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Background: Relatively little is known about why older persons develop long-term disability in community mobility.Objective: To identify the risk factors and precipitants for long-term disability in walking a quarter mile and driving a car.Design: Prospective cohort study from March 1998 to December 2009.Setting: Greater New Haven, Connecticut.Participants: 641 persons, aged 70 years or older, who were active drivers or nondisabled in walking a quarter mile. Persons who were physically frail were oversampled.Measurements: Candidate risk factors were assessed every 18 months. Disability in community mobility and exposure to potential precipitants, including illnesses or injuries leading to hospitalization or restricted activity, were assessed every month. Disability that lasted 6 or more consecutive months was considered long-term.Results: 318 (56.0%) and 269 (53.1%) participants developed long-term disability in walking and driving, respectively. Seven risk factors were independently associated with walking disability and 8 were associated with driving disability; the strongest associations for each outcome were found for older age and lower score on the Short Physical Performance Battery. The precipitants had a large effect on long-term disability, with multivariate hazard ratios for each outcome greater than 6.2 for hospitalization and greater than 2.4 for restricted activity. The largest differences in absolute risk were generally observed in participants with a specific risk factor who were subsequently hospitalized.Limitations: The observed associations may not be causal. The severity of precipitants was not assessed. The effect of the precipitants may have been underestimated because their exposure after the initial onset of disability was not evaluated.Conclusion: Long-term disability in community mobility is common among older persons. Multiple risk factors, together with subsequent precipitants, greatly increase the likelihood of long-term mobility disability.Primary Funding Source: National Institute on Aging, National Institutes of Health. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the association between sleep-- wake disturbances and frailty. DESIGN: Cross-sectional. SETTING: New Haven, Connecticut. PARTICIPANTS: Three hundred seventy-four community- living persons aged 78 and older. MEASUREMENTS: Frailty was based on the Fried phenotype, and sleep--wake disturbances were defined as daytime drowsiness, based on an Epworth Sleepiness Scale (ESS) score of 10 or greater, and as subthreshold and clinical insomnia, based on Insomnia Severity Index (ISI) scores of 8 to 14 and greater than 14, respectively. RESULTS: Mean age was 84.3; 87 (23.8%) participants were drowsy, 122 (32.8%) had subthreshold insomnia, 38 (10.2%) had clinical insomnia, and 154 (41.2%) were frail. There was a significant association between drowsiness and frailty, with unadjusted and adjusted odds ratios (ORs) of 3.79 (95% confidence interval (CI)=2.29--6.29) and 3.67 (95% CI=2.03--6.61), respectively. In contrast, clinical insomnia was significantly associated with frailty in the unadjusted analysis (OR=2.77, 95% CI=1.36--5.67) but not the adjusted analysis (OR=1.93, 95%CI=0.81--4.61)), and subthreshold insomnia was not associated with frailty in the unadjusted or adjusted analysis. CONCLUSION: In older persons, sleep--wake disturbances that present with daytime drowsiness, but not insomnia, are independently associated with frailty. Because drowsiness is potentially remediable, future studies should determine whether there is a temporal relationship between drowsiness and frailty, with the ultimate goal of informing interventions to reverse or prevent the progression of frailty. [ABSTRACT FROM AUTHOR]

Objectives: Older adults who survive critical illness are at risk for increased disability, limiting their independence and quality of life. We sought to evaluate whether the occurrence of symptoms that restrict activity, that is, restricting symptoms, is associated with increased disability following an ICU hospitalization., Design: Prospective longitudinal study of community-living adults 70 years old or older who were interviewed monthly between 1998 and 2018., Setting: South Central Connecticut, United States., Patients: Two hundred fifty-one ICU admissions from 202 participants who were discharged alive from the hospital., Interventions: None., Measurements and Main Results: Occurrence of 15 restricting symptoms (operationalized as number of symptoms and presence of ≥ 2 symptoms) and disability in activities of daily living, instrumental activities of daily living, and mobility was ascertained during monthly interviews throughout the study period. We constructed multivariable Poisson regression models to evaluate the association between post-ICU restricting symptoms and subsequent disability over the 6 months following ICU hospitalization, adjusting for known risk factors for post-ICU disability including pre-ICU disability, frailty, cognitive impairment, mechanical ventilation, and ICU length of stay. The mean age of participants was 83.5 years (sd, 5.6 yr); 57% were female. Over the 6 months following ICU hospitalization, each unit increase in the number of restricting symptoms was associated with a 5% increase in the number of disabilities (adjusted rate ratio, 1.05; 95% CI, 1.04-1.06). The presence of greater than or equal to 2 restricting symptoms was associated with a 29% greater number of disabilities over the 6 months following ICU hospitalization as compared with less than 2 symptoms (adjusted rate ratio, 1.29; 95% CI, 1.22-1.36)., Conclusions: In this longitudinal cohort of community-living older adults, symptoms restricting activity were independently associated with increased disability after ICU hospitalization. These findings suggest that management of restricting symptoms may enhance functional recovery among older ICU survivors., Competing Interests: Drs. Jain, Ferrante, and Gill received support from the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (P30AG021342). Dr. Jain was supported by the Parker B. Francis Family Foundation Fellowship Award, the Yale Physician-Scientist Development Award, the National Institute on Aging (NIA), and the National Institutes of Health (NIH) under Award Number R03AG078942. During the course of this work, Dr. Ferrante was supported by a Paul B. Beeson Emerging Leaders in Aging Career Development Award (K76 AG057023). Dr. Feder was supported by National Heart, Lung, and Blood Institute K12HL138037. Drs. Han, Leo-Summers, Ferrante, and Gill received support for article research from the NIH. Drs. Leo-Summers’s and Gill’s institution received funding from the NIH. Dr. Ferrante’s institution received funding from the NIA. Dr. Gahbauer has disclosed that she does not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: Among older persons, neighborhood disadvantage is a granular and increasingly used social determinant of health and functional well-being. The frequency of transitions into or out of a disadvantaged neighborhood over time is not known. These transitions may occur when a person moves from one location to another or when the Neighborhood Atlas, the data source for the area deprivation index (ADI) that is used to identify disadvantaged neighborhoods at the census-block level, is updated., Methods: From a prospective longitudinal study of community-living persons, aged 70 years or older in South Central Connecticut, neighborhood disadvantage was ascertained every 18 months for 22 years (from March 1998 to March 2020). ADI scores higher than the 80th state percentile were used to distinguish neighborhoods that were disadvantaged (81-100) from those that were not (1-80)., Results: At baseline, 205 (29.3%) of the 699 participants were living in a disadvantaged neighborhood. Changes in neighborhood disadvantage during 14 consecutive 18-month intervals were relatively uncommon, ranging from 1.5% to 11.8%. Nearly 80% of participants had no change in neighborhood disadvantage and less than 4% had more than one change over a median follow-up of more than 9 years. Overall, the rate of transitions into or out of neighborhood disadvantage was only 2.7 per 100 person-years. These transitions were most common when the Neighborhood Atlas was updated (2013, 2015, 2018, and 2020). Comparable results were observed when decile changes in ADI scores during the 18-month intervals were evaluated., Conclusions: In longitudinal studies of older persons with extended follow-up, it may not be necessary to update information on disadvantaged neighborhoods in circumstances when it is possible, and the degree of misclassification of neighborhood disadvantage should be relatively low in circumstances when updated information cannot be obtained., (© 2024 The American Geriatrics Society.)

Objectives: To evaluate the relationship between distressing symptoms and changes in disability after major surgery and to determine whether this relationship differs according to the timing of surgery (nonelective vs elective), sex, multimorbidity, and socioeconomic disadvantage., Background: Major surgery is a common and serious health event that has pronounced deleterious effects on both distressing symptoms and functional outcomes in older persons., Methods: From a cohort of 754 community-living persons, aged 70 or older, 392 admissions for major surgery were identified from 283 participants who were discharged from the hospital. The occurrence of 15 distressing symptoms and disability in 13 activities were assessed monthly for up to 6 months after major surgery., Results: Over the 6-month follow-up period, each unit increase in the number of distressing symptoms was associated with a 6.4% increase in the number of disabilities [adjusted rate ratio (RR): 1.064; 95% CI: 1.053, 1.074]. The corresponding increases were 4.0% (adjusted RR: 1.040; 95% CI: 1.030, 1.050) and 8.3% (adjusted RR: 1.083; 95% CI: 1.066, 1.101) for nonelective and elective surgeries. Based on exposure to multiple (ie, 2 or more) distressing symptoms, the adjusted RRs (95% CI) were 1.43 (1.35, 1.50), 1.24 (1.17, 1.31), and 1.61 (1.48, 1.75) for all, nonelective, and elective surgeries. Statistically significant associations were observed for each of the other subgroups with the exception of individual-level socioeconomic disadvantage for the number of distressing symptoms., Conclusions: Distressing symptoms are independently associated with worsening disability, providing a potential target for improving functional outcomes after major surgery., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Survivors of critical illness have multiple symptoms, but how restricting symptoms change after critical illness and whether these changes differ among vulnerable subgroups is unknown. Objectives: To evaluate changes in restricting symptoms over the six months after critical illness among older adults and to determine whether these changes differ by sex, multimorbidity, and individual- and neighborhood-level socioeconomic disadvantage. Methods: From a prospective longitudinal study of 754 community-living adults ⩾70 years old interviewed monthly (1998-2018), we identified 233 admissions from 193 participants to the ICU. The occurrence of 15 restricting symptoms, defined as those leading to restricted activity, were ascertained during interviews in the month before ICU admission (baseline) and each of the six months after hospital discharge. Measurements and Main Results: The occurrence and number of restricting symptoms increased more than threefold in the six months after a critical illness hospitalization (adjusted rate ratio [95% confidence interval], 3.1 [2.1-4.6] and 3.3 [2.1-5.3], respectively), relative to baseline. These increases were largest in the first month after hospitalization (adjusted rate ratio [95% confidence interval], 5.3 [3.8-7.3] and 5.4 [3.9-7.5], respectively] before declining and becoming nonsignificant in the third month. Increases in restricting symptoms did not differ significantly by sex, multimorbidity, or individual- or neighborhood-level socioeconomic disadvantage. Conclusions: Restricting symptoms increase substantially after a critical illness before returning to baseline three months after hospital discharge. Our findings highlight the need to incorporate symptom management into post-ICU care and for further investigation into whether addressing restricting symptoms can improve quality of life and functional recovery among older ICU survivors.

