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

¹ Hebrew SeniorLife, Institute for Aging Research, and ² Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
³ Department of Internal Medicine and Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei.

Address correspondence to Jen-Hau Chen, MD, MPH, Department of Geriatrics and Gerontology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan 10002. E-mail: jhhchen{at}ntu.edu.tw or to Susan L. Mitchell, MD, MPH, Department of Medicine, Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02131. E-mail: smitchell{at}hrca.harvard.edu

Background. Little is known about the terminal trajectories of functional decline among long-term care (LTC) residents dying with different diseases.

Methods. 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).

Results. 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).

Conclusions. 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.

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