Older age associated with disability prior to death, women more at risk than men

Persons who live to an older age are the more likely to be disabled near the end of life and require the assistance of a caregiver to complete the activities of daily living, and disability was more common in women than men two years before death, according to a report published by JAMA Internal Medicine.

The population of U.S. adults older than 85 years is expected to triple from 5.4 million to 19 million between 2008 and 2050. While many people do live into their eighth and ninth decades independently and free of disability, the end-of-life course is increasingly likely to be marked by disability, according to the study background.

Alexander K. Smith, M.D., M.S., M.P.H., of the University of California, San Francisco, and colleagues used a nationally representative sample of older Americans to determine national estimates of disability during the last two years of live. Disability was defined as needing help with at least one of the following activities of daily living: dressing, bathing, eating, transferring, walking across the room and using the toilet. The study included 8,232 decedents whose average age at death was 79 years. Of the decedents, 52 percent were women.

According to the study results, the prevalence of disability increased from 28 percent two years before death to 56 percent in the last month of life. Those adults who died at the oldest ages were more likely to have a disability two years before death (50-69 years, 14 percent; 70-79 years, 21 percent; 80-89 years, 32 percent; 90 years or more, 50 percent). Disability was more common among women two years before death (32 percent) than among men (21 percent), the results indicate.

"Our data do raise the question of whether it makes sense to sell the public a view of aging that purports that it is reasonable to expect to both live a long life and remain free of disability throughout life. Our findings add to the evidence that those who live to advanced ages will spend greater periods of time in states of disability than those who die at younger ages," the study concludes.

Symptoms that restrict daily activities are common in the last year of an older person's life and those restricting symptoms increase substantially about five months before death, according to a study by Sarwat I. Chaudhry, M.D., of the Yale University School of Medicine, New Haven, Conn., and colleagues.

The study enrolled 754 nondisabled, community-dwelling adults 70 years or older in 1998 and 1999, and of these, 491 died before June 30, 2011. The average age at death was almost 86 years. Researchers evaluated the monthly occurrence of physical and psychological symptoms that led to restrictions in daily activities.

The monthly occurrence of restricting symptoms was fairly constant from 12 months before death (20.4 percent) until five months before death (27.4 percent) when it increased rapidly and reached 57.2 percent in the month before death, according to the study results.

"Our results highlight the importance of assessing and managing symptoms in older patients, particularly those with multimorbidity," the study concludes.

In an invited commentary, Christine S. Ritchie, M.D., M.S.P.H., of the University of California, San Francisco, writes: "The article by Chaudhry et al serves as a call for two things: better palliative care for community–dwelling older adults at the end of life and better research."

"Only through these efforts will we be able to relieve symptom burden for those older adults in greatest need of relief and be prepared for the increasing number of individuals with multimorbidity and the functional challenges that they experience," Ritchie concludes.