Background: Relatively little is known about how distressing symptoms change among older persons in the setting of major surgery. Our objective was to evaluate changes in distressing symptoms after major surgery and determine whether these changes differ according to the timing of surgery (nonelective vs. elective), sex, multimorbidity, and socioeconomic disadvantage., Methods: From a prospective longitudinal study of 754 nondisabled community-living persons, 70 years of age or older, 368 admissions for major surgery were identified from 274 participants who were discharged from the hospital from March 1998 to December 2017. The occurrence of 15 distressing symptoms was ascertained in the month before and 6 months after major surgery. Multimorbidity was defined as more than two chronic conditions. Socioeconomic disadvantage was assessed at the individual level, based on Medicaid eligibility, and neighborhood level, based on an area deprivation index (ADI) score above the 80th state percentile., Results: In the month before major surgery, the occurrence and mean number of distressing symptoms were 19.6% and 0.75, respectively. In multivariable analyses, the rate ratios, denoting proportional increases in the 6 months after major surgery relative to presurgery values, were 2.56 (95% confidence interval [CI], 1.91-3.44) and 2.90 (95% CI, 2.01-4.18) for the occurrence and number of distressing symptoms, respectively. The corresponding values were 3.54 (95% CI, 2.06-6.08) and 4.51 for nonelective surgery (95% CI, 2.32-8.76) and 2.12 (95% CI, 1.53-2.92) and 2.20 (95% CI, 1.48-3.29) for elective surgery; p-values for interaction were 0.030 and 0.009. None of the other subgroup differences were statistically significant, although men had a greater proportional increase in the occurrence and number of distressing symptoms than women., Conclusions: Among community-living older persons, the burden of distressing symptoms increases substantially after major surgery, especially in those having nonelective procedures. Reducing symptom burden has the potential to improve quality of life and enhance functional outcomes after major surgery., (© 2023 The American Geriatrics Society.)

Objective: To identify the factors associated with days away from home in the year after hospital discharge for major surgery., Background: Relatively little is known about which older persons are susceptible to spending a disproportionate amount of time in hospitals and other health care facilities after major surgery., Methods: From a cohort of 754 community-living persons, aged 70+ years, 394 admissions for major surgery were identified from 289 participants who were discharged from the hospital. Candidate risk factors were assessed every 18 months. Days away from home were calculated as the number of days spent in a health care facility., Results: In the year after major surgery, the mean (SD) and median (interquartile range) number of days away from home were 52.0 (92.2) and 15 (0-51). In multivariable analysis, 5 factors were independently associated with the number of days away from home: age 85 years and older, low score on the Short Physical Performance Battery, low peak expiratory flow, low functional self-efficacy, and musculoskeletal surgery. Based on the presence versus absence of these factors, the absolute mean differences in the number of days away from home ranged from 31.2 for age 85 years and older to 53.5 for low functional self-efficacy., Conclusions: The 5 independent risk factors can be used to identify older persons who are particularly susceptible to spending a disproportionate amount of time away from home after major surgery, and a subset of these factors can also serve as targets for interventions to improve quality of life by reducing time spent in hospitals and other health care facilities., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Strong epidemiologic evidence linking indicators of geriatric vulnerability to long-term functional outcomes after major surgery is lacking. The objective of this study was to evaluate the association between geriatric vulnerability and the burden of disability after hospital discharge for major surgery., Methods: From a prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older, 327 admissions for major surgery were identified from 247 participants who were discharged from the hospital from March 1997 to December 2017. The indicators of geriatric vulnerability were ascertained immediately prior to the major surgery or during the prior comprehensive assessment, which was completed every 18 months. Disability in 13 essential, instrumental and mobility activities was assessed each month., Results: The burden of disability over the 6 months after major surgery was considerably greater for non-elective than elective surgery. In multivariable analysis, 10 factors were independently associated with disability burden: age 85 years or older, female sex, Black race or Hispanic ethnicity, neighborhood disadvantage, multimorbidity, frailty, one or more disabilities, low functional self-efficacy, smoking, and obesity. The burden of disability increased with each additional vulnerability factor, with mean values (credible intervals) increasing from 1.6 (1.4-1.9) disabilities for 0-1 vulnerability factors to 6.6 (6.0-7.2) disabilities for 7 or more vulnerability factors. The corresponding values were 1.2 (0.9-1.5) and 5.9 (5.0-6.7) disabilities for elective surgery and 2.6 (2.1-3.1) and 8.2 (7.3-9.2) disabilities for non-elective surgery., Conclusions: The burden of disability after hospital discharge for major surgery increases progressively as the number of geriatric vulnerability factors increases. These factors can be used to identify older persons who are particularly susceptible to poor functional outcomes after major surgery, and a subset may be amenable to intervention, including frailty, low functional self-efficacy, smoking, and obesity., (© 2022 The American Geriatrics Society.)

Importance: Neighborhood disadvantage is a novel social determinant of health that could adversely affect the functional well-being of older persons. Deficiencies in resource-poor environments can potentially be addressed through social and public health interventions., Objective: To evaluate whether estimates of active and disabled life expectancy differ on the basis of neighborhood disadvantage after accounting for individual-level socioeconomic characteristics and other prognostic factors., Design, Setting, and Participants: This prospective longitudinal cohort study included 754 nondisabled community-living persons, aged 70 years or older, who were members of the Precipitating Events Project in south central Connecticut from March 1998 to June 2020., Main Outcomes and Measures: Disability in 4 essential activities of daily living (bathing, dressing, walking, and transferring) was assessed each month. Scores on the Area Deprivation Index, a census-based socioeconomic measure with 17 education, employment, housing quality, and poverty indicators, were obtained through linkages with the 2000 Neighborhood Atlas. Area Deprivation Index scores were dichotomized at the 80th state percentile to distinguish neighborhoods that were disadvantaged (81-100) from those that were not (1-80)., Results: Among the 754 participants, the mean (SD) age was 78.4 (5.3) years, and 487 (64.6%) were female. Within 5-year age increments from 70 to 90, active life expectancy was consistently lower in participants from neighborhoods that were disadvantaged vs not disadvantaged, and these differences persisted and remained statistically significant after adjustment for individual-level race and ethnicity, education, income, and other prognostic factors. At age 70 years, adjusted estimates (95% CI) for active life expectancy (in years) were 12.3 (11.5-13.1) in the disadvantaged group and 14.2 (13.5-14.7) in the nondisadvantaged group. At each age, participants from disadvantaged neighborhoods spent a greater percentage of their projected remaining life disabled, relative to those from nondisadvantaged neighborhoods, with adjusted values (SE) ranging from 17.7 (0.8) vs 15.3 (0.5) at age 70 years to 55.0 (1.7) vs 48.1 (1.3) at age 90 years., Conclusions and Relevance: In this prospective longitudinal cohort study, living in a disadvantaged neighborhood was associated with lower active life expectancy and a greater percentage of projected remaining life with disability. By addressing deficiencies in resource-poor environments, new or expanded social and public health initiatives have the potential to improve the functional well-being of community-living older persons and, in turn, reduce health disparities in the US.

Background/objective: Hospitalizations for ambulatory care sensitive conditions (ACSCs) are considered potentially preventable. With little known about the functional outcomes of older persons after ACSC-related hospitalizations, our objectives were to describe: (1) the 6-month course of postdischarge functional disability, (2) the cumulative monthly probability of functional recovery, and (3) the cumulative monthly probability of incident nursing home (NH) admission., Methods: The analytic sample included 251 ACSC-related hospitalizations from a cohort of 754 nondisabled, community-living persons aged 70 years and older who were interviewed monthly for up to 19 years. Patient-reported disability scores in basic, instrumental, and mobility activities ranged from 0 to 13. Functional recovery was defined as returning within 6 months of discharge to a total disability score less than or equal to that immediately preceding hospitalization., Results: The mean age was 85.1 years, and the mean disability score was 5.4 in the month prior to the ACSC-related hospitalization. After the ACSC-related hospitalization, total disability scores peaked at month 1 and improved modestly over the next 5 months, but remained greater than the pre-hospitalization score. Functional recovery was achieved by 70% of patients, and incident NH admission was experienced by 50% within 6 months after the 251 ACSC-related hospitalizations., Conclusions: During the 6 months after an ACSC-related hospitalization, older persons exhibited total disability scores that were higher than those immediately preceding hospitalization, with 3 of 10 not achieving functional recovery and half experiencing incident NH admission. These findings provide evidence that older persons experience clinically meaningful adverse patient-reported outcomes after ACSC-related hospitalizations.

