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Frailty and type of death among older adults in China
Main outcome measures Type of death, categorised as being bedridden for fewer than 30 days with or without suffering and being bedridden for 30 or more days with or without suffering.Results Multinomial analyses showed that higher levels of frailty significantly increased the relative risk ratios of mortality for all types of death. Of those with the highest levels of frailty, men were most likely to experience 30 or more bedridden days with suffering before death (relative risk ratio 8.70, 95% confidence interval 6.31 to 12.00) and women 30 or more bedridden days with no suffering (11.53, 17.84 to 16.96). Regardless of frailty, centenarians and nonagenarians were most likely to experience fewer than 30 bedridden days with no suffering, whereas those aged 65 79 and 80 89 were more likely to experience fewer than 30 bedridden days with suffering. Adjusting for compositional differences had little impact on the link between frailty and type of death for both sexes and age groups.Conclusions The association between frailty and type of death differs by sex and age. Health scholars and clinical practitioners should consider age and sex differences in frailty to develop more effective measures to reduce preventable suffering before death.IntroductionHuman frailty is a universal feature of the ageing process that signals the progression and accumulation of physical, psychological, and social deficits in older adults.1 2 3 4 5 Evidence from clinical studies suggests that frailty is a valid and reliable proxy of biological age (as opposed to chronological age), which provides a robust measure of the balance between health assets and deficits across a variety of dimensions.3 4 5 6 7 8 9 10 11 12 Accordingly, there is increasing awareness that quantifying levels of frailty, termed a "frailty index," is important for identifying differences in ageing in a population and as a numerical tool for monitoring individual susceptibility to disease and death.11 13 14 15 16 17 18 19 Empirical studies of frailty on a national level are, however, limited.Health scholars and practitioners widely agree that promoting healthy longevity is accomplished with not only advances in age but through healthier survival and an improved quality of death.20 21 22 To date, research on the quality and type of death is primarily limited to cross sectional and non representative studies in clinical settings. Drawing from this research, consensus is growing that the extent of suffering (pain and discomfort) and number of bedridden days are basic dimensions underlying the quality of death in late life.20 23 24 25 26 27 28 In the United States it is estimated that end of life care utilises nearly one eighth of all healthcare expenditures and about one third of Medicare expenditures.29 In developing countries such as China, however, most health care occurs at home nearly 20% of the world's oldest old live in China and less than 2% of elderly people live in institutions.30 31 The degree to which this increasingly frail population dies peacefully or experiences prolonged degeneration before death is unknown.We carried out a prospective cohort analysis of the association between frailty and type of death among older adults (65 years) in China. Using data from the 2002 and 2005 waves of the Chinese longitudinal healthy longevity survey, the largest nationally representative sample of older adults in China, we examined the impact of frailty on type of death among people aged 65 to 109 and investigated whether differences in mortality varied by sex and age.MethodsThe Chinese longitudinal healthy longevity survey is a nationwide survey of one of the largest samples of people in the oldest old age group (80 years) in the world. Extensive questionnaires were used to collect information on personal characteristics, family and household characteristics, lifestyle and diet, psychological characteristics, economic resources, social support, and a myriad physical and cognitive health conditions. The survey began interviewing older adults with informed consent in 1998 from half of the counties and cities selected in 22 provinces in China. The major aim of the study was to collect a comparable sample of male and female octogenarians, nonagenarians, and centenarians. Follow up interviews of the original sample and newly added samples including adults aged 65 and older to replenish participants who had died or were lost to follow up were carried out in 2000, 2002, and 2005. The details of the sampling design, response rates, attrition, and systematic assessments of data quality across numerous measures in the survey are described elsewhere.32 33 34The current analyses utilise data from the 2002 and 2005 waves of the survey. In the 2002 wave 15919 participants aged 65 109 were interviewed. The oversampling of older adults provided data on 4845 participants aged 65 79, 3747 nonagenarians, and 3088 centenarians. Of the 15919 interviewees in 2002, 8090 adults (50.8%) were reinterviewed in 2005 and 5627 (35.3%) died before follow up in 2005. The