Trajectory Of Functional Decline Research Articles

Identification of the trajectory of functional decline for advance care planning in a nursing home population.

To identify diagnostic groups and the form of the trajectory of functional decline that has the potential to enhance advance care planning (ACP) in a nursing home (NH) population. Retrospective, longitudinal study with dependent variable (function) derived from the Resident Classification Scale (RCS), 1997-2008. Trajectory modelling used linear and curvilinear terms. The organ failure or other residents have a linear average functional decline. The organ failure residents had an average decline of 6.5 points per year and average function score at death of 68.6, CI [62.4, 74.8]. The cancer and frailty residents had significant curvilinear terms. The frailty residents had a slower rate of decline at 9.54 points per year and were most care dependent at death, with an average function score of 77.1, CI [73.8, 80.9]. Functional change is a measurable variable for a predictive tool to enhance ACP for NH residents based on their diagnosis.

Trajectories of function and biomarkers with age: the CHS All Stars Study.

Multimorbidity is a major driver of physical and cognitive impairment, but rates of decline are also related to ageing. We sought to determine trajectories of decline in a large cohort by disease status, and examined their correspondence with biomarkers of ageing processes including growth hormone, sex steroid, inflammation, visceral adiposity and kidney function pathways. We have followed the 5888 participants in the Cardiovascular Health Study (CHS) for healthy ageing and longevity since 1989-90. Gait speed, grip strength, modified mini-mental status examination (3MSE) and the digit symbol substitution test (DSST) were assessed annually to 1998-99 and again in 2005-06. Insulin-like growth hormone (IGF-1), dehydroepiandrosterone sulphate (DHEAS), interleukin-6 (IL-6), adiponectin and cystatin-C were assessed 3-5 times from stored samples. Health status was updated annually and dichotomized as healthy vs not healthy. Trajectories for each function measure and biomarker were estimated using generalized estimating equations as a function of age and health status using standardized values. Trajectories of functional decline showed strong age acceleration late in life in healthy older men and women as well as in chronically ill older adults. Adiponectin, IL-6 and cystatin-C tracked with functional decline in all domains; cystatin-C was consistently associated with functional declines independent of other biomarkers. DHEAS was independently associated with grip strength and IL-6 with grip strength and gait speed trajectories. Functional decline in late life appears to mark a fundamental ageing process in that it occurred and was accelerated in late life regardless of health status. Cystatin C was most consistently associated with these functional declines.

Trajectories of functional decline in knee osteoarthritis: the Osteoarthritis Initiative.

To describe trajectories of functional decline over 84 months and study associated risk factors among adults initially without limitation who had or were at risk of knee OA. We used annual measures of WOMAC physical function over 84 months from the OA Initiative. We included knees with no functional limitation (i.e. WOMAC = 0) at baseline. Knee-based trajectories of functional decline from WOMAC were identified from a group-based trajectory model (PROC TRAJ). We identified five trajectories from 2110 knees (1055 participants, age 61.0 ± 9.3, BMI 27.1 ± 4.4, 52% women). Half of the knees (54%) remained free of limitation over 84 months, 26% slowly declined to a WOMAC of 1.5, 9% were limitation free for the first 36 months and declined to a WOMAC of 11.3, 6% rapidly declined over the first 12 months and gradually recovered to a WOMAC of 3.3 and 5% steadily declined to a WOMAC of 13.2. Baseline radiographic disease, knee pain, obesity and depressive symptoms at baseline were associated with trajectories of worse functional decline. Five per cent of our sample initially without limitation was on a trajectory of progressive functional decline over 84 months later. We found worse disease and health status at baseline to be associated with faster decline over time.

Screening for Fall Risks in the Emergency Department: A Novel Nursing-Driven Program.

IntroductionSeniors represent the fasting growing population in the U.S., accounting for 20.3 million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT), a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and prompt interventions through a geriatric nurse liaison (GNL) model.MethodsPatients aged 65 and older presenting to an urban ED were evaluated by a team of ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical therapy (PT), social work or home health as determined by the GNL.ResultsGait assessment with the TUGT was performed on 443 elderly patients between 4/1/13 and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those screened with the TUGT, 368 patients experienced a positive result. Interventions for positive results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work consultation (n=162, 44%).ConclusionThe ED visit may provide an opportunity for older adults to be screened for fall risk. Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and place appropriate referrals based on assessment results. Identifying and intervening on high fall risk patients who visit the ED has the potential to improve the trajectory of functional decline in our elderly population.

