Cognitive Change at the End of Life in Nursing Home Residents: Differential Trajectories of Terminal Decline

Abstract

Background: Research on terminal decline has widely documented that cognitive performance steeply declines with nearing death. To date, it is unclear whether these changes are normative, based on pathologies associated with (preclinical) dementia, or both. Objectives: We analyzed heterogeneity in trajectories of terminal cognitive change in Swiss nursing home residents with the objective of examining whether terminal change is normative or whether one or multiple subgroup(s) with relative stability exist. Methods: We performed a longitudinal analysis based on routine assessments with the Resident Assessment Instrument – Minimal Data Set in 341 nursing homes between 1998 and 2014. In sum, we used 143,052 observations from 30,054 residents (69% women, average age at death 87 years) in the last 3 years of life. We analyzed trajectories of the Cognitive Performance Scale (CPS) score with latent class growth curve models and examined sociodemographic factors (age at death, sex, marital status, prior living situation) as well as functional and mental health (Activities of Daily Living Index and Depression Rating Scale) and dementia diagnosis as correlates of group membership. Results: We identified three distinct classes based on longitudinal trajectories of the CPS score. In the first group (transition from no to mild impairment, 27%), cognitive impairment increased with time to death (linear and quadratic), but remained at relatively mild levels at all times. The trajectories of the second group (transition from moderate to severe impairment, 43%) were characterized by linear and quadratic changes across time to death. The trajectories of the third group (severe impairment, 30%) were characterized by the lowest amount of linear increase across all groups and no quadratic increase indicating no accelerated change. Better functional health and absence of a dementia diagnosis predicted less impairment. Fewer depressive symptoms were associated with low as opposed to moderate or severe, but also severe versus moderate impairment. Conclusion: Our findings suggest that the majority of residents experience terminal change, with the exception of those at already high levels of impairment. Furthermore, late-life cognitive change is related to functional and mental health.

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“…The “Intact/Mild Cognitive Impairment” trajectory was consistent with prior research that mostly identified a subgroup of older adults who started with a high cognitive function and remained relatively stable over time [ 11 ]. However, unlike previous studies that commonly found trajectories of cognitive decline to various degrees [ 11 , 45 ], older nursing home residents with moderate and severe cognitive impairment at nursing home admission showed minimal changes during the six months post admission. Aside from the differences in population and setting, this could be attributed to the fact that change in cognitive function is a slow process [ 11 ], and therefore six months may not be adequate to capture substantial changes on the trajectories.…”

Changes in psychosocial factors among community‐dwelling older adults before and after Japan's declaration of a state of emergency over coronavirus disease 2019

“…The exclusion criteria were missing data on age or gender and suspected cognitive impairment at either baseline or follow‐up. The Cognitive Performance Scale (CPS) was used to assess cognitive impairment; subjects at level 2 (mild impairment) or higher were defined as having cognitive impairment 12,13 (Fig. 1).…”

“…Cognitive function is evaluated on a seven‐point scale from 0 to 6. Level 2 is suspected mild cognitive impairment and level 6 is very severe impairment 12,13 …”

Das Lebensende in der Schweiz - Individuelle und gesellschaftliche Perspektiven

“…Nicht selten werden in diesem Kontext Entwicklungsphasen angesprochen, die Sterbende durchleben können oder je nach Perspektive idealerweise erleben sollten. Im Zentrum der Thematik um das 'längere Sterben' steht die Tatsache, dass durch den medizinischen Fortschritt je nach Perspektive der Todeszeitpunkt hinausgezögert werden kann oder aber die Sterbephase zeitlich verlängert wird (Hoffmann, 2011;Lantos, 2015;Hülür, Wolf, Riese & Theill, 2018). Für die einen Personen bedeutet dies einen Gewinn an zusätzlicher, für sie höchst bedeutsamer, Lebenszeit; bei anderen Personen hingegen wird dadurch eine schwer erträgliche Leidenszeit in die Länge gezogen.…”