability trajectories, but were less likely to transition from the independent trajectory to a worse disability trajectory during the subsequent 18-month interval. Women were also less likely to die after each of the five trajectories, and these differences were at least marginally significant for all but the independent trajectory. Over the entire duration of follow-up, women suffered from a greater burden of disability than men, but these differences were greatly attenuated after adjustment for the baseline levels of disability. CONCLUSIONS: Gender differences in disability over an extended period can be explained, at least in part, by the higher mortality experienced by older men and the higher initial levels of disability among older women. These results suggest the need to take a life-course approach to better understand gender differences in disability.
Journal of the American Medical Directors Association 01/2013; 14(4). DOI:10.1016/j.jamda.2012.11.011 · 4.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Gender-specific trajectories of lower extremity function (LEF) and the potential for bias in LEF estimation due to differences in survival have been understudied.
We evaluated longitudinal data from 690 initially nondisabled adults age 70 or older from the Precipitating Events Project. LEF was assessed every 18 months for 12 years using a modified Short Physical Performance Battery (mSPPB). Hierarchical linear models with adjustments for length-of-survival estimated the intraindividual trajectory of LEF and differences in trajectory intercept and slope between men and women.
LEF declined following a nonlinear trajectory. In the full sample, and among participants with high (mSPPB 10-12) and intermediate (mSPPB 7-9) baseline LEF, the rate-of-decline in mSPPB was slower in women than in men, with no gender differences in baseline mSPPB scores. Among participants with low baseline LEF (mSPPB ≤6), men had a higher starting mSPPB score, whereas women experienced a deceleration in the rate-of-decline over time. In all groups, participants who survived longer had higher starting mSPPB scores and slower rates-of-decline compared with those who died sooner.
Over the course of 12 years, older women preserve LEF better than men. Nonadjustment for differences in survival results in overestimating the level and underestimating the rate-of-decline in LEF over time.
The Journals of Gerontology Series A Biological Sciences and Medical Sciences 11/2012; 68(7). DOI:10.1093/gerona/gls228 · 5.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Relatively little is known about why older persons develop long-term disability in community mobility.
To identify the risk factors and precipitants for long-term disability in walking a quarter mile and driving a car.
Prospective cohort study from March 1998 to December 2009.
Greater New Haven, Connecticut.
641 persons, aged 70 years or older, who were active drivers or nondisabled in walking a quarter mile. Persons who were physically frail were oversampled.
Candidate risk factors were assessed every 18 months. Disability in community mobility and exposure to potential precipitants, including illnesses or injuries leading to hospitalization or restricted activity, were assessed every month. Disability that lasted 6 or more consecutive months was considered long-term.
318 (56.0%) and 269 (53.1%) participants developed long-term disability in walking and driving, respectively. Seven risk factors were independently associated with walking disability and 8 were associated with driving disability; the strongest associations for each outcome were found for older age and lower score on the Short Physical Performance Battery. The precipitants had a large effect on long-term disability, with multivariate hazard ratios for each outcome greater than 6.2 for hospitalization and greater than 2.4 for restricted activity. The largest differences in absolute risk were generally observed in participants with a specific risk factor who were subsequently hospitalized.
The observed associations may not be causal. The severity of precipitants was not assessed. The effect of the precipitants may have been underestimated because their exposure after the initial onset of disability was not evaluated.
Long-term disability in community mobility is common among older persons. Multiple risk factors, together with subsequent precipitants, greatly increase the likelihood of long-term mobility disability.
National Institute on Aging, National Institutes of Health.
Annals of internal medicine 01/2012; 156(2):131-40. DOI:10.1059/0003-4819-156-2-201201170-00009 · 17.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Frailty among older persons is a dynamic process, characterized by frequent transitions between frailty states over time. We performed a prospective longitudinal study to evaluate the relationship between intervening hospitalizations and these transitions.
We studied 754 nondisabled community-living persons, aged 70 years or older. Frailty, assessed every 18 months for 108 months, was defined on the basis of muscle weakness, exhaustion, low physical activity, shrinking, and slow walking speed. Participants were classified as frail if they met three or more of these criteria, prefrail if they met one or two of the criteria, or nonfrail if they met none of the criteria. Hospitalizations were ascertained every month for a median of 108 months.
The exposure rates (95% confidence interval) of hospitalization per 1,000 months, based on frailty status at the start of each 18-month interval, were 19.7 (16.2-24.0) nonfrail, 32.9 (29.8-36.2) prefrail, and 57.2 (52.9-63.1) frail. The likelihood of transitioning from states of greater frailty to lesser frailty (ie, recovering) was consistently lower based on exposure to intervening hospitalizations, with adjusted hazard ratios per each hospitalization ranging from 0.46 (95% confidence interval: 0.21-1.03) for the transition from frail to nonfrail states to 0.52 (95% confidence interval: 0.42-0.65) for the transition from prefrail to nonfrail states. Hospitalization had more modest and less consistent effects on transitions from states of lesser frailty to greater frailty. Nonetheless, transitions from nonfrail to frail states were uncommon in the absence of a hospitalization.
Recovery from prefrail and frail states is substantially diminished by intervening hospitalizations. These results provide additional evidence highlighting the adverse consequences of hospitalization in older persons.
The Journals of Gerontology Series A Biological Sciences and Medical Sciences 08/2011; 66(11):1238-43. DOI:10.1093/gerona/glr142 · 5.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: To investigate how changes in frailty status and mortality risk relate to baseline frailty state, mobility performance, age, and sex.
