Freedom from symptoms is an important determinant of a good death, but little is known about
symptom occurrence during the last year of life.
To evaluate the monthly occurrence of physical and psychological symptoms leading to restrictions
in daily activities (ie, restricting symptoms) among older persons during the last year of life and
to determine the associations of demographic and clinical factors with symptom occurrence.
Design, Setting, and Participants
Prospective cohort study. Comprehensive assessments were completed every 18 months, and monthly
interviews were conducted to assess the presence of restricting symptoms. Of 1002 nondisabled
community-dwelling individuals 70 years or older in greater New Haven, Connecticut, eligible to
participate, 754 agreed and were enrolled between 1998 and 1999.
Main Outcomes and Measures
The primary outcome was the monthly occurrence of restricting symptoms as a dichotomous outcome.
The monthly mean count of restricting symptoms was a secondary outcome.
Among the 491 participants who died after their first interview and before June 30, 2011, mean
age at death was 85.8 years, 61.9% were women, and 9.0% were nonwhite. The mean number of comorbid
conditions was 2.4, and 73.1% had multimorbidity. The monthly occurrence of restricting symptoms was
fairly constant from 12 months before death (20.4%) until 5 months before death (27.4%), when it
began to increase rapidly, reaching 57.2% in the month before death. In multivariable analysis, age
younger than 85 years (odds ratio [OR], 1.30 [95% CI, 1.07-1.57]), multimorbidity (OR, 1.38 [95% CI,
1.09-1.75]), and proximity to time of death (OR, 1.14 per month [95% CI, 1.11-1.16]) were
significantly associated with the monthly occurrence of restricting symptoms. Participants who died
of cancer had higher monthly symptom occurrence (OR, 1.80 [95% CI, 1.03-3.14]) than participants who
died of sudden death, although this difference was only marginally significant
(P = .04). Symptom burden did not otherwise differ substantially
according to condition leading to death.
Conclusions and Relevance
Restricting symptoms are common during the last year of life, increasing substantially
approximately 5 months before death. Our results highlight the importance of assessing and managing
symptoms in older patients, particularly those with multimorbidity.