Objectives: Intervening illnesses and injuries have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after critical illness. We set out to evaluate the functional effects of intervening illnesses and injuries in the year after critical illness., Design: Prospective longitudinal study of 754 nondisabled community-living persons, 70 years old or older., Setting: Greater New Haven, CT, from March 1998 to December 2018., Patients: The analytic sample included 250 ICU admissions from 209 community-living participants who were discharged from the hospital., Interventions: None., Measurements and Main Results: Functional status (13 activities) and exposure to intervening illnesses and injuries leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months. In the year after critical illness, recovery of premorbid function was observed for 169 of the ICU admissions (67.6%), and the mean (sd) number of episodes of functional decline (from 1 mo to the next) was 2.2 (1.6). The adjusted hazard ratios (95% CI) for recovery were 0.18 (0.09-0.39), 0.46 (0.17-1.26), and 0.75 (0.48-1.18) for intervening hospitalizations, emergency department visits, and restricted activity, respectively. For functional decline, the corresponding odds ratios (95% CI) were 2.06 (1.56-2.73), 1.78 (1.12-2.83), and 1.25 (0.92-1.69). The effect sizes for hospitalization and emergency department visit were larger than those for any of the covariates., Conclusions: In the year after critical illness, intervening illnesses and injuries leading to hospitalization and emergency department visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors. To improve functional outcomes, more aggressive efforts will be needed to prevent and manage intervening illnesses and injuries after critical illness., Competing Interests: Dr. Gill is supported by the Yale Claude D. Pepper Older Americans Independence Center (P30AG021342). Dr. Ferrante is supported by a Paul B. Beeson Emerging Leaders in Aging Research Career Development Award from the National Institute on Aging (NIA) (K76AG057023). Drs. Gill’s, Murphy’s, and Ferrante’s institution received funding from the National Institutes of Health (NIH)/NIA. Drs. Gill, Han, Leo-Summers, Murphy, and Ferrante received support for article research from the NIH. Dr. Han’s institution received funding from NIA R01AG017560 and Yale Claude D. Pepper Older Americans Independence Center (P30AG021342). Dr. Gahbauer disclosed that he does not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objective: To evaluate the functional effects of intervening illnesses and injuries, that is, events, in the year after major surgery., Background: Intervening events have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after major surgery., Methods: From a cohort of 754 community-living persons, aged 70+ years, 317 admissions for major surgery were identified from 244 participants who were discharged from the hospital. Functional status (13 activities) and exposure to intervening hospitalizations, emergency department (ED) visits, and restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months., Results: In the year after major surgery, exposure rates (95% CI) per 100-person months to hospitalizations, ED visits, and restricted activity were 10.0 (8.0-12.5), 3.9 (2.8-5.4), and 12.3 (10.2-14.8) for functional recovery and 7.2 (6.1-8.5), 2.5 (1.9-3.2), 11.2 (9.8-12.9) for functional decline. Each of the 3 intervening events were independently associated with reduced recovery, with adjusted hazard ratios (95% CI) of 0.20 (0.09-0.47), 0.35 (0.15-0.81), and 0.57 (0.36-0.90) for hospitalizations, ED visits, and restricted activity. For functional decline, the corresponding odds ratios (95% CI) were 5.68 (3.87-8.33), 1.90 (1.13-3.20), and 1.30 (0.96-1.75). The effect sizes for hospitalizations and ED visits were larger than those for the covariates., Conclusions: Intervening illnesses/injuries are common in the year after major surgery, and those leading to hospitalization and ED visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To describe changes in the occurrence of restricting symptoms at the end of life from 1998 to 2019 and compare these changes according to the condition leading to death., Design: Prospective longitudinal study., Setting: Greater New Haven, CT., Participants: A total of 665 decedents from a cohort of 754 community-living persons, 70 years or older., Measurements: The occurrence of 16 restricting symptoms was ascertained during monthly interviews. Information on the conditions leading to death was obtained from death certificates and comprehensive assessments that were completed every 18-months. For each restricting symptom, adjusted rates (per 100 person-months) were calculated separately for six multiyear time intervals., Results: From 1998 to 2019, rates decreased for five (31.3%) restricting symptoms (difficulty sleeping; chest pain or tightness; shortness of breath; cold or flu symptoms; and nausea, vomiting, or diarrhea), increased for three (18.8%: arm or leg weakness; urinary incontinence; and memory or thinking problem), and changed little for the other eight (50.0%: poor eyesight; anxiety; depression; musculoskeletal pain; fatigue; dizziness or unsteadiness; frequent or painful urination; and swelling in feet or ankles). The decrease in rates was most pronounced for shortness of breath, with a reduction from 15.0 (95% credible interval = 11.7-18.6) in 1998 to 2001 to 8.2 (95% credible interval = 5.9-10.5) in 2014 to 2019, yielding a rate ratio (95% credible interval) of 0.92 (0.86-0.98). When evaluated according to the condition leading to death, the results were similar, with 10 of the 13 statistically significant rate ratios representing decreases in rates over time and only 3 representing increases., Conclusion: The occurrence of most restricting symptoms at the end of life has been decreasing or stable over the past two decades. These results suggest that end-of-life care has been improving, although additional efforts will be needed to further reduce symptom burden at the end of life., (© 2020 The American Geriatrics Society.)

Background: Although disability is often precipitated by an illness/injury, it may arise insidiously. Our objectives were to identify the factors associated with the development of insidious and noninsidious disability and to determine whether these risk factors differ between the two types of disability., Methods: We prospectively evaluated 754 community-living persons, 70+ years, from 1998 to 2016. The unit of analysis was an 18-month person-interval, with risk factors assessed at the start of each interval. Disability in four activities of daily living and exposure to intervening events, defined as illnesses/injuries leading to hospitalization, emergency department visits, or restricted activity, were assessed each month. Insidious and noninsidious disability were defined based on the absence and presence of an intervening event., Results: The rate of noninsidious disability (21.7%) was twice that of insidious disability (10.8%). In multivariable recurrent-event Cox analyses, six factors were associated with both disability outcomes: non-Hispanic white race, lower extremity muscle weakness, poor manual dexterity, and (most strongly) frailty, cognitive impairment, and low functional self-efficacy. Three factors were associated with only noninsidious disability (older age, number of chronic conditions, and depressive symptoms), whereas four were associated with only insidious disability (female sex, lives with others, low SPPB score, and upper extremity weakness). The modest differences in risk factors identified for the two outcomes in multivariable analyses were less apparent in the bivariate analyses., Conclusions: Although arising from different mechanisms, insidious and noninsidious disability share a similar set of risk factors. Interventions to prevent disability should prioritize this shared set of risk factors., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Few prior studies have evaluated recovery after the onset of severe disability or have distinguished between the two subtypes of severe disability., Objectives: To identify the risk factors and intervening illnesses and injuries (i.e., events) that are associated with reduced recovery after episodes of progressive and catastrophic severe disability., Design: Prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older., Setting: Greater New Haven, CT, March 1998 to December 2016., Participants: A total of 431 episodes of severe disability were evaluated from 385 participants: 116 progressive (115 participants) and 315 catastrophic (270 participants)., Measurements: Candidate risk factors were assessed every 18 months. Functional status and exposure to intervening events leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Severe disability was defined as the need for personal assistance with three or more of four essential activities of daily living. Recovery was defined as return to independent function (no disability) within 6 months of developing severe disability., Results: Recovery occurred among 35.3% (95% confidence interval [CI] = 26.0%-48.0%) and 61.6% (95% CI = 53.5%-70.9%) of the 116 progressive and 315 catastrophic severe disability episodes, respectively. In the multivariable analyses, lives alone, frailty, and intervening hospitalization were each independently associated with reduced recovery from progressive disability, with adjusted hazard ratios (95% CIs) of 0.31 (0.15-0.64), 0.23 (0.12-0.45), and 0.27 (0.08-0.95), respectively, whereas low functional self-efficacy, intervening restricted activity, and intervening hospitalization were each independently associated with reduced recovery from catastrophic disability, with adjusted hazard ratios (95% CIs) of 0.56 (0.40-0.81), 0.55 (0.35-0.85), and 0.45 (0.31-0.66), respectively., Conclusions: Recovery of independent function is considerably more likely after the onset of catastrophic than progressive severe disability, the risk factors for reduced recovery differ between progressive and catastrophic severe disability, and subsequent exposure to intervening illnesses and injuries considerably diminishes the likelihood of recovery from both subtypes of severe disability., (© 2020 The American Geriatrics Society.)

Objective: The objectives of the current study were 2-fold: first, to evaluate the incidence and time to recovery of premorbid function within 6 months of major surgery and second, to identify factors associated with functional recovery among older persons who survive a major surgery with increased disability., Background: Most older persons would not choose a surgical treatment resulting in persistently increased postsurgical disability, even if survival was assured. Potential predictors of functional recovery after major surgery have, however, not been well-studied among geriatric patients., Methods: It is a prospective longitudinal study of 754 community-living persons 70 years or older. The analytic sample included 266 person-admissions in which participants survived major surgery with increased disability and were monitored on a monthly basis for 6 months., Results: Of the 266 person-admissions assessed, 174 (65.4%) recovered to their presurgical level of function, with median time to recovery of 2 months (interquartile range, 1-3), whereas 16 (6.0%) died. Two factors were significantly associated with an increased likelihood of functional recovery: being nonfrail (hazard ratio 1.60; 95% confidence interval 1.03-2.51; P = 0.038) and having elective surgery (hazard ratio 1.72; 95% confidence interval 1.14-2.59; P = 0.009). Three factors were associated with a reduced likelihood of functional recovery: hearing impairment, greater increase in postsurgical disability in the month after hospital discharge, and years of education., Conclusions: Among older persons, nonfrailty and elective surgery were positively associated with functional recovery, whereas hearing impairment, greater increases in postsurgical disability, and years of education were associated with higher risk of protracted disability.

