Terminal Decline Research Articles

Avoidable mortality from respiratory tract infection and sudden unexplained death in children with chronic conditions: a data linkage study

ObjectiveTo determine the risk of death from two potentially avoidable causes with different aetiologies: respiratory tract infection (RTI) and sudden unexplained death (SUD) in children with and without chronic conditions.DesignWhole-country,...

Does incipient dementia explain normal cognitive decline determinants? Lothian birth cohort 1921.

The presence of an apolipoprotein E (APOE) ε4 allele, lower physical fitness, smoking, and lower serum vitamin B-12 have been reported as contributing to poorer cognitive function in LBC1921 at age 79, after adjusting for childhood intelligence. Because incident dementia was not previously ascertained within LBC1921, it is possible that preclinical or unrecognized cases at age 79 influenced findings. Dementia cases arising over approximately 16 years of follow-up were determined by a consensus using evidence from electronic medical records, death certificates, and clinical reviews. The analyses from the original reports were repeated after the exclusion of those who had developed dementia. In a subsequent set of analyses, the authors considered the potential impact of terminal decline, excluding those participants who died within 4 years of baseline testing. Positive APOE ε4 status was found to be associated with poorer Logical Memory (Wechsler, 1987) at age 79 (F(1, 355) = 8.16, p = .005, ηp2 = 0.022; n = 359) and lower Moray House Test (Scottish Council for Research in Education, 1933) score at age 79 (F(1, 357) = 4.27, p = .04, ηp2 = 0.012; n = 363). Lower age 79 IQ was associated with smoking (F(2, 360) = 3.67, p = .026, ηp2 = 0.020; n = 367), lower vitamin B-12 (Sβ = 0.11, p = .014; n = 367), and poorer physical fitness (Sβ = 0.21, p < .001; n = 359). Only the relationship with physical fitness remained significant after excluding those who died within 4 years of baseline (Sβ = 0.203, p < .001; n = 310). Unrecognized dementia had little or no effect on determinants of lifetime cognitive ageing in LBC1921. Terminal decline may have accounted for the associations with age 11 to age 79 cognitive change.

Ajit Singh (1940–2015), the Radical Cambridge Economist: Anti‐imperialist Advocate of Third World Industrialization

Ajit Singh (1940–2015), the Radical Cambridge Economist: Anti‐imperialist Advocate of Third World Industrialization

When does cognitive decline begin? A systematic review of change point studies on accelerated decline in cognitive and neurological outcomes preceding mild cognitive impairment, dementia, and death.

Older adults who ultimately develop dementia experience accelerated cognitive decline long before diagnosis. A similar acceleration in cognitive decline occurs in the years before death as well. To evaluate preclinical and terminal cognitive decline, past researchers have incorporated change points in their analyses of longitudinal data, identifying point estimates of how many years prior to diagnosis or death that decline begins to accelerate. The current systematic review aimed to summarize the published literature on preclinical and terminal change points in relation to mild cognitive impairment (MCI), dementia, and death, identifying the order in which cognitive and neurological outcomes decline and factors that modify the onset and rate of decline. A systematic search protocol yielded 35 studies, describing 16 longitudinal cohorts, modeling change points for cognitive and neurological outcomes preceding MCI, dementia, or death. Change points for cognitive abilities ranged from 3-7 years prior to MCI diagnosis, 1-11 years prior to dementia diagnosis, and 3-15 years before death. No sequence of decline was observed preceding MCI or death, but the following sequence was tentatively accepted for Alzheimer's disease: verbal memory, visuospatial ability, executive functions and fluency, and last, verbal IQ. Some of the modifiers of the onset and rate of decline examined by previous researchers included gender, education, genetics, neuropathology, and personality. Change point analyses evidence accelerated decline preceding MCI, dementia, and death, but moderators of the onset and rate of decline remain ambiguous due to between-study modeling differences, and coordinated analyses may improve comparability across future studies. (PsycINFO Database Record

