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Original Investigation |

Disability During the Last Two Years of Life

Alexander K. Smith, MD, MS, MPH1,2; Louise C. Walter, MD1,2; Yinghui Miao, MPH1,2; W. John Boscardin, PhD1,2,3; Kenneth E. Covinsky, MD, MPH1,2
[+] Author Affiliations
1Division of Geriatrics, Department of Medicine, University of California, San Francisco
2Veterans Affairs Medical Center, San Francisco, California
3Department of Epidemiology and Biostatistics, University of California, San Francisco
JAMA Intern Med. 2013;173(16):1506-1513. doi:10.1001/jamainternmed.2013.8738.
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Importance  Whereas many persons at advanced ages live independently and are free of disability, we know little about how likely older people are to be disabled in the basic activities of daily living that are necessary for independent living as they enter the last years of life.

Objective  To determine national estimates of disability during the last 2 years of life.

Design  Prospective cohort study.

Setting  A nationally representative study of older adults in the United States.

Participants  Participants 50 years and older who died while enrolled in the Health and Retirement Study between 1995 and 2010. Each participant was interviewed once at a varying time point in the last 24 months of life. We used these interviews to calculate national estimates of the prevalence of disability across the 2 years prior to death. We modeled the prevalence of disability in the 2 years prior to death for groups defined by age at death and sex.

Main Outcomes and Measures  Disability was defined as need for help with at least 1 of the following activities of daily living: dressing, bathing, eating, transferring, walking across the room, and using the toilet.

Results  There were 8232 decedents (mean [SD] age at death, 79 [11] years; 52% women). The prevalence of disability increased from 28% (95% CI, 24%-31%) 2 years before death to 56% (95% CI, 52%-60%) in the last month of life. Those who died at the oldest ages were much more likely to have disability 2 years before death (ages 50-69 years, 14%; 70-79 years, 21%; 80-89 years, 32%; 90 years or more, 50%; P for trend, <.001). Disability was more common in women 2 years before death (32% [95% CI, 28%-36%]) than men (21% [95% CI, 18%-25%]; P < .001), even after adjustment for older age at death.

Conclusions and Relevance  Those who live to an older age are likely to be disabled, and thus in need of caregiving assistance, many months or years prior to death. Women have a substantially longer period of end-of-life disability than men.

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Figure 1.
Prevalence of Unadjusted and Adjusted Disability in Activities of Daily Living During the Last 2 Years of Life

Diamonds represent the mean monthly prevalence of disability in an activity of daily living (ADL) (bathing, getting out of bed, dressing, eating, walking across a room, and using the toilet). Bars represent 95% confidence intervals. The line represents ADL disability modeled as a spline with knots at 23, 17, 10, and 2 months prior to death, adjusted for age at death, sex, race and/or ethnicity, educational attainment, and household net worth. Gray shading above and below the line represents modeled 95% confidence intervals.

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Figure 2.
Prevalence of Difficulty, Disability, and Severe Disability in Activities of Daily Living During the Last 2 Years of Life

Prevalence of difficulty or disability, defined as the need for assistance, with any of 6 activities of daily living (ADLs). Outcomes are modeled as a spline with knots at 23, 17, 10, and 2 months prior to death, adjusted for age at death, sex, race and/or ethnicity, educational attainment, and household net worth. Severe disability is defined as a report of 3 or more ADL disabilities.

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Figure 3.
Prevalence of Disability in Activities of Daily Living by Age and Sex During the Last 2 Years of Life

Prevalence of disability modeled as a spline with knots at 23, 17, 10, and 2 months prior to death, stratified by age at death and sex, adjusted for race and/or ethnicity, educational attainment, and household net worth. Panels show age at death of 50 to 69 (A), 70 to 79 (B), 80 to 89 (C), and at least 90 (D) years. Gray shading above and below the line represents modeled 95% confidence intervals.

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