remaining 2202 adults (13.8%) were lost to follow up and were ultimately dropped from the present study, leaving an analytical sample of 13717 participants.Outcome measureAs with most large scale studies, the Chinese longitudinal healthy longevity survey has limited qualitative measures to fully assess type of death. To overcome this shortcoming we integrated an objective indicator of physical failure with a subjective indicator of suffering before death to develop several categorisations of type of death between the 2002 and 2005 surveys.23 25 Firstly, we dichotomised separate variables into participants who were bedridden for fewer than 30 days before death and those who were bedridden for 30 or more days before death. Testing other cut off points for duration of being bedridden did not improve explanatory power.Secondly, we dichotomised the subjective painfulness of death on the basis of an evaluation of the decedents' next of kin (peaceful v non peaceful) reported in the 2005 survey. Most elderly people in China reside in the community,31 which provides the unique opportunity for next of kin to report on the participant's suffering immediately before death. Although both measures were ascertained from next of kin, research shows that surrogate responses from family members and others are appropriate for obtaining reliable information on the health status and quality of death among older adults.35 36Finally, we grouped the two assessments of the participants' last month of life to categorise the deaths as follows: less than 30 bedridden days with suffering, less than 30 bedridden days with no suffering,rolex datejust oyster imitation, 30 or more bedridden days with suffering, or 30 or more bedridden days with no suffering. The reference category in the multinomial regression models was survival over the three years.Frailty index and confounding risksFrailty is a physiological state of non specific vulnerability to stressors resulting from decreased physiological reserves and the deregulation of multiple physiological systems associated with advancing age.1 3 4 6 7 8 10 37 Conceptually, frailty is not just an association with specific diseases or disabilities but rather a systemic manifestation of physical and cognitive deficits, including the signs, symptoms, illnesses, and impairments that accumulate over the life course.8 37Empirically, a variety of methods have been used to quantify frailty, although the most common applications are the phenotypic approach and the frailty index.38 39 The phenotypic approach defines frailty on the basis of several items, such as weight loss, exhaustion,oyster perpetual datejust imitation, weakness, slowness, or low physical activity, and considers any three conditions as an indication of frailty.5 Alternatively, a frailty index focuses less on the specific deficits of people and more on the cumulative number of health deficiencies.8 15 Despite the similarities between these approaches, the choice of measurement is often dictated by the clinical outcome under investigation. Accordingly, recent research shows that frailty indices are more applicable for studying mortality than are phenotypic methods.8 38 39 In practice, most studies compute a frailty index as the proportion of cumulative health deficits to all possible deficits for a given individual.17Following earlier research, we constructed a frailty index using 39 variables that included objective, subjective, and proxy reports of cognitive functioning, disability,rolex datejust ii imitation, auditory and visual ability, depression, heart rhythm, and numerous chronic diseases (details available on request). Each item was assigned a value of 1 in the presence of a deficit (otherwise 0), and a value of 2 was assigned for people with two or more serious conditions that led to admission to hospital or a period of confinement in bed.13 We then constructed a frailty index by summarising all deficits and dividing by the total number of possible deficits.Although studies have shown that a frailty index does not require the same number or type of items to estimate accurate proportions of frailty levels,38 the items comprising our index are similar to those used in studies from Canada,15 the United States,8 and Hong Kong.13 We tested the validity and sensitivity of the frailty index by analysing several indices on the basis of differing combinations of variables. These results showed that as long as we included variables characterising each of the major domains of health (activities of daily living, instrumental activities of daily living, chronic illnesses, and cognitive functioning), the pattern of frailty with age remained consistent. In the Chinese longitudinal healthy longevity survey, levels of frailty increased exponentially from ages 65 to 100 and then levelled off (results not shown); therefore we split the frailty index into fourths for men and for women to account for non linear relations between levels of frailty and type of death.To obtain robust estimates we also adjusted analyses for several previously identified confounding factors.40 Various coding strategies were assessed for each measure