Report Highlights Rate of Restrictive Symptoms in Late Life
Report Highlights Rate of Restrictive Symptoms in Late Life
Symptoms that cause older people to restrict
their activities, or "restrictive symptoms," are common during the year
before death and increase dramatically beginning about 5 months before
death, according to an article published online July 8 in JAMA Internal Medicine.
These findings point to a need to assess and manage symptoms through palliative care in the community, in addition to hospice and hospital settings, write Sarwat I. Chaudry, MD, from Yale University School of Medicine, New Haven, Connecticut, and colleagues.
The researchers conducted a prospective cohort study involving 754 nondisabled, community-living people aged 70 years or older in the greater New Haven area. The researchers completed comprehensive assessments every 18 months and conducted monthly interviews with patients or proxies.
Of all 754 patients who enrolled in 1998 and 1999, 491 died by June 30, 2011, the last date covered by this analysis. Between 12 and 7 months before death, restricting symptoms remained "fairly constant" at 20.4% but increased to 27.4% 5 months before death and to 57.2% during the month before death.
Of the people who died, mean age was 85.8 years, 61.9% were women, and 9.0% were nonwhite. They had a mean number of 2.4 comorbidities, and 73.1% had multimorbidity conditions.
The most common symptom was fatigue, followed by musculoskeletal pain, dizziness/unsteadiness, limb weakness, and others. Hypertension was the most common condition, followed by arthritis, myocardial infarction, diabetes, lung disease, and others.
"Therapeutic decisions in older persons must be premised on a careful consideration of risks vs benefits. In the case of potent analgesics (such as narcotics) to alleviate restricting pain, the potential risks are particularly serious, including confusion and falls, but judicious use may improve overall physical function in many cases," the researchers write.
People who died of cancer (n = 91) had the highest occurrence of restricting symptoms (odds ratio [OR], 1.80, 95% confidence interval [CI], 1.03 - 3.14; P = .04 when sudden death is included in analysis), but occurrences were similar across other causes of death, which included frailty, organ failure, and advanced dementia.
In multivariate analyses, controlling for age, sex, race, education, morbidity, and other factors, monthly restricting symptom occurrences were significantly associated with multimorbidity (OR, 1.38; 95% CI, 1.09 - 1.75; P = .008), age younger than 85 years (OR, 1.30; 95% CI, 1.07 - 1.57; P = .009), and proximity to death (OR, 1.14; 95% CI, 1.11 - 1.16; P < .001).
Generalizability of the study results is limited by the fact that all
study participants were members of a single health plan, the
researchers write, but demographic characteristics of the study
population are similar, except in race, to the US population.
In an accompanying commentary, Christine S. Ritchie, MD, MSPH, from the University of California, San Francisco, writes that the article "serves as a call for 2 things: better palliative care for community-dwelling older adults at the end of life and better research....
Only through these efforts will we be able to relieve symptom burden for those older adults in greatest need of relief and be prepared for the increasing number of individuals with multimorbidity and the functional challenges that they experience."
This research was supported by the National Institute on Aging. The authors have disclosed no relevant financial relationships. Dr. Ritchie is also supported by the National Institute on Aging, as well as the Commonwealth Fund and the American Academy of Hospice and Palliative Medicine, and is a board member of the American Academy of Hospice and Palliative Medicine.
JAMA Intern Med. Published online July 8, 2013. Abstract
Medscape Medical News
These findings point to a need to assess and manage symptoms through palliative care in the community, in addition to hospice and hospital settings, write Sarwat I. Chaudry, MD, from Yale University School of Medicine, New Haven, Connecticut, and colleagues.
The researchers conducted a prospective cohort study involving 754 nondisabled, community-living people aged 70 years or older in the greater New Haven area. The researchers completed comprehensive assessments every 18 months and conducted monthly interviews with patients or proxies.
Of all 754 patients who enrolled in 1998 and 1999, 491 died by June 30, 2011, the last date covered by this analysis. Between 12 and 7 months before death, restricting symptoms remained "fairly constant" at 20.4% but increased to 27.4% 5 months before death and to 57.2% during the month before death.
Of the people who died, mean age was 85.8 years, 61.9% were women, and 9.0% were nonwhite. They had a mean number of 2.4 comorbidities, and 73.1% had multimorbidity conditions.
The most common symptom was fatigue, followed by musculoskeletal pain, dizziness/unsteadiness, limb weakness, and others. Hypertension was the most common condition, followed by arthritis, myocardial infarction, diabetes, lung disease, and others.
"Therapeutic decisions in older persons must be premised on a careful consideration of risks vs benefits. In the case of potent analgesics (such as narcotics) to alleviate restricting pain, the potential risks are particularly serious, including confusion and falls, but judicious use may improve overall physical function in many cases," the researchers write.
People who died of cancer (n = 91) had the highest occurrence of restricting symptoms (odds ratio [OR], 1.80, 95% confidence interval [CI], 1.03 - 3.14; P = .04 when sudden death is included in analysis), but occurrences were similar across other causes of death, which included frailty, organ failure, and advanced dementia.
In multivariate analyses, controlling for age, sex, race, education, morbidity, and other factors, monthly restricting symptom occurrences were significantly associated with multimorbidity (OR, 1.38; 95% CI, 1.09 - 1.75; P = .008), age younger than 85 years (OR, 1.30; 95% CI, 1.07 - 1.57; P = .009), and proximity to death (OR, 1.14; 95% CI, 1.11 - 1.16; P < .001).
In an accompanying commentary, Christine S. Ritchie, MD, MSPH, from the University of California, San Francisco, writes that the article "serves as a call for 2 things: better palliative care for community-dwelling older adults at the end of life and better research....
Only through these efforts will we be able to relieve symptom burden for those older adults in greatest need of relief and be prepared for the increasing number of individuals with multimorbidity and the functional challenges that they experience."
This research was supported by the National Institute on Aging. The authors have disclosed no relevant financial relationships. Dr. Ritchie is also supported by the National Institute on Aging, as well as the Commonwealth Fund and the American Academy of Hospice and Palliative Medicine, and is a board member of the American Academy of Hospice and Palliative Medicine.
JAMA Intern Med. Published online July 8, 2013. Abstract
Medscape Medical News
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