Reports of coal’s terminal decline may be exaggerated

We estimate the cumulative future emissions expected to be released by coal power plants that are currently under construction, announced, or planned. Even though coal consumption has recently declined and plans to build new coal-fired capacities have been shelved, constructing all these planned coal-fired power plants would endanger national and international climate targets. Plans to build new coal-fired power capacity would likely undermine the credibility of some countries’ (Intended) Nationally Determined Contributions submitted to the UNFCCC. If all the coal-fired power plants that are currently planned were built, the carbon budget for reaching the 2 °C temperature target would nearly be depleted. Propositions about ‘coal’s terminal decline’ may thereby be premature. The phase-out of coal requires dedicated and well-designed policies. We discuss the political economy of policy options that could avoid a continued build-up of coal-fired power plants.

The Spanish Resurgence, 1713–1748

Chris Storrs's book is a welcome counterpoint to the dominant thrust of the scholarship on eighteenth-century Spain and its empire, which tends to focus on the Atlantic and to neglect Spain's long-standing possessions and strategic interests in the Mediterranean. In this rich and erudite political, diplomatic, and military history, Storrs examines the first half of the eighteenth century, which corresponds to the reign of Philip V. The narrative begins with the aftermath of the War of the Spanish Succession, which resulted in the replacement of the Hapsburg by the Bourbon dynasty, and concludes with the War of the Austrian Succession. In particular, Storrs wishes to recover Spain as an expanding power on the offensive and not the defensive, above all in North Africa and Italy.This effort is by no means an innocent recasting of Spain's place in Europe but rather a polemical one. Building on his earlier study The Resilience of the Spanish Monarchy, 1665–1700 (Oxford University Press, 2006), Storrs seeks to counter the still prevailing view that Spain was a power in terminal decline, experiencing a brief revival during the reign of Charles III (1759–1788) before the final collapse of its global empire in the early nineteenth century. In Storrs's account, military defeats in northern and central Europe in the previous centuries came to be accepted, and Spain reimagined its sphere of influence and pursued a consciously Mediterranean-oriented policy in these years.The interest in North Africa owed something undoubtedly, as Storrs explains, to a vestigial religious, even crusading, mentality, but it was also driven by strategic considerations, as a potential source of grain and timber. Success in North Africa was equivocal, with the gains outweighed by the loss of troops and treasure, but it formed part of a comprehensive western Mediterranean strategy that found greater, lasting gains in Italy, where Naples and Sicily came under Bourbon control and where Milan, the Duchy of Savoy, and Piedmont were occupied in the mid-1740s. In 1746, 56,000 troops under Spanish command were on Italian soil. Moreover, while historians tend to treat Anglo-Spanish rivalry in the Americas and Caribbean—disputes over the asiento, contraband, piracy, the Darien colony, and Oliver Cromwell's Western Design, among others—the Mediterranean itself was the site of equally belligerent disputes, over Minorca and Gibraltar.There is, then, some validity to Storrs's claim that “until the Spanish resurgence in the western Mediterranean is restored to its true place in the history of international affairs in Europe, relations between the European powers in that generation will not be properly understood” (p. 12). His book is a valiant and largely successful effort to redress the woeful imbalance of existing Atlantic-focused historiography. It might be said that focusing on the latter eighteenth century would further bolster Storrs's contention for the importance of the Mediterranean. After all, Charles III ruled at Naples for a quarter century before his accession to the Spanish throne, and his preoccupation with the geopolitics of Italy was at least as sustained as his commitment to the Americas.Though Storrs's case for the importance of the Mediterranean is persuasive, his decision to set America aside, ostensibly because it has been the object of study for most other historians of the period, is less so. If not quite a case of Hamlet without the Prince of Denmark, it comes dangerously close to embodying this quip. Given that fully a quarter of the Spanish state's revenues derived from the Americas, to say nothing of profits gained by merchants through reexports of Spanish American products to northern Europe, Storrs's decision to ignore the Atlantic sphere requires more justification than he offers in the book. The book would have been improved by integrating the Atlantic and the Mediterranean into a single narrative, thus offering a more capacious, even global interpretation of the Spanish state's strategies than one finds in Storrs's book or, indeed, in Atlantic-centered histories.This criticism aside, The Spanish Resurgence should be of interest to historians of colonial Spanish America, as it provides a very fine portrait of the Spanish state during the first stirrings of the vaunted Bourbon reforms. It is an entreaty to historians of Spanish America who aim to contextualize Spanish governance and aspirations in a truly transatlantic framework. This richly textured and well-researched account deserves attention from Latin Americanists, even though Storrs largely ignores Latin America.