and the results were similar; therefore, we dichotomised all of the confounding variables (except age). Measures of demographic background included age categorisations of 65 79 (reference group), 80 89, 90 99, and 100 and older, people from non Han ethnic minorities, and those living in urban areas. Measures of socioeconomic status included education (any formal education), primary lifetime occupation as a white collar worker, economic independence (primary financial source from own work or pension),imitation mens rolex oyster perpetual datejust watch, family in good economic standing (self rated as rich compared with other families in the community), and being in receipt of adequate drugs for any illnesses. Social contact and support measures included current marital status, close proximity to children (coresiding with biological or adopted children, including a spouse's child, or having one or more biological children living in the same village or street block), and religious activity almost every day or sometimes. Measures for health practices included exercising on a regular basis and having ever smoked in the past five years.Statistical analysisWe computed sample distributions of the study variables separately by sex and level of frailty. To test differences in the distributions of frailty for dichotomous variables we used Kendall's tests and for categorical variables Pearson's 2 tests. Multinomial logistic regression models were used to estimate the relative risk ratios and 95% confidence intervals associated with levels of frailty and the four types of death. We used two sets of nested regression models to adjust for the confounding risk factors. The first set of analyses tested the effects of frailty by sex while adjusting for basic personal information (age, ethnicity, and urban residence). In the second set of analyses we included the additional confounding variables for socioeconomic status, social contact and support, and health practices. We then computed the predicted proportions of the types of death (among decedents) across age and frailty for men and for women.All analyses were done using Stata version 10.1. Overall, few data were missing for study variables (41 Research shows that including variables related to sample selection produces unbiased estimates in the absence of weights42 and our preliminary analyses showed that the pattern of findings was consistent with those based on weighted data. Therefore we did not use weighted data in the regression analyses.ResultsTables 1 and 2 present the sample distributions of the study variables by sex and level of frailty. Among those in the lowest fourth (least frail) for frailty, 84.9% of men and 86.1% of women survived to 2005 compared with just over 25% of men and women in the highest fourth (most frail) for frailty. Among decedents, about 25% of men and women had fewer than 30 bedridden days before death, although women were less likely than men to suffer before death. A greater proportion of women than men had 30 or more bedridden days either with or without suffering before death. Those with the most frailty had the highest rates for all types of death. Men with the most frailty were more likely to suffer before death (17.9% withTable 1 Characteristics of men in 2002 wave of Chinese longitudinal healthy longevity survey by level of frailty. Values are percentages of participants unless stated otherwiseView this table:View popupView inlineAlthough men had a slightly younger age distribution (and death rates) than women, both sexes exhibited commensurate increases in age across levels of frailty. Similar proportions of men and women were from ethnic minority groups (about 6%) and lived in urban areas (about 43%); however, men and women from ethnic minority groups were less frail than those of Han ethnicity. There was no trivariate difference between sex, frailty, and urban residence. At nearly all levels of frailty men had higher socioeconomic status, were more likely to be married, took regular exercise, and had smoked in the past five years compared with women. Women were more likely to live close to their children and engage in religious activities compared with men. For both sexes, socioeconomic status, social contacts and support, and exercise declined across levels of frailty. Conversely, the proportion of participants who smoked was lower for men and women with higher levels of frailty.For both sexes the proportion of participants who did not suffer before death increased with age and the proportion who suffered decreased with age (figs 1 and 2). Across levels of frailty, the most pronounced patterns were the precipitous declines in the numbers of participants who experienced fewer than 30 bedridden days with suffering and increases in the number of participants who experienced 30 or more bedridden days with no suffering, particularly among women. Consistent with tables 1 and 2, the plotted probabilities also indicated that women were more likely to experience no suffering before death compared with men.Fig 1 proportion of type of death among deceased sample by age and sex in 2002 and 2005 waves of Chinese longitudinal healthy longevity survey