Trajectories of decline in cognition and daily functioning in preclinical dementia

IntroductionAlthough preclinical dementia is characterized by decline in cognition and daily functioning, little is known on their temporal sequence. We investigated trajectories of cognition and daily functioning in preclinical dementia, during 18 years of follow-up. MethodsIn 856 dementia cases and 1712 controls, we repetitively assessed cognition and daily functioning with memory complaints, mini-mental state examination (MMSE), instrumental activities of daily living (IADL), and basic activities of daily living (BADL). ResultsDementia cases first reported memory complaints 16 years before diagnosis, followed by decline in MMSE, IADL, and finally BADL. Vascular dementia related to earlier decline in daily functioning but later in cognition, compared with Alzheimer's disease. Higher education related to larger preclinical cognitive decline, whereas apolipoprotein E (APOE) ε4 carriers declined less in daily functioning. DiscussionThese results emphasize the long hierarchical preclinical trajectory of functional decline in dementia. Furthermore, they show that various pathologic, environmental, and genetic factors may influence these trajectories of decline.

Trajectories of functional decline and behavioral changes in primary progressive aphasia

Trajectories of functional decline and behavioral changes in primary progressive aphasia

The Role of Occupations in Differentiating Health Trajectories in Later Life

This study characterizes heterogeneous trajectories of health among older Americans and investigates how employment histories differentiate them. Using the 1998-2010 waves of the Health and Retirement Study, we examine the impact of longest-held occupations on patterns of limitations in activities of daily living. We use latent class growth analysis to identify distinct health trajectory classes and linear growth curve analysis to model the pattern of limitation accumulation for individuals. All analyses are stratified by sex and race, to account for differential labor markets and health experiences of these demographic groups. A limitation of this analysis is its reliance on broad occupational categories rather than specific measures of working conditions. In future work, we plan to incorporate data on specific occupations and merge them with detailed information on occupational characteristics available in the O*NET database (an online repository that has updated the Dictionary of Occupational Titles used in previous research on aging and retirement and occupational epidemiology).The paper found that: White respondents (both male and female) are substantially more likely to be in the healthiest class compared to black respondents. Certain occupations are protective against membership in poor health classes, but the list of protective occupational categories differs substantially by sex and race. The impact of occupations on health trajectories was diminished when we controlled for educational attainment and smoking, suggesting the important role of education in sorting individuals into occupations that differ in physical and cognitive demands that likely influence health. The policy implications of the findings are: Life expectancy alone does not capture all the health information that would be relevant for assessing the capacity of American workers to stay on the job beyond traditional retirement ages. Legislators should consider differences in health and in the trajectories of functional decline across demographic groups defined by sex, race, and occupational exposures when debating further increases in the Social Security retirement age.

Patterns of Functional Decline in Hospice: What Can Individuals and Their Families Expect?

To describe the trajectory of functional decline after an individual is referred to hospice. Electronic health record-based retrospective cohort study. Three hospice programs in the U.S. southeast, northeast, and midwest. Individuals in hospice. Palliative Performance Scale (PPS) scores measured at intervals between hospice enrollment and death, on a scale from 10 to 100. In 8,669 decedents, there was an average 13.8-point decline in PPS score. After adjusting for baseline PPS score and length of stay in hospice, three distinct trajectories were identified, each of which consisted of two diagnoses whose rates of decline had 95% confidence intervals (CIs) that overlapped. The most rapid decline was observed for individuals with cancer (adjusted decline 8.44 points/wk; 95% CI=8.03-8.82) and stroke (adjusted decline 7.67 points/wk, 95% CI=7.08-8.29). A significantly slower decline was observed in individuals with pulmonary disease (adjusted decline 5.02 points/wk, 95% CI=4.24-5.75) and cardiac disease (adjusted decline 4.53 points/wk, 95% CI=4.05-5.05). Individuals with debility (adjusted decline 1.86 points/wk, 95% CI=0.95-2.78) and dementia (adjusted decline 1.98 points/wk, 95% CI=1.01-2.89) had the slowest decline. In an inverse probability-weighted sample of individuals who had a PPS score recorded in the last day of life (n=1,959, 22.6%), 35.9% had a PPS score of at least 40, indicating some oral intake, variable mental status, limited self-care, and an ability to get out of bed for at least part of the day. Although functional status generally declines in individuals in hospice, this decline is heterogeneous. Some individuals retain some physical and cognitive function until the last day of life.