Reconciling faith and reason: T. H. Green’s theory of human agency

ABSTRACTThe Victorian age was a period in which Christian Orthodoxy was undermined by new and emerging forms of reasoned inquiry. The commonly-held view amongst historians is that the intellectual life in the era was composed of two hostile camps; those who defended Christian Orthodoxy and those who championed the new sciences. The received view is that, when faced by the new fields of reasoned inquiry, Christianity’s prominence within British intellectual life and discourse went into terminal decline. The intention of this article is to demonstrate that there was a middle ground between the two camps. In particular, this article aims to demonstrate that attempts were made to reconcile Christianity with the findings of the emerging forms of reasoned inquiry. This will be achieved through providing an examination of T. H. Green’s theory of Human Agency. Green was one of the most prominent philosophers of the Victorian age. Through his theory of human agency, Green consciously engaged in the debate that existed between theistic Christianity and the emerging forms of reason inquiry of the time.

Corporate Romanticism: Liberalism, Justice, and the Novel by Daniel M. Stout

Reviewed by: Corporate Romanticism: Liberalism, Justice, and the Novel by Daniel M. Stout Peter Denney STOUT, DANIEL M. Corporate Romanticism: Liberalism, Justice, and the Novel. New York: Fordham University Press, 2017. 254 pp. $30.00 paperback. In the wake of Brexit and the election of Donald Trump, it has become common to regard liberalism as in crisis, or even terminal decline. While critics have been warning about this crisis for over a century, the concern has intensified in recent years, not least because of the rise of social media as a vehicle for the transmission of anti-liberal ideas. Social media can be an agent of liberalism as well as an incubator of rancor, prejudice, and conspiracy theory. Overall, however, Facebook and Twitter have possibly eroded the ground that fertilizes liberal ideas by fostering a mix of rampant individualism and systematic depersonalization. From this perspective, the crisis of liberalism may have entered an alarming, new phase. Specifically, the consensus around many liberal convictions has perhaps been weakened by a cultural form that promotes an individualistic attitude often in tension with social justice, while depersonalizing users, whose identities are transformed into units of big data. The consolidation of liberalism during the Romantic period has long been associated with an earlier cultural form, the novel. In the famous formulation of Ian Watt, the realist novel, which finds its culmination in the fiction of Jane Austen, constitutes an instantiation of liberal subjectivity, attending to the private thoughts and personal feelings of characters, who are imagined as autonomous agents, always shaped but never determined by social encounters. Like its eighteenth-century predecessor, Romantic fiction is thus assumed to be preoccupied with autonomy. Its development is viewed as part of a broader transition to modernity, by which (as argued by Charles Taylor, among others) individuals are extricated from traditional, integrated forms of collective life. The scholarly orthodoxy linking liberalism, individualism, and fiction in the first half of the nineteenth century can no longer be maintained in any simple way thanks to the important new book by Daniel M. Stout, Corporate Romanticism: Liberalism, Justice, and the Novel. In this perceptive, clever, and astonishingly original book, Stout argues that the Romantic period witnessed the emergence of new forms of collectivity, from the business corporation to the industrial city, which caused considerable doubt about, on the one hand, whether autonomous individuals actually existed and, on the other, whether discrete actions could be adequately identified in a world so depersonalized and networked that it became difficult to make confident determinations of justice. Put simply, at the very moment when liberalism was crystallizing into a coherent cluster of ideas, it was wracked by anxieties about how to define a person and how to link effects to causes so as to attribute agency and responsibility. One key reason for this confusion included the rise of the business corporation, especially the strengthening of the legal fiction of corporate personhood. Another contributing factor was the growth of large-scale industrial production and the related [End Page 598] increase in population density, which, together, not only subjected individuals to the collateral damage of institutions in the forms, say, of pollution or congestion, but dissociated actions from their effects by exposing them as links in a virtually endless chain. A great strength of Stout’s book is to tease out this other side of modernity in a way that resonates with contemporary experiences of global capitalism, while always remaining sensitive to the historical contexts of the ideas under examination. The result is a compelling, highly relevant demonstration that liberalism was never a monolithic phenomenon, being marked by contradictions from the beginning. Even more than political or economic commentary, early nineteenth-century fiction provides a unique vantage point to see these contradictions between individualism and corporatization, liberal subjectivity and collective personhood, as characters exhibit an agency that is ultimately revealed to be futile. Far from dramatizing autonomy, Stout shows that the Romantic novel contributed to a strain of “liberalism without individualism” (18). In doing so, he makes a significant revision to our understanding of the culture of liberalism, while helping us to read the literature of the period in an entirely new way. The book examines...