Main outcome measures Type of death, categorised as being bedridden for fewer than 30 days with or without suffering and being bedridden for 30 or more days with or without suffering.Results Multinomial analyses showed that higher levels of frailty significantly increased the relative risk ratios of mortality for all types of death. Of those with the highest levels of frailty, men were most likely to experience 30 or more bedridden days with suffering before death (relative risk ratio 8.70, 95% confidence interval 6.31 to 12.00) and women 30 or more bedridden days with no suffering (11.53, 17.84 to 16.96). Regardless of frailty, centenarians and nonagenarians were most likely to experience fewer than 30 bedridden days with no suffering, whereas those aged 65 79 and 80 89 were more likely to experience fewer than 30 bedridden days with suffering. Adjusting for compositional differences had little impact on the link between frailty and type of death for both sexes and age groups.Conclusions The association between frailty and type of death differs by sex and age. Health scholars and clinical practitioners should consider age and sex differences in frailty to develop more effective measures to reduce preventable suffering before death.IntroductionHuman frailty is a universal feature of the ageing process that signals the progression and accumulation of physical, psychological, and social deficits in older adults.1 2 3 4 5 Evidence from clinical studies suggests that frailty is a valid and reliable proxy of biological age (as opposed to chronological age), which provides a robust measure of the balance between health assets and deficits across a variety of dimensions.3 4 5 6 7 8 9 10 11 12 Accordingly, there is increasing awareness that quantifying levels of frailty, termed a "frailty index," is important for identifying differences in ageing in a population and as a numerical tool for monitoring individual susceptibility to disease and death.11 13 14 15 16 17 18 19 Empirical studies of frailty on a national level are, however, limited.Health scholars and practitioners widely agree that promoting healthy longevity is accomplished with not only advances in age but through healthier survival and an improved quality of death.20 21 22 To date, research on the quality and type of death is primarily limited to cross sectional and non representative studies in clinical settings. Drawing from this research, consensus is growing that the extent of suffering (pain and discomfort) and number of bedridden days are basic dimensions underlying the quality of death in late life.20 23 24 25 26 27 28 In the United States it is estimated that end of life care utilises nearly one eighth of all healthcare expenditures and about one third of Medicare expenditures.29 In developing countries such as China, however, most health care occurs at home nearly 20% of the world's oldest old live in China and less than 2% of elderly people live in institutions.30 31 The degree to which this increasingly frail population dies peacefully or experiences prolonged degeneration before death is unknown.We carried out a prospective cohort analysis of the association between frailty and type of death among older adults (65 years) in China. Using data from the 2002 and 2005 waves of the Chinese longitudinal healthy longevity survey, the largest nationally representative sample of older adults in China, we examined the impact of frailty on type of death among people aged 65 to 109 and investigated whether differences in mortality varied by sex and age.MethodsThe Chinese longitudinal healthy longevity survey is a nationwide survey of one of the largest samples of people in the oldest old age group (80 years) in the world. Extensive questionnaires were used to collect information on personal characteristics, family and household characteristics, lifestyle and diet, psychological characteristics, economic resources, social support, and a myriad physical and cognitive health conditions. The survey began interviewing older adults with informed consent in 1998 from half of the counties and cities selected in 22 provinces in China. The major aim of the study was to collect a comparable sample of male and female octogenarians, nonagenarians, and centenarians. Follow up interviews of the original sample and newly added samples including adults aged 65 and older to replenish participants who had died or were lost to follow up were carried out in 2000, 2002, and 2005. The details of the sampling design, response rates, attrition, and systematic assessments of data quality across numerous measures in the survey are described elsewhere.32 33 34The current analyses utilise data from the 2002 and 2005 waves of the survey. In the 2002 wave 15919 participants aged 65 109 were interviewed. The oversampling of older adults provided data on 4845 participants aged 65 79, 3747 nonagenarians, and 3088 centenarians. Of the 15919 interviewees in 2002, 8090 adults (50.8%) were reinterviewed in 2005 and 5627 (35.3%) died before follow up in 2005. The remaining 2202 adults (13.8%) were lost to follow up and were ultimately dropped