Trajectory of Functional Decline Before and After Ischemic Stroke

Previous research in our cohort showed a delayed decline in functional status after first ischemic stroke. We compared the long-term trajectory of functional status before and after ischemic stroke. The Northern Manhattan Study contains a prospective, population-based study of stroke-free individuals age ≥40 years, followed for a median of 11 years. The Barthel index (BI), a commonly used measure of activities of daily living, was assessed annually. Generalized estimating equations were used to assess functional decline over time before stroke and beginning 6 months after stroke. Follow-up was censored at the time of recurrent stroke. Among 3298 participants, 210 participants had an ischemic stroke during follow-up and had poststroke BI assessed. Mean age (±SD) was 77±9 years, 38% were men, 52% were Hispanic, 37% had diabetes, and 31% had coronary artery disease. There was no difference in rate of functional decline over time before and after stroke (P=0.51), with a decline of 0.96 BI points per year before stroke (P<0.0001) and 1.24 BI points after stroke (P=0.001). However, when stratified by insurance status, among those with Medicaid or no insurance, in a fully adjusted model, there was a difference in slope before and after stroke (P=0.04), with a decline of 0.58 BI points per year before stroke (P=0.02) and 1.94 BI points after stroke (P=0.001). In this large, prospective, population-based study with long-term follow-up, there was a significantly steeper decline in functional status after ischemic stroke compared with before stroke among those with Medicaid or no insurance, after adjusting for confounders.

PC-FACS

PC-FACS

End-Stage Renal Disease: A New Trajectory of Functional Decline in the Last Year of Life

To determine the functional trajectory in the last year of life in end-stage renal disease managed without dialysis. Longitudinal cohort study of functional status over time and toward death. Three renal units in the United Kingdom. Patients with Stage 5 chronic kidney disease managed conservatively (without dialysis). The main outcome measure was functional status, measured using the Karnofsky Performance Scale. Seventy-five participants (mean age 80.7, 62% response rate) recruited and followed up monthly for up to 2 years (median 8-month follow-up, range 1-23 months). Forty-nine (66%) died during follow-up. Those who died had similar distribution of age, ethnicity, primary renal pathology, and comorbidity as those still alive at study end. Analysis according to time before death revealed that functional status remained stable during the last year of life but declined steeply in the last month of life. This distinctive renal trajectory, reported here for the first time, contrasts with that previously described in other conditions. This has important clinical implications-the steep functional decline indicates that healthcare services need to be rapidly responsive to changing needs in this population as function declines in the last months and weeks of life.

An intervention for delirium superimposed on dementia based on cognitive reserve theory

Delirium superimposed on dementia (DSD) accelerates the trajectory of functional decline and results in prolonged hospitalization, re-hospitalization, premature nursing home placement, and death. In this article we propose a theory-based intervention for DSD that is derived from the literature on cognitive reserve and neuroplasticity. We begin by defining cognitive reserve, the guiding framework for our hypothesis. We review the pathophysiology and neuropsychology of delirium noting the similarities with dementia–these two conditions reflecting acute and chronic reductions in cognitive reserve, respectively. We then review the evidence for activity-dependent plasticity as a possible mechanism for sparing cognitive reserve in dementia and its potential for addressing DSD. Cognitive training (CT) in the form of stimulating activities has been shown to evoke cognitive processing and facilitate plasticity in dementia. Because of the similarities between dementia and delirium, the use of recreational activities as a vehicle for supporting attentional capacity, and delivering cognitive stimulation, may hold promise for the resolution of DSD. Based on integrated evidence from the literature, we hypothesize that engagement in cognitively stimulating recreational activities will help reduce delirium severity and duration in persons with dementia while providing improved quality of life and reduced costs of care.

Promoting Healthy Lifestyles in Older Cancer Survivors to Improve Health and Preserve Function

Currently, there are about 7 million cancer survivors in this country aged 65 and older, and this number is expected to increase rapidly, given trends toward aging and improvements in early detection and treatment. Unfortunately, cancer survivors are at risk for several comorbid conditions and accelerated functional decline. A previous cross-sectional study of 688 older breast and prostate cancer survivors found significant associations between lifestyle practices and levels of physical functioning, with positive associations noted for physical activity and fruit and vegetable consumption and negative associations observed for dietary fat. In a more-recent cross-sectional study of 753 older survivors of breast, prostate, and colorectal cancer, significant associations were also observed between physical function, and physical activity (rho=0.22, P<.001) and diet quality (rho=0.07, P=.046), and a significant negative association was also found between physical function and body mass index (rho=-0.29, P<.001). Therefore, lifestyle interventions may be helpful in positively reorienting the trajectory of functional decline in this vulnerable population, although there are substantial barriers, such as travel, that must be overcome in delivering behavioral interventions to older cancer survivors. Previously reported results from the Pepper Center-funded Leading the Way in Exercise and Diet Project intervention development study suggested that an exercise and diet intervention delivered using telephone counseling and mailed materials was readily accepted and appeared to be of benefit. Larger trials, such as Reach-out to ENhancE Wellness in Older Survivors, have recently produced compelling data.