Importance: Severe disability greatly diminishes quality of life and often leads to a protracted period of long-term care or death, yet the processes underlying severe disability have not been fully evaluated., Objective: To evaluate potential risk factors and precipitants associated with severe disability that develops progressively (during ≥2 months) vs catastrophically (from 1 month to the next)., Design, Setting, and Participants: Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2016, with 754 nondisabled community-living persons aged 70 years or older. Data analysis was conducted from November 2018 to May 2019., Main Outcomes and Measures: Candidate risk factors were assessed every 18 months. Functional status and potential precipitants, including illnesses or injuries leading to hospitalization, emergency department visit, or restricted activity, were assessed each month. Severe disability was defined as the need for personal assistance with at least 3 of 4 essential activities of daily living. The analysis was based on person-months within 18-month intervals., Results: The mean (SD) age for the 754 participants was 78.4 (5.3) years, 487 (64.6%) were women, and 683 (90.5%) were non-Hispanic white participants. The incidence of progressive and catastrophic severe disability was 3.5% and 9.7%, respectively, based on 3550 intervals. In multivariable analysis, 6 risk factors were independently associated with progressive disability (≥85 years: hazard ratio [HR], 1.6; 95% CI, 1.1-2.4; hearing impairment: HR, 1.7; 95% CI, 1.0-2.8; frailty: HR, 2.4; 95% CI, 1.6-3.7; cognitive impairment: HR, 2.0; 95% CI, 1.3-3.1; low functional self-efficacy: HR, 1.8; 95% CI, 1.2-2.8; low peak flow: HR, 1.7; 95% CI, 1.2-2.4), and 4 were independently associated with catastrophic disability (visual impairment: HR, 1.4; 95% CI, 1.1-1.8; hearing impairment: HR, 1.3; 95% CI, 1.0-1.7; poor physical performance: HR, 1.8; 95% CI, 1.3-2.5; low peak flow: HR, 1.3; 95% CI, 1.0-1.7). The associations of the precipitants were much more pronounced than those of the risk factors, with HRs as high as 321.4 (95% CI, 194.5-531.0) for hospitalization and catastrophic disability and 48.3 (95% CI, 31.0%-75.4%) for hospitalization and progressive disability. Elimination of an intervening hospitalization was associated with a decrease in the risk of progressive and catastrophic severe disability of 3.0% (95% CI, 3.0%-3.1%) and 12.3% (95% CI, 12.1%-12.5%), respectively. Risk differences were 0.6% (95% CI, 0.6%-0.6%) and 1.3% (95% CI, 1.3%-1.4%) for emergency department visit and 0.1% (95% CI, 0.1%-0.2%) and 0.4% (95% CI, 0.4%-0.4%) for restricted activity, and ranged from 0.1% (95% CI, 0.1%-0.1%) to 0.3% (95% CI, 0.3%-0.3%) for the independent risk factors, for progressive and catastrophic disability, respectively., Conclusions and Relevance: The findings of this study suggest that whether it develops progressively or catastrophically, severe disability among older community-living adults arises most commonly in the setting of an intervening illness or injury. To reduce the burden of severe disability, more aggressive efforts will be needed to prevent and manage intervening illnesses or injuries and to facilitate recovery after these debilitating events.

Objectives: To determine for each basic, instrumental, and mobility activity after hospitalization for acute medical illness: (1) disability prevalence immediately before and monthly for 6 months after hospitalization; (2) disability incidence 1 month after hospitalization; and (3) recovery time from incident disability during months 2 to 6 after hospitalization., Design: Prospective cohort study., Setting: New Haven, Connecticut., Participants: A total of 515 community-living persons, mean age 82.7 years, hospitalized for acute noncritical medical illness and alive within 1 month of hospital discharge., Measurements: Disability was defined monthly for each basic (bathing, dressing, walking, transferring), instrumental (shopping, housework, meal preparation, taking medications, managing finances), and mobility activity (walking a quarter mile, climbing flight of stairs, lifting/carrying 10 pounds, driving) if help was needed to perform the activity or if a car was not driven in the prior month., Results: Disability was common 1 and 6 months after hospitalization for activities frequently involved in leaving the home to access care including walking a quarter mile (prevalence 65% and 53%, respectively) and driving (65% and 61%). Disability was also common for activities involved in self-managing chronic health conditions including meal preparation (53% and 41%) and taking medications (41% and 31%). New disability was common and often prolonged. For example, 43% had new disability walking a quarter mile, and 30% had new disability taking medications, with mean recovery time of 1.9 months and 1.7 months, respectively. Findings were similar for the subgroup of persons residing at home (ie, not in a nursing home) at the first monthly follow-up interview after hospitalization., Conclusion: Disability in specific functional activities important to leaving home to access care and self-managing health conditions is common, often new, and present for prolonged time periods after hospitalization for acute medical illness. Post-discharge care should support patients through extended periods of vulnerability beyond the immediate transitional period. J Am Geriatr Soc 68:486-495, 2020., (© 2020 The American Geriatrics Society.)

The Precipitating Events Project (PEP Study) is an ongoing longitudinal study of 754 nondisabled community-living persons age 70 years or older who were members of a large health plan in greater New Haven, Connecticut, USA. The study was established to rigorously evaluate the epidemiology of disability in older persons and to elucidate the role of intervening illnesses and injuries on the disabling process. Of the eligible members, 75.2% agreed to participate and were enrolled between March 1998 and October 1999. Participants have completed comprehensive home-based assessments at 18-month intervals and have been interviewed monthly over the phone with a completion rate of 99%. Detailed participant-level data on health care utilization are obtained annually through linkages with Medicare claims. Through June 2019, 702 (93.1%) participants have died after a median of 109 months, while 43 (5.7%) have dropped out of the study after a median of 27 months. Death certificates are available for all decedents. To date, 117 original reports have been published using data from the PEP Study, including many focusing on other high priority areas such as end of life, frailty, depressive symptoms, aging stereotypes, pain, sleep, and methodologic research. The PEP Study welcomes proposals to access data for meritorious analyses from qualified investigators., Competing Interests: The authors have no conflict of interest.

Objectives: To evaluate the time course of "taking to bed" at the end of life and determine whether it differs according to age, sex, and condition leading to death., Design: Prospective longitudinal study., Setting: Greater New Haven, Connecticut., Participants: A total of 651 decedents from a cohort of 754 community-living persons, 70+ years of age., Measurements: During the last 2 years of life, the occurrence of bed rest and number of days in bed, two indicators of bed rest burden, were ascertained each month. Bed rest was defined as staying in bed for at least a half day due to an illness, injury, or other problem., Results: The occurrence of bed rest increased modestly from 12.4% at 24 months before death to 19.0% at 5 months before death, before increasing exponentially to 51.6% at 1 month before death. The median number of days in bed fluctuated within a narrow range of 3 to 7 from 24 months to 4 months before death, before increasing substantially to a high of 14 at 1 month before death. In the last 2 years of life, the burden of bed rest did not differ by age but was significantly greater in women than men. Among the conditions leading to death, the burden of bed rest was highest among persons dying from organ failure and cancer, lowest for sudden death, and intermediate for frailty, advanced dementia, and other conditions., Conclusion: The burden of bed rest at the end of life is greater in women than men, does not differ by age, and is highest among persons dying from organ failure and cancer. The steep increases observed in the last 3 to 5 months of life suggest that taking to bed may be an indicator that death is approaching and should prompt discussions about referral to hospice among older persons with serious illness., (© 2019 The American Geriatrics Society.)

Background: Days spent at home has recently been identified as an important patient-centered outcome; yet, relatively little is known about time spent at home at the end of life among community-living older persons., Methods: The analytic sample included 457 decedents from an ongoing cohort study of 754 community-living persons, aged ≥70 years. Days spent at home were calculated as 180 days minus the number of days in a hospital, nursing home, or hospice facility. The condition leading to death was determined from death certificates and comprehensive assessments., Results: The median number of days at home was 159 (interquartile range 125-174). There were 138 (30.2%) decedents at home during the entire 6-month period, while 163 (35.7%) were at home for fewer than 150 days. Days at home did not differ significantly by age (P = .922), sex (P = .238), or race/ethnicity (P = .199), but did differ according to the condition leading to death (P = .001), with the lowest value observed for organ failure (150 [106.5-168.5]), highest values for sudden death (177 [172-179]) and cancer (167 [140-174]), and intermediate values for advanced dementia (164 [118-174]), frailty (160.5 [130-174]), and other conditions (153 [118-175])., Conclusions: Among community-living older persons, days spent at home in the last 6 months of life do not differ by age, sex, or race/ethnicity, but are significantly lower for persons dying from organ failure. Additional efforts may be warranted to optimize time spent at home at the end of life, especially among older persons dying from organ failure., (Copyright © 2018. Published by Elsevier Inc.)

Objectives: To address the competing risk of death in longitudinal studies of older persons, we demonstrate sensitivity analyses that evaluate robustness of associations between exposures and three outcome types: dichotomous, count, and time to event., Design: A secondary analysis of data from a prospective cohort study., Setting: Community-based data from the Precipitating Events Project in New Haven, CT., Participants: Persons 70 years and older who were initially community dwelling and without disability in the four basic activities of daily living (N = 754)., Measurements: Missing outcome values from decedents were multiply imputed under different scenarios. Three outcomes were examined: dichotomous fall-related hospitalization (FRH); a count (0-13) of total disability in each of the 6 months after discharge; and days to functional recovery among those whose disability worsened in the hospital. Each outcome had a different exposure: for dichotomous, indicators of being overweight or obese; for count, frailty from the Fried phenotype (0-5, where not frail = 0, prefrail = 1-2, and frail = 3-5); for days to recovery, vision impairment., Results: For FRH, being overweight or obese lost significance when decedents were kept in the risk pool without outcome events for over 10 years. For disability count and time to recovery, with follow-up of 6 months, exposures only lost significance under highly implausible clinical scenarios., Conclusion: This method facilitates evaluation of potential bias from the competing risk of death in longitudinal studies for nondeath outcomes that are not necessarily time to event. Results suggest that death introduces substantive bias when long-term follow-up results in cumulatively high levels of mortality. J Am Geriatr Soc 67:357-362, 2019., (© 2018 The American Geriatrics Society.)