from the present study, leaving an analytical sample of 13717 participants.Outcome measureAs with most large scale studies, the Chinese longitudinal healthy longevity survey has limited qualitative measures to fully assess type of death. To overcome this shortcoming we integrated an objective indicator of physical failure with a subjective indicator of suffering before death to develop several categorisations of type of death between the 2002 and 2005 surveys.23 25 Firstly, we dichotomised separate variables into participants who were bedridden for fewer than 30 days before death and those who were bedridden for 30 or more days before death. Testing other cut off points for duration of being bedridden did not improve explanatory power.Secondly, we dichotomised the subjective painfulness of death on the basis of an evaluation of the decedents' next of kin (peaceful v non peaceful) reported in the 2005 survey. Most elderly people in China reside in the community,31 which provides the unique opportunity for next of kin to report on the participant's suffering immediately before death. Although both measures were ascertained from next of kin, research shows that surrogate responses from family members and others are appropriate for obtaining reliable information on the health status and quality of death among older adults.35 36Finally, we grouped the two assessments of the participants' last month of life to categorise the deaths as follows: less than 30 bedridden days with suffering, less than 30 bedridden days with no suffering,rolex datejust oyster imitation, 30 or more bedridden days with suffering, or 30 or more bedridden days with no suffering. The reference category in the multinomial regression models was survival over the three years.Frailty index and confounding risksFrailty is a physiological state of non specific vulnerability to stressors resulting from decreased physiological reserves and the deregulation of multiple physiological systems associated with advancing age.1 3 4 6 7 8 10 37 Conceptually, frailty is not just an association with specific diseases or disabilities but rather a systemic manifestation of physical and cognitive deficits, including the signs, symptoms, illnesses, and impairments that accumulate over the life course.8 37Empirically, a variety of methods have been used to quantify frailty, although the most common applications are the phenotypic approach and the frailty index.38 39 The phenotypic approach defines frailty on the basis of several items, such as weight loss, exhaustion,oyster perpetual datejust imitation, weakness, slowness, or low physical activity, and considers any three conditions as an indication of frailty.5 Alternatively, a frailty index focuses less on the specific deficits of people and more on the cumulative number of health deficiencies.8 15 Despite the similarities between these approaches, the choice of measurement is often dictated by the clinical outcome under investigation. Accordingly, recent research shows that frailty indices are more applicable for studying mortality than are phenotypic methods.8 38 39 In practice, most studies compute a frailty index as the proportion of cumulative health deficits to all possible deficits for a given individual.17Following earlier research, we constructed a frailty index using 39 variables that included objective, subjective, and proxy reports of cognitive functioning, disability,rolex datejust ii imitation, auditory and visual ability, depression, heart rhythm, and numerous chronic diseases (details available on request). Each item was assigned a value of 1 in the presence of a deficit (otherwise 0), and a value of 2 was assigned for people with two or more serious conditions that led to admission to hospital or a period of confinement in bed.13 We then constructed a frailty index by summarising all deficits and dividing by the total number of possible deficits.Although studies have shown that a frailty index does not require the same number or type of items to estimate accurate proportions of frailty levels,38 the items comprising our index are similar to those used in studies from Canada,15 the United States,8 and Hong Kong.13 We tested the validity and sensitivity of the frailty index by analysing several indices on the basis of differing combinations of variables. These results showed that as long as we included variables characterising each of the major domains of health (activities of daily living, instrumental activities of daily living, chronic illnesses, and cognitive functioning), the pattern of frailty with age remained consistent. In the Chinese longitudinal healthy longevity survey, levels of frailty increased exponentially from ages 65 to 100 and then levelled off (results not shown); therefore we split the frailty index into fourths for men and for women to account for non linear relations between levels of frailty and type of death.To obtain robust estimates we also adjusted analyses for several previously identified confounding factors.40 Various coding strategies were assessed for each measure and the results were similar; therefore, we dichotomised all of the confounding