DESIGN: Cohort study.
SETTING: The Yale Precipitating Events Project, New Haven, Connecticut.
PARTICIPANTS: Seven hundred fifty-four community-dwelling people aged 70 and older at baseline followed up at 18, 36, and 54 months.
MEASUREMENTS: Frailty status, assessed at 18-month intervals, was defined using a frailty index (FI) as the number of deficits in 36 health variables. Mobility was defined as time in seconds on the rapid gait test, in which participants walked back and forth over a 20-foot course as quickly as possible. Multistate transition probabilities were calculated with baseline frailty, mobility, age, and sex estimated using Poisson and logistic regressions in survivors and those who died, respectively.
RESULTS: In multivariable analyses, baseline frailty status and age were significantly associated with changes in frailty status and risk of death, whereas mobility was significantly associated with the frailty but not with mortality. At all values of the FI, participants with better mobility were more likely than those with poor mobility to remain stable or to improve. For example, at 54 months, 20.6% (95% confidence interval (CI)=16–25.2) of participants with poor mobility had the same or fewer deficits, compared with 32.4% (95% CI=27.9–36.9) of those with better mobility.
CONCLUSION: A multistate transition model effectively measured the probability of change in frailty status and risk of death. Mobility, age, and baseline frailty were significant factors in frailty state transitions.
Journal of the American Geriatrics Society 02/2011; 59(3):524 - 529. DOI:10.1111/j.1532-5415.2011.03300.x · 4.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Disability among older persons is a complex and highly dynamic process, with high rates of recovery and frequent transitions between states of disability. The role of intervening illnesses and injuries (ie, events) on these transitions is uncertain.
To evaluate the relationship between intervening events and transitions among states of no disability, mild disability, severe disability, and death and to determine the association of physical frailty with these transitions.
Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2008 of 754 community-living persons aged 70 years or older who were nondisabled at baseline in 4 essential activities of daily living: bathing, dressing, walking, and transferring. Telephone interviews were completed monthly for more than 10 years to assess disability and ascertain exposure to intervening events, which included illnesses and injuries leading to either hospitalization or restricted activity. Physical frailty (defined as gait speed >10 seconds on the rapid gait test) was assessed every 18 months through 108 months.
Transitions between no disability, mild disability, and severe disability and 3 transitions from each of these states to death, evaluated each month.
Hospitalization was strongly associated with 8 of the 9 possible transitions, with increased multivariable hazard ratios (HRs) as high as 168 (95% confidence interval [CI], 118-239) for the transition from no disability to severe disability and decreased HRs as low as 0.41 (95% CI, 0.30-0.54) for the transition from mild disability to no disability. Restricted activity also increased the likelihood of transitioning from no disability to both mild and severe disability (HR, 2.59; 95% CI, 2.23-3.02; and HR, 8.03; 95% CI, 5.28-12.21), respectively, and from mild disability to severe disability (HR, 1.45; 95% CI, 1.14-1.84), but was not associated with recovery from mild or severe disability. For all 9 transitions, the presence of physical frailty accentuated the associations of the intervening events. For example, the absolute risk of transitioning from no disability to mild disability within 1 month after hospitalization for frail individuals was 34.9% (95% CI, 34.5%-35.3%) vs 4.9% (95% CI, 4.7%-5.1%) for nonfrail individuals. Among the possible reasons for hospitalization, fall-related injury conferred the highest likelihood of developing new or worsening disability.
Among older persons, particularly those who were physically frail, intervening illnesses and injuries greatly increased the likelihood of developing new or worsening disability. Only the most potent events, ie, those leading to hospitalization, reduced the likelihood of recovery from disability.
JAMA The Journal of the American Medical Association 11/2010; 304(17):1919-28. DOI:10.1001/jama.2010.1568 · 35.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Despite the importance of functional status to older persons and their families, little is known about the course of disability at the end of life.
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.
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).
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.
New England Journal of Medicine 04/2010; 362(13):1173-80. DOI:10.1056/NEJMoa0909087 · 55.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To identify the factors associated with accurate recall of prior disability.
Greater New Haven, Connecticut.
Ninety-two participants, included in each of two analytical samples, who were nondisabled at the present time in four essential activities of daily living (ADLs; bathing, dressing, transferring, and walking) but who had had at least 1 month of disability during the prior year as determined from monthly telephone interviews.
Participants who did not need help from another person at the present time were asked to recall whether they had needed help from another person to complete the relevant ADL at any time during the previous 12 months.
Forty-five (48.9%) and 46 (50.0%) of the 92 participants accurately recalled having had disability in the prior year in the first and second analytical samples, respectively. Having at least a high school education was the only factor independently associated with accurate recall in the first analytical sample, with an adjusted odds ratio (AOR) of 3.03 (95% confidence interval (CI)=1.11-8.31), whereas a composite disability scale that considered the timing and severity of prior disability was the only factor independently associated with accurate recall in the second analytic sample (AOR=5.38, 95% CI=1.81-16.1).
The results of the current study, coupled with those of previous studies, suggest potential strategies that could be used to more completely and accurately ascertain the occurrence of disability in older persons.
Journal of the American Geriatrics Society 10/2009; 57(10):1897-901. DOI:10.1111/j.1532-5415.2009.02478.x · 4.57 Impact Factor