Objectives: We hypothesized that distinct sets of functional trajectories can be identified in the year before and after major surgery, with unique transition probabilities from pre to postsurgical functional trajectories, and that outcomes would be better among participants undergoing elective versus nonelective surgery., Background: Major surgery is common and can be highly morbid in older persons. The relationship between the course of disability (ie, functional trajectory) before and after surgery in older adults has not been well-studied for most operations., Methods: Prospective cohort study of 754 community-living persons 70 years or older. The analytic sample included 250 participants who underwent their first major surgery during the study period., Results: Before surgery, 4 functional trajectories were identified: no disability (n = 60, 24.0%), and mild (n = 84, 33.6%), moderate (n = 73, 29.2%), and severe (n = 33, 13.2%) disability. After surgery, 4 functional trajectories were identified: rapid (n = 39, 15.6%), gradual (n = 76, 30.4%), partial (n = 70, 28.0%), and little (n = 57, 22.8%) improvement. Rapid improvement was seen for n = 31 (51.7%) participants with no disability before surgery, but was uncommon among those with mild disability (n = 8, 9.5%) and was not observed in the moderate and severe trajectory groups. For participants with mild to moderate disability before surgery, gradual improvement (n = 46, 54.8%) and partial improvement (n = 36, 49.3%) were most common. Most participants with severe disability (n = 27, 81.8%) before surgery exhibited little improvement. Outcomes were better for participants undergoing elective versus nonelective surgery., Conclusions: Functional prognosis in the year after major surgery is highly dependent on premorbid function.

Objectives: To compare rates of restricted activity and associated symptoms and problems in the last 6 months of life with those in the period before the last 6 months of life., Design: Prospective cohort study., Setting: Greater New Haven, Connecticut., Participants: Community-living persons aged 70 and older (N=754)., Measurements: The occurrence of restricted activity (staying in bed for at least half the day or cutting down on usual activities) and 24 prespecified symptoms and problems leading to restricted activity was ascertained monthly for nearly 19 years., Results: Rates of restricted activity per 100 person-months were 36.5 in the last 6 months of life versus 16.1 in the period before the last 6 months of life (P<.001). Of 737 participants with 1 month or more of restricted activity, rates of restricting symptoms per 100 person-months of restricted activity ranged from 8.0 for frequent or painful urination to 65.6 for been fatigued, and rates of restricting problems ranged from 0.1 for problem with alcohol to 23.4 for been afraid of falling. Rates were significantly higher in the last 6 months of life than in the prior period for 13 of the 24 restricting symptoms and problems (P<.05), most notably for shortness of breath (38.6 vs 21.8), weakness (37.3 vs 18.9), and confusion (31.2 vs 9.8). Mean (standard error) number of restricting symptoms and problems was significantly higher in the last 6 months of life (6.1 (0.1)) than in the prior period (4.7 (0.03)) (P<.001)., Conclusion: Rates of restricted activity and associated symptoms and problems are substantially greater in the last 6 months of life than in the period before the last 6 months of life. Enhanced palliative care strategies may be needed to diminish the burden of distressing symptoms and problems at the end of life. J Am Geriatr Soc 66:2282-2288, 2018., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objectives: To evaluate the prognostic effect of changes in physical function at different intervals over the prior year on subsequent outcomes after accounting for present function., Design: Prospective longitudinal study., Setting: Greater New Haven, Connecticut, from March 1998 to January 2006., Participants: Community-living persons aged 71 and older who completed an 18-month comprehensive assessment (N=658)., Measurements: Disability in 13 activities of daily living, instrumental activities of daily living, and mobility activities was assessed at the 18-month comprehensive assessment and at 12, 6, and 3 months before 18 months. Time to death and long-term nursing home admission, defined as 3 months and longer, were ascertained for up to 5 years after 18 months., Results: In the bivariate models, disability at 18 months and change in disability between 18 months and each of the 3 prior time-points (12, 6, 3 months) were significantly associated with time to death. The risk of death, for example, increased by 24% for each 1-point increase in 18-month disability score (on a scale from 0 to 13) and by 22% for each 1-point change in disability score between 18 months and prior 12 months (on a scale from -13 to 13). In a set of multivariable models with and without covariates, the associations were maintained for 18-month disability but not for change in disability between 18 months and each of the 3 prior time-points. The results were comparable for time to long-term nursing home admission except that 2 of the associations were not statistically significant., Conclusion: When evaluating risk of adverse outcomes, such as death and long-term nursing home admission, an assessment of change in physical function at different intervals over the prior year, although a strong bivariate predictor, did not provide useful prognostic information beyond that available from current level of function., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Background: Frailty is a strong indicator of vulnerability among older persons, but its association with ICU outcomes has not been evaluated prospectively (ie, with objective measurements obtained prior to ICU admission). Our objective was to prospectively evaluate the relationship between frailty and post-ICU disability, incident nursing home admission, and death., Methods: The parent cohort included 754 adults aged ≥ 70 years, who were evaluated monthly for disability in 13 functional activities and every 18 months for frailty (1998-2014). Frailty was assessed using the Fried index, where frailty, prefrailty, and nonfrailty were defined, respectively, as at least three, one or two, and zero criteria (of five). The analytic sample included 391 ICU admissions., Results: The mean age was 84.0 years. Frailty and prefrailty were present prior to 213 (54.5%) and 140 (35.8%) of the 391 admissions, respectively. Relative to nonfrailty, frailty was associated with 41% greater disability over the 6 months following a critical illness (adjusted risk ratio, 1.41; 95% CI, 1.12-1.78); prefrailty conferred 28% greater disability (adjusted risk ratio, 1.28; 95% CI, 1.01-1.63). Frailty (odds ratio, 3.52; 95% CI, 1.23-10.08), but not prefrailty (odds ratio, 2.01; 95% CI, 0.77-5.24), was associated with increased nursing home admission. Each one-point increase in frailty count (range, 0-5) was associated with double the likelihood of death (hazard ratio, 2.00; 95% CI, 1.33-3.00) through 6 months of follow-up., Conclusions: Pre-ICU frailty status was associated with increased post-ICU disability and new nursing home admission among ICU survivors, and death among all admissions. Pre-ICU frailty status may provide prognostic information about outcomes after a critical illness., (Copyright © 2018 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Rationale: Cognitive impairment is common among older adults, yet little is known about the association of pre-intensive care unit cognitive status with outcomes relevant to older adults maintaining independence after a critical illness., Objectives: To evaluate whether pre-intensive care unit cognitive status is associated with post-intensive care unit disability, new nursing home admission, and mortality after a critical illness among older adults., Methods: In this prospective cohort study, 754 persons aged 70 years or more were monitored from March 1998 to December 2013 with monthly assessments of disability. Cognitive status was assessed every 18 months, using the Mini-Mental State Examination (range, 0-30), with scores classified as 28 or higher (cognitively intact), 24-27 (minimal impairment), and less than 24 (moderate impairment). The primary outcome was disability count (range, 0-13), assessed monthly over 6 months after an intensive care unit stay. The secondary outcomes were incident nursing home admission and time to death after intensive care unit admission. The analytic sample included 391 intensive care unit admissions., Results: The mean age was 83.5 years. The prevalence of moderate impairment, minimal impairment, and intact cognition (the comparison group) was 17.3, 46.2, and 36.5%, respectively. In the multivariable analysis, moderate impairment was associated with nearly a 20% increase in disability over the 6-month follow-up period (adjusted relative risk, 1.19; 95% confidence interval, 1.04-1.36), and minimal impairment was associated with a 16% increase in post-intensive care unit disability (adjusted relative risk, 1.16; 95% confidence interval, 1.02-1.32). Moderate impairment was associated with more than double the likelihood of a new nursing home admission (adjusted odds ratio, 2.37; 95% confidence interval, 1.01-5.55). Survival differed significantly across the three cognitive groups (log-rank P = 0.002), but neither moderate impairment (adjusted hazard ratio, 1.19; 95% confidence interval, 0.65-2.19) nor minimal impairment (adjusted hazard ratio, 1.00; 95% confidence interval, 0.61-1.62) was significantly associated with mortality in the multivariable analysis., Conclusions: Among older adults, any impairment (even minimal) in pre-intensive care unit cognitive status was associated with an increase in post-intensive care unit disability over the 6 months after a critical illness; moderate cognitive impairment doubled the likelihood of a new nursing home admission. Pre-intensive care unit cognitive impairment was not associated with mortality from intensive care unit admission through 6 months of follow-up. Pre-intensive care unit cognitive status may provide prognostic information about the likelihood of older adults maintaining independence after a critical illness.

