The Last 2 Years of Life: Functional Trajectories of Frail Older People

Abstract

Patients with advanced frailty, with or without cognitive impairment, have an end-of-life functional course marked by slowly progressive functional deterioration, with only a slight acceleration in the trajectory of functional loss as death approaches. Patients with cognitive impairment have particularly high rates of functional impairment at the time of death. These results suggest that end-of-life care systems that are targeted toward patients with functional trajectories clearly suggesting impending death (such as the Medicare hospice benefit) are poorly suited to older people dying with progressive frailty.

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context

“…Our personal data revealed family members' concerns about the quality of care received, rather than the amount of care, focusing, for example, on how Sheila's pain was not being effectively managed, influenced to some degree by the vastly different care philosophies of the two doctors responsible for her treatment. In hindsight, greater communication among formal care providers and family members about her potential "palliative status" after her entry into RC, may have resulted in different responses to her care (e.g., improved pain and symptom management is key emphasis within palliative approaches; Covinsky et al, 2003;Kane & West, 2005). Even telling family members that the pathways ahead will be rocky and unpredictable would be more helpful than silence or limited guidance, education, or instruction (Gitlin & Wolff, 2011).…”

“…At the same time, the pace of change can be much slower compared to those with other life-threatening illnesses such as cancer or heart failure (Moorhouse & Mallery, 2012), leading some researchers to suggest that persons with dementia represent a distinct subgroup with unique service requirements (Covinsky, Eng, Lui, Sands, & Yaffe, 2003;Kane & West, 2005). For some, the slower pace of change can make it harder to recognize their palliative status, thereby restricting access to specialized, end-oflife services when needed (Covinsky et al, 2003).…”

“…At the same time, the pace of change can be much slower compared to those with other life-threatening illnesses such as cancer or heart failure (Moorhouse & Mallery, 2012), leading some researchers to suggest that persons with dementia represent a distinct subgroup with unique service requirements (Covinsky, Eng, Lui, Sands, & Yaffe, 2003;Kane & West, 2005). For some, the slower pace of change can make it harder to recognize their palliative status, thereby restricting access to specialized, end-oflife services when needed (Covinsky et al, 2003). Research also indicates that persons with dementia experience more care transitions than others (Coleman & Boult, 2003) and have a higher risk of adverse events such as medication errors, hospitalizations, stress and anxiety, and other problems than those without the disease (Manderson et al, 2012).…”

Palliative care for frail older people

“…Thus, identifying the start of a 'terminal phase' is challenging. 12 This, coupled with the complex needs and high symptom burden of this group, makes it appropriate to introduce palliative care from diagnosis, with a naturally increasing emphasis on this approach as frailty advances. 10 …”

Functional mobility on discharge day after total knee and hip replacement surgery

“…Independent mobility is associated with higher levels functional ability and quality of life (2,3). In contrast, lower levels of mobility has been found to be associated with poorer health outcomes such as higher rates of mortality, health-care costs and requirements for supported care (4). Functional mobility demands include stepping over objects, ascending and descending stairs, performing roll onto side, lying to sit, sitting independently, standing from a chair without using arms, standing independently, standing on both feet, standing on toes, tandem standing, walking distance, walking assistance, picking up a pen from the floor, walking backwards, and jumping (5).…”