One of the consequences of increased life expectancy and not dying of heart disease or cancer is the increased risk of dementia and frailty. Research is beginning to emerge on the trajectory of dementia and there is increasing understanding of the markers of progress of these disorders (Section 2.6.2).
Dementia
Life expectancy is reduced in the elderly with dementia, the incidence and prevalence of which increases with age (Hall P, Schroder C et.al. 2002; Jagger C, Matthews R et.al. 2009; Brodaty H, Seeher K et.al. 2012; Tinetti M,
McAvay G et.al. 2012) and is estimated to effect a third of Australians 85 years and older (Australian Institute of Health and Welfare 2012). Dementia was the strongest predictor of mortality compared with other life-shortening diseases in the elderly (Tschanz J, Corcoran C et.al. 2004) and the burden on the health system is already substantial (Moschetti K, Cummings P et.al. 2012).
Reporting of dementia will increase as awareness and treatment options for the disease increases (Brodaty H, Breteler M et.al. 2011).
Mitchell and Teno argue that for too long dementia has been under recognized as a terminal illness and that a better understanding of the clinical trajectory of
Page 53 of 242 end-stage dementia is a critical step toward improving the care of patients with this condition’ (Mitchell S, Teno J et.al. 2009).A further finding of their study of nursing home residents with advanced dementia, is that life expectancy was reduced to the same extent as other end-of-life conditions and that the patients in the study died of conditions caused by dementia and not other fatal events such as a myocardial infarction (Mitchell S, Teno J et.al. 2009, p1535).
Figure 2.5 Proportion of NH residents with diagnosed dementia or mental illness in 2010
(AIHW 2011, p64)
More than half of NH residents in 2010, shown in Figure 2.5 above, had a diagnosis of dementia and another quarter of residents had a mental illness other than dementia (Australian Institute of Health and Welfare 2011) and only a quarter of the residents having neither.
The findings of the studies described above, confirm the growing concern that with an increasingly aged population, NH will have more admissions of the oldest-old needing dementia specific, high needs care.
Frailty
Lynn simply defines frailty as a fatal chronic condition in which all of the body’s systems have little reserve and small upsets cause cascading health problems (Lynn J and Adamson D 2003, p5). Community services are usually familiar with the concept of frailty (Rochat S, Cumming R et.al. 2010). They
Page 54 of 242 know these are people who are only just coping at home, not sick, not well, but managing until they have a fall or get the flu. Frailty is associated with
mortality and admission to nursing home (Rockwood K, Mitniski A et.al. 2006). Interventions for the frail elderly still living in the community may prevent unnecessary admission to hospital (Gill T, Baker D et.al. 2002; Hjaltadottir I, Hallberg I et.al. 2011; Weaver F, Hickey E et.al. 2007; Rosenberg T 2012).
Identifying frailty is difficult in studies of population level cause of death data because of the focus on a single underlying cause of death (Figure 2.6 below). This leads to an underestimation of the extent of co-existing disease
contributing to the burden of illness leading to death (Tinetti M, McAvay G et.al. 2012). With age, the principle causes of death changes proportionally (AIHW Mortality FAQ 20124). As the graphs below show (Figure 2.6), cancer as the predominant cause of death in older Australians declines while deaths from cardiovascular causes increase with age, the trend being more obvious in females.
Figure 2.6 Major causes of death in older age groups for Australians in 2005
Data for graphs from the AIHW National Mortality Database 2005
4 http://www.aihw.gov.au/deaths-faq/ 0 10 20 30 40 50 60 45-64 65-84 85+ P e rce nt age of T ot al D e at hs Age Group
cardiovascular cancer respiratory other MALES 0 10 20 30 40 50 60 45-64 65-84 85+ P e rce nt age of T ot al D e at hs Age Group
cardiovascular cancer respiratory other
Page 55 of 242 The correct identification of frailty is important because frailty is highly
predictive of adverse health outcomes (Weiss C 2011). The frailty trajectory can be identified by measures associated with frailty – declines in physical function, weight loss, anorexia and fatigue – that have no identifiable or reversible cause (Stevenson J, Abernethy A et.al. 2004). However, the definition of ‘frailty status’ varies leading to different estimates of the prevalence and difficulty in comparing research studies (Collard R, Boter H et.al. 2012).
The trajectory of frailty has been identified in elderly populations living in the community and nursing home. Kenneth Covinsky describes the functional trajectory of patients enrolled in a community support program as slowly progressive functional deterioration, with only a slight acceleration in the trajectory of functional loss as death approaches (Covinsky K, Eng C et.al. 2003). In a comparison study of three measures of frailty in an elderly nursing home population identified only a weak association with age but correlated moderately well with a disability measure. By all three frailty measures compared in this study, frailty was significantly associated with increased risk of mortality, disability and cognitive decline (Rockwood K, Abeysundera M et.al. 2007). However there is some contention in the applicability of frailty scores in everyday clinical practice (Pijpers E, Ferreira I et.al. 2012).
The research by Lunney classified frailty from death certificate as well as physician claim data in an elderly population (Lunney J, Lynn J et.al. 2002). The functional trajectory of frailty was identified in subsequent research where any subject with a nursing home admission was classified as being frail
(Lunney J, Lynn J et.al. 2003). As suggested by Lunney, this single frailty trajectory with characteristically low levels of functional ability compared to the other trajectories of decline may comprise multiple trajectories as shown in Figure 2.7 (below). The trajectory of decline for frailty is described by Lunney as ‘bimodal’ whereby the trajectory of prolonged , diminishing capacity ends with a short period of rapid decline precipitated by a critical event such as a
Page 56 of 242 stroke, infection or an acute exacerbation of an underlying chronic disease (Lunney in Cowen P and Moorhead S 2006, p 315).
Figure 2.7 From Lunney (Cowen and Moorehead, eds, p315): Possible trajectories of dying for frail elders
The relationship between frailty and dementia in nursing home residents is not clear in the literature and despite Lunney (Lunney J, Lynn J et.al. 2002; Lunney J, Lynn J et.al. 2003) included dementia in the frailty group, future studies are needed to further distinguish differences in order to target interventions for treatment and alleviation of symptoms specific to each.
This section has given an overview of the most common health conditions that residents of Australian nursing homes live with. Due to the increasing life expectancy of Australia’s elderly and the increased proportion of elderly baby boomers, new admissions to NH can be expected to have higher care needs, particularly for dementia specific care and frailty, than ever before.
Page 57 of 242