“A Shooting Star of Conservatism”: George S. Benson, the National Education Program and the “Radical Right”

This article reassesses the so-called “Radical Right,” a political phenomenon that emerged in the early 1960s and was especially associated with a controversial conservative anticommunism. The article argues that the National Education Program (NEP), which was founded in Arkansas in 1943, made an important and unheralded contribution to the Radical Right and the consequential activism it stimulated in pockets of the South and Southwest. The article also, however, argues that the Radical Right ultimately made a less significant contribution to the subsequent resurgence of conservatism than has often been suggested. Conventional wisdom maintains that it aligned religious, economic, and racial concerns under the umbrella of anticommunism and thereby fostered a distinctly modern conservatism; the NEP demonstrates that these concerns were not as disparate or marginal prior to the 1960s as this narrative assumes. The Radical Right's fixation with communist subversion also often diluted efforts to promote conservative principles – the NEP became less focussed on advancing ideological principles during this period. After the mid-1950s, moreover, the declining legitimacy of McCarthyite politics outwith parts of the South and Southwest undermined the NEP's wider efforts, precipitated the organization's terminal decline, and ensured that the Radical Right created problems for the broader conservative movement.

Effects of Early Integrated Palliative Care on Caregivers of Patients with Lung and Gastrointestinal Cancer: A Randomized Clinical Trial.

The family and friends (caregivers) of patients with advanced cancer often experience tremendous distress. Although early integrated palliative care (PC) has been shown to improve patient-reported quality of life (QOL) and mood, its effects on caregivers' outcomes is currently unknown. We conducted a randomized trial of early PC integrated with oncology care versus oncology care alone for patients who were newly diagnosed with incurable lung and noncolorectal gastrointestinal cancers and their caregivers. The early PC intervention focused on addressing the needs of both patients and their caregivers. Eligible caregivers were family or friends who would likely accompany patients to clinic visits. The intervention entailed at least monthly patient visits with PC from the time of diagnosis. Caregivers were encouraged, but not required, to attend the palliative care visits. We used the Hospital Anxiety and Depression Scale (HADS) and Medical Health Outcomes Survey Short-Form to assess caregiver mood and QOL. Two hundred seventy-five caregivers (intervention n = 137; control n = 138) of the 350 patients participated. The intervention led to improvement in caregivers' total distress (HADS-total adjusted mean difference = -1.45, 95% confidence interval [CI] -2.76 to -0.15, p = .029), depression subscale (HADS-depression adjusted mean difference = -0.71, 95% CI -1.38 to -0.05, p = .036), but not anxiety subscale or QOL at week 12. There were no differences in caregivers' outcomes at week 24. A terminal decline analysis showed significant intervention effects on caregivers' total distress (HADS-total), with effects on both the anxiety and depression subscales at 3 and 6 months before patient death. Early involvement of PC for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. This work demonstrates that the benefits of early, integrated PC models in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. Early involvement of palliative care for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. The findings of this trial demonstrate that the benefits of the early, integrated palliative care model in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. These findings contribute novel data to the growing evidence base supporting the benefits of integrating palliative care earlier in the course of disease for patients with advanced cancer and their caregivers.