Cost Trajectories at the End of Life: The Canadian Experience

A significant proportion of health care resources are consumed at end of life. As a result, decision and policy makers seek cost savings to enhance program planning. Most literature, however, combines the cost of all dying patients and, subsequently, fails to recognize the variation between trajectories of functional decline and utilization of health care services. In this article, we classified dying Albertans by categories of functional decline and assessed their utilization and costs. We used data from two years of health care utilization and costs for three annual cohorts of permanent residents of Alberta, Canada (April 1999 to March 2002). Literature, expert opinion, and cluster analysis were used to categorize the deceased according to sudden death, terminal illness, organ failure, frailty, and other causes of death. Expenditures were decomposed into constituent quantities and prices. We found that nearly 18,000 die per year in Alberta: sudden death (7.1%), terminal illness (29.8%), organ failure (30.5%), frailty (30.2%), and other causes (2.3%). Inpatient care remains the primary cost driver for all trajectories. Significant and predictable health care services are required by noncancer patients. Trajectories of costs are significantly different for the four categories of dying Albertans. Trajectories of dying are a useful classification for analyzing health care use and costs.

Terminal Trajectories of Functional Decline in the Long-Term Care Setting

Little is known about the terminal trajectories of functional decline among long-term care (LTC) residents dying with different diseases. A retrospective cohort study was performed on 747 individuals aged 65 or older who died between January 1994 and December 2004 in a 675-bed LTC facility in Massachusetts. Three study groups were created: advanced dementia, n = 314 (42%); terminal cancer, n = 63 (8%); and organ failure (congestive heart failure and chronic obstructive pulmonary disease), n = 370 (50%). Quarterly scores of 7 activities of daily living (ADLs) during the last year of life derived from the Minimum Data Set were compared among the three groups. Each activity was rated from 0 to 4 (higher scores indicate more dependence; total range, 0-28). The mean age of all individuals at death was 91 +/- 6 (standard deviation) years. Functional decline was greatest during the last 3 months of life, but this decline was most precipitous in the terminal cancer and organ failure groups compared to the advanced dementia group. The mean change in ADL scores during the last year of life differed among the three groups (p <.001), with the greatest decline in the terminal cancer group (from initial score 13 to final score 25), followed by the organ failure group (13 to 22), and finally, the advanced dementia group (24 to 27). The terminal trajectories of functional decline among LTC residents vary by underlying diseases. An understanding of these trajectories may be useful to clinicians and families caring for LTC residents near the end of life.

The Functional Transitions Model: Maximizing Ability in the Context of Progressive Disability Associated with Alzheimer's Disease

The Functional Transitions Model (FTM) integrates the theoretical notions of progressive functional decline associated with Alzheimer's disease (AD), excess disability, and transitions occurring intermittently along the trajectory of functional decline. Application of the Functional Transitions Model to clinical practice encompasses the paradox of attempting to minimize excess disability while anticipating the progressive functional decline associated with AD. It is suggested that times of functional transition are times of decision making and opportunities for interdisciplinary collaboration to identify and minimize excess disability, for revision of goals and expectations, and for provision of support to patients and caregivers. The model also is applicable as a conceptual framework for education and research.

Impact of genome instability on transcription regulation of aging and senescence

Genomic instability has been implicated as a major stochastic mechanism of aging. Using a transgenic mouse model with chromosomally integrated lacZ mutational target genes, mutations were found to accumulate with age at an organ- and tissue-specific rate. Also, the spectrum of age-accumulated mutations was found to differ greatly from organ-to-organ; while initially similar, mutation spectra of different tissues diverged significantly over the lifetime. To explain how genomic instability, which is inherently stochastic, can be a causal factor in aging, it is proposed that randomly induced mutations may adversely affect normal patterns of gene regulation, resulting in a mosaic of cells at various stages on a trajectory of functional decline, eventually resulting in cell death or neoplastic transformation. To directly address this question, we demonstrate that it is now possible to analyze single cells, isolated from old and young tissues, for specific alterations in gene expression.

Patterns of functional decline at the end of life.

Clinicians have observed various patterns of functional decline at the end of life, but few empirical data have tested these patterns in large populations. To determine if functional decline differs among 4 types of illness trajectories: sudden death, cancer death, death from organ failure, and frailty. Cohort 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. 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. 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], 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]). 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.