Voces a favor y en contra de la LOMCE

As explained in the Methodology Chapter, the research for this thesis will emulate the methodology described by Lunney and colleagues (Lunney J, Lynn J et.al. 2002; Lunney J, Lynn J et.al. 2003) to identify the same trajectories of decline in a nursing home population. Hence the measure that will be used to identify the trajectory is the Resident Classification Scale, a tool validated for this population with a high level of care need. This section will explore what is known about ageing and other options that could be used in a study of

trajectories of ageing. Rather than the result of the failure of a specific body system or gene it is now believed that constitutes ‘ageing’ is an extremely complex multifactorial process (Weinert B and Timiras P 2003).

The literature that identifies factors that can be measured longitudinally (as trajectories) can be grouped into seven subheadings, domains or indicators of the ageing process. The following is a summary of this literature:

Physiological Indicators

Physiological indicators – characteristics of the disease process and consequences of multiple co-morbidities or frailty are a good measure of trajectory if no reversible causes are present (Stevenson J, Abernethy A et.al. 2004):

Peak flow rate is a strong predictor of total mortality in the elderly, independent of smoking, respiratory disease, cardiovascular risk factors, socio-economic status, cognition, functional independence and self-assessed health (Cook N, Evans D et.al. 1991);

Slow gait speed and physical inactivity are strong predictors for development of disability in the elderly (Vermeulen J, Neyens J et.al. 2011);

A decline or significantly variation from baseline of the hormone DHEAS (dehydoepiandrosterone is a hormone proposed to be

Page 104 of 242 associated with ageing) is highly predictive of mortality. DHEAS levels in individuals varies, but taken in series, that is as a trajectory, DHEAS levels provide a biological marker of the rate of ageing (Cappola A, O'Meara E et.al. 2009);

Blood pressure declines in the years before death (Rogers M, Ward K et.al. 2011);

Malnutrition in the elderly leads to a downward trajectory leading to poor health and decreased quality of life (Chen C, Schilling L et.al. 2001);

Grip strength declines with age but plateaus in the oldest old (Frederiksen H, Hjelmborg J et.al. 2006).

Dementia and Cognition

Studies of cognitive decline have identified trajectories that are either gradual and linear; or curvilinear and more accelerated – called the ‘terminal drop’ preceding death in the elderly. However, the observed rate of change in cognition is tempered by the presence or otherwise of other co-morbidities (MacDonald S, Hultsch D et.al. 2011; Aarsland D, Muniz G et.al. 2011);

Motor decline (measured by gait speed) increases longitudinally with the development of other signs of dementia (Buracchio T, Dodge H et.al. 2010);

MMSE scores are higher but decline faster in elderly with higher education levels compared with elderly with lower education levels (Castro-Costa E, Dewey M et.al. 2011);

Decline and the rate of decline in Plasma β-amyloid levels is

associated with cognitive decline particularly memory loss in dementia (Cosentino S, Stern Y et.al. 2010);

The development of psychosis in Alzheimer’s disease is more likely to occur in individuals with a rapid onset of cognitive deterioration compared with Alzheimer’s sufferers who do not develop psychosis

Page 105 of 242 suggesting that there are different trajectories for Alzheimer’s disease (Emanuel J, Lopez O et.al. 2011);

Cognitive decline is associated with a loss of hippocampal activation over time (O'Brien J, O'Keefe K et.al. 2010);

Cognitive and motor function decline parallels the trajectory of

neuropathological changes in AD (Almkvist O and Bäckman L 1993); Test scores for memory and speed worsen with age and the decline is hastened by poor health, lower activity and blood pressure. However variability in test scores also increase with age suggesting that the processes involved with cognitive ageing are complex (Christensen H, Mackinnon A et.al. 2001);

In non-demented elderly, poorer scores in cognitive domains predicted sharp functional decline followed by death (Dodge H, Du Y et.al. 2006);

Cognitive decline is associated with decline in hand grip strength (Taekema D, Ling C et.al. 2012).

Other disease

Cognitive decline, not attributable to the ageing process, is significantly associated with cardiac surgery not heart failure in vascular dementia (Okonkwo O, Cohen R et.al. 2010).

Psycho-social

Quality of life worsens in the last 3 months of life before death in cancer patients (Geisinger J, Wintner L et.al. 2011);

Self-esteem declines with ageing (from 60 years), associated with socio-economic status and physical health (Orth U, Trzesniewski K et.al. 2010);

Self-reported health status is a predictor of mortality (Leinonen R, Heikkinen E et.al. 2001);

Preferences for life prolonging therapy in elderly with advanced illness have an inconsistent trajectory, influenced by transient factors rather than stable core values (Fried T, O'Leary J et.al. 2007);

Page 106 of 242 Mild-moderate drinking of alcohol compared to non-drinking was associated with less cognitive decline in the elderly (Ganguli M, Vander Bilt J et.al. 2005);

Association of loss of social networks and cognitive decline (Giles L, Anstey K et.al. 2012).

Physical function (ADLS and IADLs)

Decline in physical activity is associated with increasing functional limitations and self-efficacy (McAuley E, Hall K et.al. 2009);

Age per se is not closely correlated with dysfunction (Bortz W 1990). Pain increases physical impairment and reduces physical performance over time (Bryant L, Grigsby J et.al. 2007);

Functional impairment in the last year of life for frail elderly is slowly progressive, with a slight acceleration in functional loss prior to death (Covinsky K, Eng C et.al. 2003);

Socio-demographic and chronic conditions predict functional limitation over time (Deeg D 2005).

Policy and health Services

Integration of palliative care services into the end-of –life trajectory of patients with chronic disease reduced acute care service use and

increased satisfaction with care (Brumley R, Enguidanos S et.al. 2003).

Carers, family and health professionals

Physical decline in community living elderly is associated with an increase in informal care supporter, conversely cognitive decline is associated with a net loss of informal care support (Aartsen M, van Tilburg T et.al. 2004);

Caregivers experience trajectories of grief and depression following the death of the cared for patient with AD (Aneshensel C, Botticello A et.al. 2004);

Page 107 of 242 Family members have a poor understanding of the trajectory of disease which made decision making regarding their loved one’s care at the end-of-life more painful (Forbes S, Bern-Klug M et.al. 2000).

When reviewing the literature relevant to the concept of a ‘trajectory’ literature it became clear that there is a difference between cross-sectional and

longitudinal studies that measured the outcome more than once. That is, with more than two measures, a trajectory could be identified. The studies included in the preceding précis of the available literature have identified changes

related to the domains of ageing that could be used in a study of trajectory in an elderly population. This section has been exploratory only. None of the

measures identified here will be used specifically in this thesis research. However, there inclusion in the literature review has provided a broader view of potential measures of ageing for trajectory research as well as the strengths and limitations of the method chosen for this research.

2.6.4 What measures are available to identify the trajectories of