The Policy of Serbian Expansionism, with Specific Reference to Albanians in the Decade Preceding the Balkan Wars

ABSTRACTThe Balkans at the end of the nineteenth century was in flux. The Eastern Crisis, the Treaty of San Stefano and the Congress of Berlin had established a new political geography in the region that was fated not to hold for long. Here were intertwined the interests of the Great Powers and the newly established Balkan states. The Ottoman Empire which had controlled the region for centuries was in terminal decline. The newly established states supported by the Great Powers very quickly established expansionist policies cloaked in the guise of ‘liberation’ for the remaining Balkan lands from the Ottoman Empire. The question of the Albanian population of the region was largely ignored in European diplomacy. Serbia became fixated on expansion towards the Adriatic and the occupation of Albanian lands. After tracing the historical context of Serbian expansionism and its codification in Načertanije, this article makes full use of (chiefly Serbian) diplomatic sources in order to survey the practical implementation of this policy especially with regard to the Albanian population of the Ottoman territories in Europe in the decade before 1912.

Trajectory of Total Cholesterol in the Last Years of Life Over Age 80 Years: Cohort Study of 99,758 Participants.

Epidemiological studies suggest that lower total cholesterol (TC) may be associated with higher mortality. This study aimed to evaluate whether a decline in TC before death might account for the association of TC with mortality over age 80 years. Cohort study using primary care electronic health records of 99,758 participants aged 80-105 years from the UK Clinical Practice Research Datalink. Hazard ratios for all-cause mortality were adjusted for age, gender, frailty, comorbidity, blood pressure, and smoking. Fractional polynomial models were fitted to evaluate longitudinal trends in TC before death or end-of-study. Adjusted odds ratios were estimated using generalized estimating equations. There were 63,630 women and 36,128 men, mean age 86 years, with 29,200 deaths. There were 41,164 treated with statins at cohort entry. Compared with TC values of 4.5-5.4 mmol/L, TC values <3.0 mmol/L were associated with higher mortality (statin treated hazard ratios 1.53, 95% confidence interval 1.43-1.64, p < .001; not treated, 1.41, 1.29-1.54, p < .001). A secular decline in TC values accelerated in the last 2 years of life. In the last quarter of follow-up, the adjusted odds of TC < 3.0 mmol/L for those who died, compared with surviving participants, were 3.33 (2.84-3.91, p < .001) for untreated and 1.88 (1.68-2.11, p < .001) for statin-treated participants. TC values show a terminal decline in the last years of life. Reverse causation may contribute to the association of lower TC with higher mortality in nonrandomized studies.

The role of morbidity for proxy-reported well-being in the last year of life.

Late-life well-being often shows steep deteriorations, but the contributing factors are not well understood, in part because data about people's final year of life are scarce. Here, we draw from and test theoretical perspectives that health-related vulnerabilities undermine the experience and skills older adults typically use to maintain well-being (Charles, 2010). To do so, we examined how various morbidity factors shape final-year well-being trajectories. We applied change score models to retrospective proxy-reports from the Socio-Economic Panel (N = 1,776; age at death = 19-101 years; 47% women) and covary for characteristics of the deceased and the bereaved proxy. Terminal decline in proxy-reported well-being amounted to 0.57 SD in less than a year, with larger individual differences at 3 months versus 12 months before death. Declines were reportedly steeper for those in poor health, need of care, not dying from sudden causes of death, dying with cancer, and not dying at home. People who entered their final year with preserved well-being and cognition experienced steeper final-year decrements. Morbidity factors conjointly accounted for less than 20% of variance, indicating that health decrements shape final-year well-being in multifaceted ways, but are not the be-all and the end-all of why well-being declines for some, but not for others. Unique effects of particular morbidity factors were modest, suggesting that prevailing multimorbidity makes the particular conditions in part interchangeable. Extending self-report data typically available until 1 year before death, our findings suggest that proxy-based results move our understanding of terminal well-being decline further. (PsycINFO Database Record

How does availability of county-level healthcare services shape terminal decline in well-being?