variables (except age). Measures of demographic background included age categorisations of 65 79 (reference group), 80 89, 90 99, and 100 and older, people from non Han ethnic minorities, and those living in urban areas. Measures of socioeconomic status included education (any formal education), primary lifetime occupation as a white collar worker, economic independence (primary financial source from own work or pension),imitation mens rolex oyster perpetual datejust watch, family in good economic standing (self rated as rich compared with other families in the community), and being in receipt of adequate drugs for any illnesses. Social contact and support measures included current marital status, close proximity to children (coresiding with biological or adopted children, including a spouse's child, or having one or more biological children living in the same village or street block), and religious activity almost every day or sometimes. Measures for health practices included exercising on a regular basis and having ever smoked in the past five years.Statistical analysisWe computed sample distributions of the study variables separately by sex and level of frailty. To test differences in the distributions of frailty for dichotomous variables we used Kendall's tests and for categorical variables Pearson's 2 tests. Multinomial logistic regression models were used to estimate the relative risk ratios and 95% confidence intervals associated with levels of frailty and the four types of death. We used two sets of nested regression models to adjust for the confounding risk factors. The first set of analyses tested the effects of frailty by sex while adjusting for basic personal information (age, ethnicity, and urban residence). In the second set of analyses we included the additional confounding variables for socioeconomic status, social contact and support, and health practices. We then computed the predicted proportions of the types of death (among decedents) across age and frailty for men and for women.All analyses were done using Stata version 10.1. Overall, few data were missing for study variables (41 Research shows that including variables related to sample selection produces unbiased estimates in the absence of weights42 and our preliminary analyses showed that the pattern of findings was consistent with those based on weighted data. Therefore we did not use weighted data in the regression analyses.ResultsTables 1 and 2 present the sample distributions of the study variables by sex and level of frailty. Among those in the lowest fourth (least frail) for frailty, 84.9% of men and 86.1% of women survived to 2005 compared with just over 25% of men and women in the highest fourth (most frail) for frailty. Among decedents, about 25% of men and women had fewer than 30 bedridden days before death, although women were less likely than men to suffer before death. A greater proportion of women than men had 30 or more bedridden days either with or without suffering before death. Those with the most frailty had the highest rates for all types of death. Men with the most frailty were more likely to suffer before death (17.9% withTable 1 Characteristics of men in 2002 wave of Chinese longitudinal healthy longevity survey by level of frailty. Values are percentages of participants unless stated otherwiseView this table:View popupView inlineAlthough men had a slightly younger age distribution (and death rates) than women, both sexes exhibited commensurate increases in age across levels of frailty. Similar proportions of men and women were from ethnic minority groups (about 6%) and lived in urban areas (about 43%); however, men and women from ethnic minority groups were less frail than those of Han ethnicity. There was no trivariate difference between sex, frailty, and urban residence. At nearly all levels of frailty men had higher socioeconomic status, were more likely to be married, took regular exercise, and had smoked in the past five years compared with women. Women were more likely to live close to their children and engage in religious activities compared with men. For both sexes, socioeconomic status, social contacts and support, and exercise declined across levels of frailty. Conversely, the proportion of participants who smoked was lower for men and women with higher levels of frailty.For both sexes the proportion of participants who did not suffer before death increased with age and the proportion who suffered decreased with age (figs 1 and 2). Across levels of frailty, the most pronounced patterns were the precipitous declines in the numbers of participants who experienced fewer than 30 bedridden days with suffering and increases in the number of participants who experienced 30 or more bedridden days with no suffering, particularly among women. Consistent with tables 1 and 2, the plotted probabilities also indicated that women were more likely to experience no suffering before death compared with men.Fig 1 proportion of type of death among deceased sample by age and sex in 2002 and 2005 waves of Chinese longitudinal healthy longevity survey
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