Context Clinicians have observed various patterns of functional decline at the end of life, but few empirical data have tested these patterns in large populations. Objective To determine if functional decline differs among 4 types of illness trajectories: sudden death, cancer death, death from organ failure, and frailty. Design, Setting, and Participants Cohort analysis of data from 4 US regions in the prospective, longitudinal Established Populations for Epidemiologic Studies of the Elderly (EPESE) study. Of the 14456 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 Measures Self-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. Results Mean 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], PϽ.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], PϽ.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], PϽ.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]). Conclusions Trajectories 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.

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Abstract-Cardiovascular risk factors often cluster into a metabolic syndrome that may increase the risk of dementia. The objective of the present study was to assess the long-term association between clustered metabolic cardiovascular risk factors measured at middle age and the risk of dementia in old age. This prospective cohort study of cardiovascular disease was started in 1965 and was extended to a study of dementia in 1991. The subjects were Japanese-American men with an average age of 52.7Ϯ4.7 (meanϮSD) years at baseline. Dementia was diagnosed in 215 men, according to international criteria, and was based on a clinical examination, neuropsychological testing, and an informant interview. The z scores were calculated for 7 risk factors (random postload glucose, diastolic and systolic blood pressures, body mass index, subscapular skinfold thickness, random triglycerides, and total cholesterol). The relative risk (RR [95% CI]) of dementia (subtypes) per 1 SD increase in the sum of the z scores was assessed after adjustment for age, education, occupation, alcohol consumption, cigarette smoking, and years of childhood lived in Japan. The z-score sum was higher in demented subjects than in nondemented subjects, indicating a higher risk factor burden (0.74 versus Ϫ0.06, respectively; Pϭ0.008). Per SD increase in the z-score sum, the risk of dementia was increased by 5% (RR 1.05, 95% CI 1.02 to 1.09). The z-score sum was specifically associated with vascular dementia (RR [1][2][3][4][5] Factors commonly included in this syndrome are hypertension, obesity, dyslipidemia, and glucose intolerance. 1-5 Development of these risk factors is thought to reflect a common underlying pathology. The syndrome leads to an increased risk of diabetes and cardiovascular disease. 1-5 Both these clinical conditions have been linked to an increased risk of vascular dementia (VaD) 6,7 and Alzheimer's disease (AD), 7,8 the 2 most common subtypes of dementia in the elderly. Therefore, the metabolic cardiovascular syndrome may be a subclinical condition that also increases the risk of dementia.The clinical states of AD and VaD are characterized by hypometabolic features, such as low blood pressure, body mass index (BMI), and glucose levels. Therefore, to investigate the association of these risk factors with dementia, they should be measured long before the clinical onset of dementia. Most studies investigating the relation of metabolic cardiovascular risk factors to AD have been cross-sectional. 9 -16 Most prospective studies on the association of individual metabolic risk factors with the risk of AD have been based on a relatively short follow-up time. 17,18 Furthermore, most studies on the risk factors for VaD focus on clinical stroke and hypertension. 6 To our knowledge, there are no studies on the relationship between the clustering of metabolic risk factors and the risk of dementia with a long follow-up.The Honolulu-Asia Aging Study (HAAS) gave us the opportunity to examine the long-term association between the metabolic cardiovas...