Both lifespan psychology and life course sociology highlight that contextual factors influence individual functioning and development. In the current study, we operationalize context as county-level care services in inpatient and outpatient facilities (e.g., number of care facilities, privacy in facilities) and investigate how the care context shapes well-being in the last years of life. To do so, we combine 29 waves of individual-level longitudinal data on life satisfaction from now deceased participants in the nationwide German Socio-Economic Panel Study (N=4557; age at death: M=73.35, SD=14.20; 47% women) with county-level data from the Federal Statistical Office. Results from three-level growth models revealed that having more inpatient care facilities, more employees per resident, and more staff in administration are each uniquely associated with higher late-life well-being, independent of key individual (age at death, gender, education, disability) and county (affluence, demographic composition) characteristics. Number of employees in physical care, residential comfort, and flexibility and care indicators in outpatient institutions were not found to be associated with levels or change in well-being. We take our results to provide empirical evidence that some contextual factors shape well-being in the last years of life and discuss possible routes how local care services might alleviate terminal decline.

Monopoly regulation, discontinuity & stranded assets

For regulated electricity utilities, if trend-load growth enters a state of terminal decline through disruptive competition and costs are unable to contract at a similar rate, the regulatory outcomes that follow produce strikingly different results to an equivalent episode in a competitive market, where profits fall and assets are written-off. Under economic regulation, prices rise to offset volumetric losses and in the presence of disruptive competition, a destructive price spiral can ensue. In these circumstances, some component of the regulated utility's assets meet the definition of ‘stranded’. Failure to deal with stranded assets will eventually, and needlessly, damage shareholders, consumers and welfare. However, the ‘regulatory compact’ makes this an especially complex area of economics. Zero recovery of stranded monopoly assets is not credible policy. A normative analysis of economics and law suggests full recovery is not credible either. In this article, asset stranding experience from the US is reviewed and a series of policy principles are established; viz. asset stranding is a case-by-case proposition involving recovery via non-bypassable pricing mechanisms, quantified and packaged as a partial Return of Capital, possibly financed by Transition Bonds on a time-limited basis. Financial risk tolerances of the utility and the stability of post-stranding consumer tariffs are important parameters that should guide the policy approach to asset stranding. But ultimately, asset stranding is a policy choice, not an analytical determination.

Trajectories of End of Life: A Systematic Review.

Because End of life (EOL) is becoming an increasingly long life stage, this paper aims to describe the delineation of EOL by reviewing studies which examine (a) terminal decline (TD), the timing of change in slope of decline in specific abilities; and (b) trajectories of decline in areas such as function, health care expenditures, and well-being according to cause of death. Studies were identified through Google Scholar, PsycNET, and PubMed. TD was identified in diverse domains. Most findings focused on decline of cognitive abilities, and they reported this to occur 3-7 years prior to death. TD in wellbeing was found to begin 3-5 years prior to death. Trajectories by cause of death generally examined sudden death, terminal illness, organ failure, and frailty, and findings described differences in costs, function, and wellbeing, though examining a shorter predeath period than the TD literature. Further research is needed to combine methods of investigation in order to assist the health care system in personalizing services to the trajectories of decline, and in enabling caregivers to prepare for the EOL experience.

Natural Theology Reconsidered (Again)

ABSTRACTNeither the “traditional” nor the “revisionist” accounts of the nature and fate of natural theology are adequate to the task of explaining the peculiar trajectory of its history and, in particular, the consensus view of its apparent terminal decline. Contrary to the accepted narrative, natural theology was not fatally undermined by the scientific revolution. Even if temporarily marginalized by disciplines such as systematics and dogmatics, natural theology never went away. It is still with us, and it provides a healthy grasp of the divine presence in the natural world.

