1. End of Life Care of Older Adults
Kenneth Rockwood MD, FRCPC, FRCP, FCAHS
Professor of Geriatric Medicine
Dalhousie University & Capital District Health Authority
Halifax, Canada

2. Objectives To describe how frail elderly people die.
To suggest practical steps to classify patients who are at a high risk of death by the:
initial patient assessment, and;
daily monitoring of mobility & balance
To suggest an alternative to current expenditure patterns.

3. Case 1: an 86 year old man, brought by ambulance, with a fall and a cough
Retired policeman; dyspnea, productive cough.
PMH: COPD, CHF, IHD, dyslipidemia, myelodysplastic syndrome, CRF, dementia
BP: 80/40; new atrial fibrillation, rate 100.
Labs: Na+ 127, hgb 76, worse urea/creat (380 from 216).
Admitted for an acute exacerbation of COPD, atrial fibrillation. (shock)

4. Case 2 – an 86 year old woman, brought by ambulance, with a fall
An 86 year old woman comes to the hospital by ambulance, having fallen.
Daughter notes: unwell x ~3 weeks; weight loss. More confused x 48 hours, hallucinating.
PMH: hypertension, IHD, PVD, DM, etc.
O/e: bp is 96/50. “Systolic heart murmur”. PVD.
Electrolytes: Na+ of 133 (Cl- 96; HCO3- 25). Urea is 18, Cr 142. CBC: hgb 107, with normal indices.
What is wrong with this woman? Is she ill? How should we investigate her? How should we treat her?

5. The clinical challenge
Only one of these patients will live for more than 4 days.
Which one will die?
How long is the other likely to live?
How can you tell?

6. Deficits accumulate characteristically, both between groups (community vs. institution/ clinical) and within groups*
Slope <0.01
1.0
Clinical and institutional samples, n=2,573
0.5
0.3
Legend
0.2
Mean accumulation of deficits
The slope is ~0.03
Community samples
n=33,559
ALSA
CSHA-screen
CSHA-exam
0.1
NHANES
NPHS
SOPS
Breast cancer
0.05
CSHA-inst
Myoc Infarct
Log scale
US-LTHS
H70-75 70 75 80 85 90 95 65
Age (years)
Mitnitski, et al., J Am Geriatr Soc, 2005;53:2184-9

7. At any age, women accumulate more deficits than do men
At any age, women accumulate more deficits than do men. For men & women, deficit accumulation is highly correlated (r>0.95) with mortality
Mitnitski et al. J Am Geriatr Soc, 2005;53:2184-9

8. Relationship between age, frailty & survival

9. Why the deficit count matters: transitions from n deficits to death during 5 years; Canadian Study of Health & Aging, N=8,547
Of 8,547 people at baseline, only 18 had >17/31 possible deficits, and only 7 (of 5586) had >17/31 at follow-up
Survival limit close to the frailty
Index of about 0.7
A limit to of the number of deficits suggests exhaustion of reserve capacity
– is it operationalizable clinically?
Mitnitski, Bao, Rockwood. Mech Ageing Dev 2006;127: Rockwood & Mitnitski Mech Ageing Dev 2006;127:494-6.

10. A frailty index based on a Comprehensive Geriatric Assessment (FI-CGA) better stratifies 70-month survival than does age
FI-CGA
Age 1 1 70
0.1
0.8
0.8 80
0.2
0.6
0.6
Survival probability 90
0.3
0.4
0.4
0.2
100
0.2
0.5
0.4 10 20 30 40 50 60 70 10 20 30 40 50 60 70
Survival time (months)
Rockwood, Rockwood, Mitnitski, J Am Geriatric Soc 2010;58: 10

11. Cartoons of end of life trajectories

12. Failure kinetics of systems with different levels of redundancy
From Gavrilov & Gavrilova Sci Aging Knowledge Env, 2003; 28:1-10

13. Loss of redundancy in relation to deficit accumulation in a Frailty Index based on Comprehensive Geriatric Assessment
Panel A
Panel B
Log of the Frailty Index
-0.5
-0.5 -1 -1
-1.5
-1.5 -2 -2
-2.5
-2.5 -3 -3 70 75 80 85 90 95
100 70 75 80 85 90 95
100
Age, years
Rockwood, Rockwood, Mitnitski., J Am Geriatrics Soc, 2010;58:

14. Current Outcomes of Acute Care
What is the problem?
One in three older adults admitted to hospital leaves hospital more disabled; half never get better. 00 14

15. Case 2. Information from standard, September PGY-1 IM, hx & pe

16. Case 2 – Information from completed CGA

17. Case 1 – 86 year old retired policeman - CGA

18. Measuring mobility: the HABAM
The Hierarchy of Balance & Mobility
In bed-mobility
Cannot move off pressure points
Moves side to side
Can push to sit up
Can swing legs over the side
MacKnight & Rockwood Age Ageing 1995;24:126-30
MacKnight & Rockwood J Clin Epidemiol 2000;53:1242-7
Rockwood et al. J Am Geriatr Soc, 2008; 56:

19. Hierarchical Assessment of Balance and Mobility: embracing complexity through pattern recognition in a state variable
Rockwood et al., J Am Geriatr Soc, 2008;56:

20. Mean value of first 14-day HABAM scores by discharge disposition
Hubbard et al., submitted, 2010

21. Risk of death within 30 days in relation to HABAM scores
Absolute risk of death of patients who score the lowest on each of the HABAM domains at any point of the hospital stay: 45% (36-54).
Hubbard et al., submitted.
Relative risk of death of patients whose HABAM scores decline in the first 48 hours, versus those in whom the scores stay the same or improve: 27.2 ( ).
Rockwood, Rockwood & Mitnitski, submitted.

22. Outcome – case 1
The patient died on the 4th hospital day.

23. Signs that death is near - weeks
In the weeks prior to death
Decline in exercise tolerance
Decline in mobility – speed, distance, independence
Decline in balance – falls and near falls
Decline in function
Decline in appetite
Decline in level of enjoyment

24. Signs that death is near - days
In the days prior to death
Further decline in mobility and activities, to become bedfast
Sleeps more
Change in respiratory pattern
Tends to pocket food in the mouth when eating
A rally in energy or alertness
Intimations that people who have died are somehow present
Respiratory panic

25. Signs that death is near - hours
In the hours prior to death
Noisy breathing / death rattle
Distal to proximal mottling of the extremities
Mottling of the trunk
Cooling of the extremities lower first, distal to proximal
Lowering of the blood pressure
Increase in pulse

26. Hospital & 3 month outcomes – case 2
No evident cause other than polypharmacy.
Discharged after two weeks.
Six medications d/c’d (atorvastatin, bisoprolol, hctz, warfarin, alendronate, rabeprezole)
One medication reduced (lorazepam, to 1 qhs)
Three meds started (galantamine, at 8mg/day and citalopram, at 10 mg/day and iron).
At 3 months: lorazepam has been discontinued, trazadone added (50 mg hs) galantamine increased to 16 mg/day and citalopram to 20 mg/day, and the rabeprezole has been restarted. Her insomnia, renal failure, delirium, mobility impairment and anemia have resolved, her dementia and orthostatic hypotension have improved.

27. List of Frailty States: 1. Very Fit
2. Well
3. Managing Well
4. Vulnerable
5. Mildly Frail
6. Moderately Frail
7. Severely Frail
8. Very Severely Frail
9. Terminally ill
© Geriatric Medicine Research Unit, Dalhousie University, 2008

28. Principles of “comfort care”
Focus on symptoms that are distressing to the patient and/or their family.
Pain
Breathing
“the death rattle”
Thirst, hunger
Existential crisis

29. Discussion (1)
In general, people die when they are not fit enough to withstand their illness (or the intervention).
Quantifying fitness/frailty & illness/intervention is a worthwhile goal.
The numbers work with amazing elegance, so that “clinico-mathematical correlation”.
One example appears to be the beguiling stability of very frail people.

30. Discussion (2)
For frail elderly people, the risk of death is expressed chronically by their level of frailty, which can be quantified using the FI-CGA, and acutely, by changes in mobility & balance, quantified by the HABAM.
The Frailty Scale / card is a rough, qualitative surrogate.

31. Discussion (3) Next challenges:
Routine assessments of frailty state and of mobility & balance, with a goal of rational resource allocation (cf. age-based rationing).
Efficient, interprofessional collaborative practice, to not replicate “one thing wrong at once care” with a multidisciplinary team.

32. Acknowledgments Arnold Mitnitski Funding sources:
Fountain Innovation Fund of the QEII Health Sciences Foundation
Canadian Institutes of Health Research
Mathematics of Information Technology and Computer Science program, National Research Council
Alzheimer Society of Canada
Dalhousie Medical Research Foundation
Colleagues & students:
Arnold Mitnitski
Nadar Fallah
Xiaowei Song
Ruth Hubbard
Melissa Andrew
Michael Rockwood
Samuel Searle
Paige Moorhouse, Laurie Mallery & “PATH”

33. Frailty Index score is <0.10.
2. Well –
People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.
Frailty Index score is <0.10.
Well older adults share most attributes of the very fit, except for regular, vigorous exercise. Like them, some may complain of memory symptoms, but without objective deficits.

34. 6. Moderately Frail
– People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing. Often rate health no better than ‘fair’. Typically, walking is slow. Frailty index ~0.35 – 0.45.
If a memory problem causes the dependency, often recent memory will be very impaired, even though they seemingly can remember their past life events well.