Objectives: To evaluate joint trajectories of cognition and frailty and their association with the cumulative burden of patient-reported outcomes, including hospitalization, nursing home admission, and disability., Design: Longitudinal study of 754 community-living persons aged 70 or older., Participants: 690 participants who had a baseline and at least one follow-up assessment of cognition and frailty between 1998 and 2009., Measurements: Cognition was assessed using the Mini-Mental State Examination (MMSE). Frailty was defined by the 5 criteria for the Fried phenotype: muscle weakness, exhaustion, low physical activity, shrinking, and slow walking speed. A group-based, mixture modeling approach was used to fit the joint trajectories of cognition and frailty. The cumulative burden of hospitalization, nursing home admission, and disability over 141 months associated with the joint trajectories was evaluated using a series of generalized estimating equation Poisson models., Results: Four joint trajectories were identified, including No cognitive frailty (27.8%), Slow cognitive decline and progressive frailty (45.5%), Rapid cognitive decline and progressive frailty (20.2%), and Cognitive frailty (6.5%). For each joint trajectory group, the interval-specific incidence density rates of all patient-reported outcomes tended to increase over time, with the exception of hospitalization for which the increasing trend was apparent only for the Slow cognitive decline and progressive frailty group. The No cognitive frailty group had the lowest cumulative burden of all patient-reported outcomes [eg, nursing home admissions, 7.5/1000 person-months, 95% confidence interval (CI): 4.8-11.7], whereas the Cognitive frailty group had the highest cumulative burden (eg, nursing home admissions, 381.1/1000 person-months, 95% CI: 294.5-493.1), with the exception of hospitalization. Compared with the No cognitive frailty group, the 3 other joint trajectory groups all had significantly greater burden of the patient-reported outcomes., Conclusion: Community-living older persons exhibit distinct joint trajectories of cognition and frailty and experience an increasing burden of nursing home admission and disability as they age, with the greatest burden for those on a cognitive frailty trajectory., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the relationship between the presence and number of restricting symptoms and number of disabilities and subsequent admission to hospice at the end of life., Design: Prospective cohort study., Setting: Greater New Haven, Connecticut, from March 1998 to December 2014., Participants: Decedents from a cohort of 754 persons aged 70 and older (N = 562)., Measurements: Hospice admissions were identified primarily from Medicare claims, and 15 restricting symptoms and disability in 13 activities were assessed during monthly interviews., Results: During their last year of life, 244 (43.4%) participants were admitted to hospice. The median duration of hospice was 12.5 days (interquartile range 4-43 days). Although the largest increases were observed in the last 2 months of life, the prevalence of restricting symptoms and mean number of restricting symptoms and disabilities in the preceding months were high and trending upward. During a specific month, the likelihood of hospice admission increased by 66% (adjusted hazard ratio (aHR) = 1.66, 95% confidence interval (CI) = 1.30-2.12) in the setting of any restricting symptoms, by 9% (aHR = 1.09, 95% CI = 1.05-1.12) for each additional restricting symptom, and by 10% (aHR = 1.10, 95% CI = 1.05-1.14) for each additional disability. Each additional month with any restricting symptoms increased the likelihood of hospice admission by 7% (aHR = 1.07, 95% CI = 1.01-1.13)., Conclusion: Hospice services appear to be suitably targeted to older persons with the greatest needs at the end of life, although the short duration of hospice suggests that additional strategies are needed to better address the high burden of distressing symptoms and disability at the end of life., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Objectives: To evaluate the association between the type of acute hospitalization and subsequent course of disability in older persons discharged to a skilled nursing facility (SNF)., Design: Longitudinal study of 754 community-living persons aged 70 or older., Participants: The analytical sample included 365 participants who had one or more admissions to a SNF after an acute hospitalization (n=520 index admissions)., Measurements: Information on hospitalizations, SNF admissions, and disability was ascertained over 15years. The primary and secondary outcomes were disability burden and recovery of pre-hospital function, respectively, assessed monthly over a 6-month period. Index admissions were classified into four mutually exclusive groups based on the type of hospitalization: elective major surgery, non-elective major surgery, critical illness, and other., Results: Disability worsened considerably after hospitalization for each of the four groups. Relative to elective major surgery, the disability burden over 6months was significantly greater for non-elective major surgery, critical illness, and other hospitalizations, with adjusted rate ratios (RRs) of 1.37 (95% CI 1.19 to 1.59), 1.37 (95% CI 1.19 to 1.58), and 1.29 (95% CI 1.14 to 1.47), respectively. Overall, recovery to pre-hospital function was observed in only 132 (25.4%) admissions. Relative to elective major surgery, the likelihood of recovering pre-hospital function was considerably lower for each of the three other groups. The results were consistent for basic, instrumental and mobility activities., Conclusion: Among older persons discharged to a SNF after an acute hospitalization, the functional course over 6months was generally poor, with recovery to pre-hospital function observed in only one out of every four cases. Relative to elective major surgery, functional outcomes were worse for non-elective major surgery, critical illness, and other hospitalizations., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Rationale: Most of the 1.4 million older adults who survive the intensive care unit (ICU) annually in the United States face increased disability, but little is known about those who achieve functional recovery., Objectives: Our objectives were twofold: to evaluate the incidence and time to recovery of premorbid function within 6 months of a critical illness and to identify independent predictors of functional recovery among older ICU survivors., Methods: Potential participants included 754 persons aged 70 years or older who were evaluated monthly in 13 functional activities (1998-2012). The analytic sample included 218 ICU admissions from 186 ICU survivors. Functional recovery was defined as returning to a disability count less than or equal to the pre-ICU disability count within 6 months. Twenty-one potential predictors were evaluated for their associations with recovery., Measurements and Main Results: Functional recovery was observed for 114 (52.3%) of the 218 admissions. In multivariable analysis, higher body mass index (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.03-1.12) and greater functional self-efficacy (HR, 1.05; 95% CI, 1.02-1.08), a measure of confidence in performing various activities, were associated with recovery, whereas pre-ICU impairment in hearing (HR, 0.38; 95% CI, 0.22-0.66) and vision (HR, 0.59; 95% CI, 0.37-0.95) were associated with a lack of recovery., Conclusions: Among older adults who survived an ICU admission with increased disability, pre-ICU hearing and vision impairment were strongly associated with poor functional recovery within 6 months, whereas higher body mass index and functional self-efficacy were associated with recovery. Future research is needed to evaluate whether interventions targeting these factors improve functional outcomes among older ICU survivors.

Background: Despite documented age-related declines in self-reported functional status and measured physical capacity, it is unclear whether these functional indicators follow similar trajectories over time or whether the patterns of change differ by sex., Methods: We used longitudinal data from 687 initially nondisabled adults, aged 70 or older, from the Precipitating Events Project, who were evaluated every 18 months for nearly 14 years. Self-reported disability was assessed with a 12-item disability scale. Physical capacity was measured using grip strength and a modified version of Short Physical Performance Battery. Hierarchical linear models estimated the intra-individual trajectory of each functional indicator and differences in trajectories' intercept and slope by sex., Results: Self-reported disability, grip strength, and Short Physical Performance Battery score declined over 13.5 years following nonlinear trajectories. Women experienced faster accumulation of self-reported disability, but slower declines in measured physical capacity, compared with men. Trajectory intercepts revealed that women had significantly weaker grip strength and reported higher levels of disability compared with men, with no differences in starting Short Physical Performance Battery scores. These findings were robust to adjustments for differences in sociodemographic characteristics, length-of-survival, health risk factors, and chronic-disease status., Conclusions: Despite the female disadvantage in self-reported disability, older women preserve measured physical capacity better than men over time. Self-reported and measured indicators should be viewed as complementary rather than interchangeable assessments of functional status for both clinical and research purposes, especially for sex-specific comparisons., (© The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Prior work has shown that symptoms leading to restrictions in daily activities are common at the end of life. Hospice is a Medicare benefit designed to alleviate distressing symptoms in the last 6 months of life. The effect of hospice on the burden of such symptoms is uncertain., Methods: From an ongoing cohort study of 754 community-dwelling older persons, aged ≥70 years, we evaluated 241 participants who were admitted to hospice from March 1998 to December 2013. A set of 15 physical and psychological symptoms leading to restricted activity (ie, cut down on usual activities or spend at least half the day in bed) were ascertained during monthly telephone interviews in the year before and 3 months after hospice admission., Results: The prevalence and mean number of restricting symptoms increased progressively until about 2 months before hospice admission, before increasing precipitously to a peak around the time of hospice admission. After the start of hospice, both the prevalence and the mean number of restricting symptoms dropped markedly. For several symptoms deemed most amenable to hospice treatment, including depression and anxiety, the prevalence dropped to levels comparable to or lower than those observed 12 months before the start of hospice. The trends observed in symptom prevalence and mean number of symptoms before and after hospice did not differ appreciably according to hospice admission diagnosis or sex. The median duration of hospice (before death) was only 15 days., Conclusion: The burden of restricting symptoms increases progressively several months before the start of hospice, peaks around the time of hospice admission, and decreases substantially after the start of hospice. These results, coupled with the short duration of hospice, suggest that earlier referral to hospice may help to alleviate the burden of distressing symptoms at the end of life., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To identify distinct sets of disability trajectories in the year before and after a Medicare qualifying skilled nursing facility (Q-SNF) admission, evaluate the associations between the pre-and post-Q-SNF disability trajectories, and determine short-term outcomes (readmission, mortality)., Design, Setting, and Participants: Prospective cohort study including 754 community-dwelling older persons, 70+ years, and initially nondisabled in their basic activities of daily living. The analytic sample included 394 persons, with a first hospitalization followed by a Q-SNF admission between 1998 and 2012., Main Outcomes and Measures: Disability in the year before and after a Q-SNF admission using 13 basic, instrumental, and mobility activities. Secondary outcomes included 30-day readmission and 12-month mortality., Results: The mean (SD) age of the sample was 84.9 (5.5) years. We identified 3 disability trajectories in the year before a Q-SNF admission: minimal disability (37.3% of participants), mild disability (44.6%), and moderate disability (18.2%). In the year after a Q-SNF admission, all participants started with moderate to severe disability scores. Three disability trajectories were identified: substantial improvement (26.0% of participants), minimal improvement (36.5%), and no improvement (37.5%). Among participants with minimal disability pre-Q-SNF, 52% demonstrated substantial improvement; the other 48% demonstrated minimal improvement (32%) or no improvement (16%) and remained moderately to severely disabled in the year post-Q-SNF. Among participants with mild disability pre-Q-SNF, 5% showed substantial improvement, whereas 95% showed little to no improvement. Of participants with moderate disability pre-Q-SNF, 15% remained moderately disabled showing little improvement, whereas 85% showed no improvement. Participants who transitioned from minimal disability pre-Q-SNF to no improvement post-Q-SNF had the highest rates of 30-day readmission and 12-month mortality (rate/100 person-days 1.3 [95% CI 0.6-2.8] and 0.3 [95% CI 0.15-0.45], respectively)., Conclusions: Among older persons, distinct disability trajectories were observed in the year before and after a Q-SNF admission. The likelihood of improvement in disability was greatly constrained by the pre-Q-SNF disability trajectory. Most older persons remained moderately to severely disabled in the year following a Q-SNF admission., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate relationships between age, clinical characteristics, and breathlessness sufficient to have people spend at least half a day a month in bed or to cut down on their usual activities (restricting breathlessness) during the last year of life., Design: Secondary data analysis., Setting: General community., Participants: Nondisabled persons aged 70 and older (N=754)., Measurements: Monthly telephone interviews were conducted to determine the occurrence of restricting breathlessness. The primary outcome was percentage of months with restricting breathlessness reported during the last year of life., Results: Data regarding breathlessness were available for 548 of 589 (93.0%) participants who died (mean age 86.7, range 71-106; 38.8% male) between enrollment (March 1998 to October 1999) and June 2013; 311 of these (56.8%) reported restricting breathlessness at some point during the last year of life, but none reported it every month. Frequency increased in the months closer to death, irrespective of cause. Restricting breathlessness was associated with anxiety (0.25 percentage points greater in months with breathlessness per percentage point months reported anxiety, 95% confidence interval (CI)=0.16-0.34, P<.001), depression (0.14, 95% CI=0.05-0.24, P=.003), and mobility problems (0.07, 0.03-0.1, P<.001). Percentage months of restricting breathlessness was greater if chronic lung disease was noted at the most-recent comprehensive assessment (6.62 percentage points, 95% CI=4.31-8.94, P<.001), heart failure (3.34 percentage points, 95% CI=0.71-5.97, P=.01), and ex-smoker status (3.01 percentage points, 95% CI=0.94-5.07, P=.004) but decreased with older age (-0.19 percentage points, 95% CI=-0.37 to -0.02, P=.03)., Conclusion: Restricting breathlessness increased in this elderly population in the months preceding death from any cause. Breathlessness should be assessed and managed in the context of poor prognosis., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Background: Increasing evidence suggests that illnesses and injuries leading to restricted activity have adverse functional consequences, but whether the two components of restricted activity have comparable effects is unknown. We evaluated whether an illness/injury leading to bed rest represents a more potent exposure than one leading to cutting down on one's usual activities without bed rest., Methods: We prospectively evaluated 754 community-living persons, 70+ years. Telephone interviews were completed monthly for >15 years to assess disability in four basic, five instrumental, and four mobility activities and to ascertain exposure to illnesses/injuries leading to cut down activities and bed rest, respectively. For each of the three functional domains, transitions between no disability, mild disability, and severe disability were evaluated each month., Results: For each domain, cut down activities and bed rest were significantly associated with at least one transition. The associations were consistently stronger, however, for bed rest than for cut down activities. Bed rest was a particularly potent exposure for transitions from no disability to severe disability, with hazard ratios as high as 8.94 (95% CI, 5.69-14.1) for the mobility activities, and for all transitions from severe disability (representing recovery), with hazard ratios as low as 0.25 (0.12-0.54) for the transition to no disability for the basic activities., Conclusions: In the setting of an illness/injury, bed rest was more strongly associated with a set of clinically meaningful transitions in functional status than cut down activities. Prompt medical attention may be warranted when an older person takes to bed because of an illness/injury., (© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To evaluate the role of intervening hospital admissions on trajectories of disability in the last year of life., Design: Prospective cohort study., Setting: Greater New Haven, Connecticut, United States, from March 1998 to June 2013., Participants: 552 decedents from a cohort of 754 community living people, aged 70 years or older, who were initially non-disabled in four essential activities of daily living: bathing, dressing, walking, and transferring., Main Outcome Measure: Occurrence of admissions to hospital and severity of disability (range 0-4), ascertained during monthly interviews for more than 15 years., Results: In the last year of life, six distinct trajectories of disability were identified, from least disabled to most disabled: 95 participants (17.2%) had no disability, 61 (11.1%) had catastrophic disability, 53 (9.6%) had accelerated disability, 61 (11.1%) had progressively mild disability, 127 (23.0%) had progressively severe disability, and 155 (28.1%) had persistently severe disability. 392 (71.0%) participants had at least one hospital admission and 248 (44.9%) had multiple hospital admissions. For each trajectory the course of disability closely tracked the monthly prevalence of hospital admission. In a set of multivariable models that included several potential confounders, hospital admission in a given month had a strong independent effect on the severity of disability, in both relative and absolute terms. The largest absolute effect was observed for catastrophic disability, with a mean increase in disability score of 1.9 (95% confidence interval 1.5 to 2.4) in the setting of a hospital admission, corresponding to a rate ratio (or relative effect) of 2.0 (95% confidence interval 1.5 to 2.7)., Conclusions: In the last year of life, acute hospital admissions play an important role in the disabling process. Knowledge about the course of disability before these intervening events may facilitate clinical decision making at the end of life. For older patients admitted to hospital with progressive or persistent levels of severe disability, representing more than half of the decedents, clinicians might consider a palliative care approach to facilitate discussions about advance care planning and to better deal with personal care needs., (© Gill et al 2015.)

