title: Functional trajectories in the year before hospice.
abstract: OBJECTIVE
  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.
authors.affiliation: Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut.
authors.forename: Hans F
authors.initials: HF
authors.lastname: Stabenau
authors.affiliation: Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut.
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Morrison
authors.affiliation: Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut.
authors.forename: Evelyne A
authors.initials: EA
authors.lastname: Gahbauer
authors.affiliation: Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut.
authors.forename: Linda
authors.initials: L
authors.lastname: Leo-Summers
authors.affiliation: Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut.
authors.forename: Heather G
authors.initials: HG
authors.lastname: Allore
authors.affiliation: Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut thomas.gill@yale.edu.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Gill
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000375:Aging; D002318:Cardiovascular Diseases; D015331:Cohort Studies; D004185:Disability Evaluation; D018450:Disease Progression; D005260:Female; D016330:Frail Elderly; D017051:Hospice Care; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D020380:Needs Assessment; D009369:Neoplasms; D019636:Neurodegenerative Diseases; D010166:Palliative Care; D011446:Prospective Studies; D012140:Respiratory Tract Diseases; D013997:Time Factors
keywords: aging; disability evaluation; end of life care; frail elderly; hospice; longitudinal studies; palliative care; practice-based research