TERMINAL DROP OF WELL-BEING IN VERY OLD AGE

Those who survive into oldest-old age may expect and have developed resilience towards terminal processes, hence showing less terminal decline in well-being than evidenced with samples with a broader range of age-at-death. The present study analyzed time-to-death-related change in a broad range of facets of well-being (affective, eudaimonic, death-related fears), making use of longitudinal oldest-old data (N=125, aged 87–96 at baseline) that provides up to 18 measurements with short (3–6 month) intervals, hence enabling observation of changes in close proximity to death. Confirming our expectations, terminal drop did not unfold de-differentiated across all facets of well-being, but appeared pronounced only for indicators of positive affect. Further analyses suggest that this terminal drop was driven by loss of functional abilities. Altogether, the findings point at the oldest-olds’ resilience towards terminal experiences – except the interruption of positive affect due to terminal loss of behavioral competences which are needed for prohedonic activities.

TRIGLYCERIDES AS A MODERATOR OF ACCELERATED COGNITIVE LOSS PRIOR TO DEATH AND DEMENTIA

Cognitive aging is frequently characterized by accelerated loss with an onset some years before death (terminal decline) or dementia diagnosis (pre-clinical dementia). Recent evidence suggest that an elevated level of serum triglycerides may contribute to accumulation of cerebral amyloids (Aβ) and potentially also cognitive decline. We evaluated this issue using data from the H70 study. The sample consisted of 392 individuals, systematically selected from the general population of 70 years-olds living in Gothenburg, Sweden, born in 1901–1902, and repeatedly measured on three cognitive outcomes (i.e., speed, spatial, verbal) at ages 70, 75, 79, 81, 85, 88, 90, 92, 95, 97, 99, and 100, or until death. Triglycerides levels were derived from blood samples taken at age 70 and complete date of death was retrieved from population register. Dementia diagnosis was made according to DSM-III-R. We fitted several random change point, and polynomial, quadratic mixed effects models to the data. Our findings revealed no evidence that triglycerides levels moderate the onset of the acceleration in either the terminal or the pre-clinical dementia models. Elevated levels of triglycerides were however consistently associated with poorer cognitive performance and, against expectation, also with less steep decline. When we compared the effect sizes to results using serum total cholesterol as moderator we found that the cognitive trajectory was more strongly associated with the levels of triglycerides than total cholesterol. These findings support the claim that triglycerides have a role in cognitive aging but not to the degree that it moderates the onset of the acceleration.

Systolic Blood Pressure Trajectory, Frailty, and All-Cause Mortality >80 Years of Age: Cohort Study Using Electronic Health Records.

Clinical trials show benefit from lowering systolic blood pressure (SBP) in people ≥80 years of age, but nonrandomized epidemiological studies suggest lower SBP may be associated with higher mortality. This study aimed to evaluate associations of SBP with all-cause mortality by frailty category >80 years of age and to evaluate SBP trajectories before death. A population-based cohort study was conducted using electronic health records of 144 403 participants ≥80 years of age registered with family practices in the United Kingdom from 2001 to 2014. Participants were followed for ≤5 years. Clinical records of SBP were analyzed. Frailty status was classified using the e-Frailty Index into the categories of fit, mild, moderate, and severe. All-cause mortality was evaluated by frailty status and mean SBP in Cox proportional-hazards models. SBP trajectories were evaluated using person months as observations, with mean SBP and antihypertensive treatment status estimated for each person month. Fractional polynomial models were used to estimate SBP trajectories over 5 years before death. During follow-up, 51 808 deaths occurred. Mortality rates increased with frailty level and were greatest at SBP <110 mm Hg. In fit women, mortality was 7.7 per 100 person years at SBP 120 to 139 mm Hg, 15.2 at SBP 110 to 119 mm Hg, and 22.7 at SBP <110 mm Hg. For women with severe frailty, rates were 16.8, 25.2, and 39.6, respectively. SBP trajectories showed an accelerated decline in the last 2 years of life. The relative odds of SBP <120 mm Hg were higher in the last 3 months of life than 5 years previously in both treated (odds ratio, 6.06; 95% confidence interval, 5.40-6.81) and untreated (odds ratio, 6.31; 95% confidence interval, 5.30-7.52) patients. There was no evidence of intensification of antihypertensive therapy in the final 2 years of life. A terminal decline of SBP in the final 2 years of life suggests that nonrandomized epidemiological associations of low SBP with higher mortality may be accounted for by reverse causation if participants with lower blood pressure values are closer, on average, to the end of life.