Importance: Little is known about functional trajectories of older persons in the year before and after admission to the intensive care unit (ICU) or how pre-ICU functional trajectories affect post-ICU functional trajectories and death., Objectives: To characterize functional trajectories in the year before and after ICU admission and to evaluate the associations among pre-ICU functional trajectories and post-ICU functional trajectories, short-term mortality, and long-term mortality., Design, Setting, and Participants: Prospective cohort study of 754 community-dwelling persons 70 years or older, conducted between March 23, 1998, and December 31, 2012, in greater New Haven, Connecticut. The analytic sample included 291 participants who had at least 1 admission to an ICU through December 2011., Main Outcomes and Measures: Functional trajectories in the year before and after an ICU admission based on 13 basic, instrumental, and mobility activities. Additional outcomes included short-term (30 day) and long-term (1 year) mortality., Results: The mean (SD) age of participants was 83.7 (5.5) years. Three distinct pre-ICU functional trajectories identified were minimal disability (29.6%), mild to moderate disability (44.0%), and severe disability (26.5%). Seventy participants (24.1%) experienced early death, defined as death in the hospital (50 participants [17.2%]) or death after hospital discharge but within 30 days of admission (20 participants [6.9%]). Among the remaining 221 participants, 3 distinct post-ICU functional trajectories identified were minimal disability (20.8%), mild to moderate disability (28.1%), and severe disability (51.1%). More than half of the participants (53.4%) experienced functional decline or early death after critical illness. The pre-ICU functional trajectories of mild to moderate disability and severe disability were associated with more than double (adjusted hazard ratio [HR], 2.41; 95% CI, 1.29-4.50) and triple (adjusted HR, 3.84; 95% CI, 1.84-8.03) the risk of death within 1 year of ICU admission, respectively. Other factors associated with 1-year mortality included ICU length of stay (adjusted HR, 1.03; 95% CI, 1.00-1.05), mechanical ventilation (adjusted HR, 2.89; 95% CI, 1.91-4.37), and shock (adjusted HR, 2.68; 95% CI, 1.63-4.38)., Conclusions and Relevance: Among older persons with critical illness, more than half died within 1 month or experienced significant functional decline over the following year, with particularly poor outcomes in those who had high levels of premorbid disability. These results may help to inform discussions about prognosis and goals of care before and during critical illness.

Objectives: To evaluate the relationship between intervening illnesses and injuries leading to hospitalization and restricted activity, respectively, and prolongation of disability in four essential activities of daily living in newly disabled older persons., Design: Prospective cohort study., Setting: Greater New Haven, Connecticut., Participants: Community-living persons aged 70 and older who had at least one episode of disability from March 1998 to June 2013 (N=632)., Measurements: Disability and exposure to intervening illesses and injuries leading to hospitalization and restricted activity, respectively, were assessed every month. Prolongation of disability was operationalized in two complementary ways: as a dichotomous outcome, based on the persistence of any disability, and as a count of the number of disabled activities., Results: During a median follow-up of 114 months, the 632 participants experienced 2,764 disability episodes. The mean exposure rates for hospitalization and restricted activity were 80.7 (95% confidence interval (CI)=73.7-88.4) and 173.6 (95% CI=162.5-185.5), respectively, per 1,000 person-months. After adjustment for multiple disability risk factors, the likelihood of disability prolongation was 2.5 times as great (odds ratio (OR) 2.54, 95% CI=2.05-3.15) for hospitalization and 1.2 times as great (1.21, 95% CI=1.06-1.40) for restricted activity as for no hospitalization or restricted activity, and the mean number of disabilities was 35% (risk ratio (RR)=1.35, 95% CI=1.30-1.39) greater in the setting of hospitalization and 7% (1.07, 95% CI=1.05-1.09) greater in the setting of restricted activity., Conclusion: Intervening illnesses and injuries leading to hospitalization and restricted activity, respectively, are strongly associated with prolongation of disability in newly disabled older adults. Efforts to prevent and more-aggressively manage these intervening events have the potential to break the cycle of disability in older persons., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Purpose: We undertook a study to identify distinct functional trajectories in the year before hospice, to determine how patients with these trajectories differ according to demographic characteristics and hospice diagnosis, and to evaluate the association between these trajectories and subsequent outcomes., Methods: From an ongoing cohort study of 754 community-living persons aged 70 years or older, we evaluated data on 213 persons who were subsequently enrolled in hospice from March 1998 to December 2011. Disability in 13 basic, instrumental, and mobility activities was assessed during monthly telephone interviews through June 2012., Results: In the year before hospice, we identified 5 clinically distinct functional trajectories, representing worsening cumulative burden of disability: late decline (10.8%), accelerated (10.8%), moderate (21.1%), progressively severe (24.9%), and persistently severe (32.4%). Participants with a cancer diagnosis (34.7%) had the most favorable functional trajectories (ie, lowest burden of disability), whereas those with neurodegenerative disease (21.1%) had the worst. Median survival in hospice was only 14 days and did not differ significantly by functional trajectory. Compared with participants in the persistently severe trajectory, those in the moderate trajectory had the highest likelihood of surviving and being independent in at least 1 activity in the month after hospice admission (adjusted odds ratio = 5.5; 95% CI, 1.9-35.9)., Conclusions: The course of disability in the year before hospice differs greatly among older persons but is particularly poor among those with neurodegenerative disease. Late admission to hospice (as shown by the short survival), coupled with high levels of severe disability before hospice, highlight potential unmet palliative care needs for many older persons at the end of life., (© 2015 Annals of Family Medicine, Inc.)

Objective: The objective of this study was to describe the rates of residential relocations over the course of 10.5 years and evaluate differences in these relocation rates according to gender and decedent status., Design: Prospective, longitudinal study with monthly telephone follow-up for up to 126 months., Setting: Greater New Haven, CT., Participants: There were 754 participants, aged 70 years or older, who were initially community-living and nondisabled in their basic activities of daily living., Measurements: Residential location was assessed during monthly interviews and included community, assisted living facility, and nursing home. A residential relocation was defined as a change of residential location for at least 1 week and included relocations within (eg, community-community) or between (community- assisted living) locations. We calculated the rates of relocations per 1000 patient-months and evaluated differences by gender and decedent status., Results: Sixty-six percent of participants had at least one residential relocation (range 0-12). Women had lower rates of relocations from nursing home to community (rate ratio [RR] 0.59, P = .02); otherwise, there were no gender differences. Decedents had higher rates of relocation from community to assisted living (RR 1.71, P = .002), from community to nursing home (RR 3.64, P < .001), between assisted living facilities (RR 3.65, P < .001), and from assisted living to nursing home (RR 2.5, P < .001). In decedents, relocations from community to nursing home (RR 3.58, P < .001) and from assisted living to nursing home (RR 3.3, P < .001) were most often observed in the last year of life., Conclusions: Most older people relocated at least once during 10.5 years of follow-up. Women had lower rates of relocation from nursing home to community. Decedents were more likely to relocate to a residential location providing a higher level of assistance, compared with nondecedents. Residential relocations were most common in the last year of life., (Copyright © 2014 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The frailty index (FI) is used to measure the health status of ageing individuals. An FI is constructed as the proportion of deficits present in an individual out of the total number of age-related health variables considered. The purpose of this study was to systematically assess whether dichotomizing deficits included in an FI affects the information value of the whole index., Methods: Secondary analysis of three population-based longitudinal studies of community dwelling individuals: Nova Scotia Health Survey (NSHS, n = 3227 aged 18+), Survey of Health, Ageing and Retirement in Europe (SHARE, n = 37546 aged 50+), and Yale Precipitating Events Project (Yale-PEP, n = 754 aged 70+). For each dataset, we constructed two FIs from baseline data using the deficit accumulation approach. In each dataset, both FIs included the same variables (23 in NSHS, 70 in SHARE, 33 in Yale-PEP). One FI was constructed with only dichotomous values (marking presence or absence of a deficit); in the other FI, as many variables as possible were coded as ordinal (graded severity of a deficit). Participants in each study were followed for different durations (NSHS: 10 years, SHARE: 5 years, Yale PEP: 12 years)., Results: Within each dataset, the difference in mean scores between the ordinal and dichotomous-only FIs ranged from 0 to 1.5 deficits. Their ability to predict mortality was identical; their absolute difference in area under the ROC curve ranged from 0.00 to 0.02, and their absolute difference between Cox Hazard Ratios ranged from 0.001 to 0.009., Conclusions: Analyses from three diverse datasets suggest that variables included in an FI can be coded either as dichotomous or ordinal, with negligible impact on the performance of the index in predicting mortality.

Importance: Although a serious fall injury is often a devastating event, little is known about the course of disability (ie, functional trajectories) before a serious fall injury or the relationship between these trajectories and those that follow the fall., Objectives: To identify distinct sets of functional trajectories in the year immediately before and after a serious fall injury, to evaluate the relationship between the prefall and postfall trajectories, and to determine whether these results differed based on the type of injury., Design, Setting, and Participants: Prospective cohort study conducted in greater New Haven, Connecticut, from March 16, 1998, to June 30, 2012, in 754 community-living persons aged 70 years or older who were initially nondisabled in their basic activities of daily living. Of the 130 participants who subsequently sustained a serious fall injury, 62 had a hip fracture and 68 had another fall-related injury leading to hospitalization., Main Outcomes and Measures: Functional trajectories, based on 13 basic, instrumental, and mobility activities assessed during monthly interviews, were identified in the year before and the year after the serious fall injury., Results: Before the fall, 5 distinct trajectories were identified: no disability in 16 participants (12.3%), mild disability in 34 (26.2%), moderate disability in 34 (26.2%), progressive disability in 23 (17.7%), and severe disability in 23 (17.7%). After the fall, 4 distinct trajectories were identified: rapid recovery in 12 participants (9.2%), gradual recovery in 35 (26.9%), little recovery in 26 (20.0%), and no recovery in 57 (43.8%). For both hip fractures and other serious fall injuries, the probabilities of the postfall trajectories were greatly influenced by the prefall trajectories, such that rapid recovery was observed only among persons who had no disability or mild disability, and a substantive recovery, defined as rapid or gradual, was highly unlikely among those who had progressive or severe disability. The postfall trajectories were consistently worse for hip fractures than for the other serious injuries., Conclusions and Relevance: The functional trajectories before and after a serious fall injury are quite varied but highly interconnected, suggesting that the likelihood of recovery is greatly constrained by the prefall trajectory.

Little is known about the deleterious effects of injurious falls relative to those of other disabling conditions or whether these effects are driven largely by hip fractures. From a cohort of 754 community-living elders of New Haven, Connecticut, we matched 122 hospitalizations for an injurious fall (59 hip-fracture and 63 other fall-related injuries) to 241 non-fall-related hospitalizations. Participants (mean age: 85.7 years) were evaluated monthly for disability in 13 activities and admission to a nursing home from 1998 to 2010. For both hip-fracture and other fall-related injuries, the disability scores were significantly greater during each of the first 6 months after hospitalization than for the non-fall-related admissions, with adjusted risk ratios at 6 months of 1.5 (95% confidence interval (CI): 1.3, 1.7) for hip fracture and 1.4 (95% CI: 1.2, 1.6) for other fall-related injuries. The likelihood of having a long-term nursing home admission was considerably greater after hospitalization for a hip fracture and other fall-related injury than for a non-fall-related reason, with adjusted odds ratios of 3.3 (95% CI: 1.3, 8.3) and 3.2 (95% CI: 1.3, 7.8), respectively. Relative to other conditions leading to hospitalization, hip-fracture and other fall-related injuries are associated with worse disability outcomes and a higher likelihood of long-term nursing home admissions.

Background: Gender-specific trajectories of lower extremity function (LEF) and the potential for bias in LEF estimation due to differences in survival have been understudied., Methods: We evaluated longitudinal data from 690 initially nondisabled adults age 70 or older from the Precipitating Events Project. LEF was assessed every 18 months for 12 years using a modified Short Physical Performance Battery (mSPPB). Hierarchical linear models with adjustments for length-of-survival estimated the intraindividual trajectory of LEF and differences in trajectory intercept and slope between men and women., Results: LEF declined following a nonlinear trajectory. In the full sample, and among participants with high (mSPPB 10-12) and intermediate (mSPPB 7-9) baseline LEF, the rate-of-decline in mSPPB was slower in women than in men, with no gender differences in baseline mSPPB scores. Among participants with low baseline LEF (mSPPB ≤6), men had a higher starting mSPPB score, whereas women experienced a deceleration in the rate-of-decline over time. In all groups, participants who survived longer had higher starting mSPPB scores and slower rates-of-decline compared with those who died sooner., Conclusions: Over the course of 12 years, older women preserve LEF better than men. Nonadjustment for differences in survival results in overestimating the level and underestimating the rate-of-decline in LEF over time.

Objectives: Across the life span, women live longer than men but experience higher rates of disability. To more completely evaluate these gender differences, the current study set out to compare the trajectories and burden of disability over an extended period between older men and women., Design: Prospective, longitudinal study with 13.5 years of follow-up., Setting: Greater New Haven, Connecticut., Participants: Participants were 754 persons, aged 70 years or older, who were initially community-living and nondisabled in their basic activities of daily living., Measurements: Disability in 13 basic, instrumental, and mobility activities was assessed during monthly interviews, whereas demographic and clinical covariates were measured during comprehensive assessments every 18 months., Results: Five distinct trajectories were identified over successive 18-month intervals: independent, mild disability, mild to moderate disability, moderate disability, and severe disability. Women were more likely than men to experience the moderate and severe disability trajectories, but were less likely to transition from the independent trajectory to a worse disability trajectory during the subsequent 18-month interval. Women were also less likely to die after each of the five trajectories, and these differences were at least marginally significant for all but the independent trajectory. Over the entire duration of follow-up, women suffered from a greater burden of disability than men, but these differences were greatly attenuated after adjustment for the baseline levels of disability., Conclusions: Gender differences in disability over an extended period can be explained, at least in part, by the higher mortality experienced by older men and the higher initial levels of disability among older women. These results suggest the need to take a life-course approach to better understand gender differences in disability., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Frailty among older persons is a dynamic process, characterized by frequent transitions between frailty states over time. We performed a prospective longitudinal study to evaluate the relationship between intervening hospitalizations and these transitions., Methods: We studied 754 nondisabled community-living persons, aged 70 years or older. Frailty, assessed every 18 months for 108 months, was defined on the basis of muscle weakness, exhaustion, low physical activity, shrinking, and slow walking speed. Participants were classified as frail if they met three or more of these criteria, prefrail if they met one or two of the criteria, or nonfrail if they met none of the criteria. Hospitalizations were ascertained every month for a median of 108 months., Results: The exposure rates (95% confidence interval) of hospitalization per 1,000 months, based on frailty status at the start of each 18-month interval, were 19.7 (16.2-24.0) nonfrail, 32.9 (29.8-36.2) prefrail, and 57.2 (52.9-63.1) frail. The likelihood of transitioning from states of greater frailty to lesser frailty (ie, recovering) was consistently lower based on exposure to intervening hospitalizations, with adjusted hazard ratios per each hospitalization ranging from 0.46 (95% confidence interval: 0.21-1.03) for the transition from frail to nonfrail states to 0.52 (95% confidence interval: 0.42-0.65) for the transition from prefrail to nonfrail states. Hospitalization had more modest and less consistent effects on transitions from states of lesser frailty to greater frailty. Nonetheless, transitions from nonfrail to frail states were uncommon in the absence of a hospitalization., Conclusions: Recovery from prefrail and frail states is substantially diminished by intervening hospitalizations. These results provide additional evidence highlighting the adverse consequences of hospitalization in older persons.