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David Oliver: “Progressive dwindling,” frailty, and realistic expectations

BMJ 2017; 358 doi: (Published 05 September 2017) Cite this as: BMJ 2017;358:j3954

Re: David Oliver: “Progressive dwindling,” frailty, and realistic expectations

‘Progressive dwindling’ or ‘terminal decline’ and end-of-life care.

David Oliver’s commentary highlights the some of the difficulties faced by geriatricians responsible for the care of frail older adults. Accumulating evidence shows that a key aspect of the frailty syndrome is its relation to adverse outcomes including hospital admissions, falls, fractures and mortality.1-4 Oliver adopts the terminology of ‘progressive dwindling’ to refer to the progressive and accelerating functional decline that may occur at the end-of-life in very old people. Other writers have referred to this process as one of ‘terminal decline’ or ‘terminal drop.’ 5 Empirical evidence of terminal decline has been reported for cognitive functioning, 6 and subjective health measures.7 Our recent study using electronic health records in people aged 80 years and over, revealed a substantial terminal decline in blood pressure in the final two years of life that was not observed in patients who did not die.8 Diehr and colleagues observed that ‘It is difficult to distinguish changes in health due to aging from those related to dying.’7 Researchers and clinicians should aim to determine whether these processes are distinguishable in order to improve end-of-life care for older people.

Rathi Ravindrarajah, Research Associate
Martin Gulliford, Professor of Public Health
King’s College London, School of Population Health Sciences

1. Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age and Ageing 2016 doi: 10.1093/ageing/afw039

2. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. The Lancet 2013;381(9868):752-62. doi: 10.1016/S0140-6736(12)62167-9

3. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. The journals of gerontology Series A, Biological sciences and medical sciences 2001;56(3):M146-56. [published Online First: 2001/03/17]

4. Xue Q-L. The Frailty Syndrome: Definition and Natural History. Clinics in geriatric medicine 2011;27(1):1-15. doi: 10.1016/j.cger.2010.08.009

5. Palmore E, Cleveland W. Aging, terminal decline, and terminal drop. Journal of gerontology 1976;31(1):76-81. [published Online First: 1976/01/01]

6. Siegler IC. The terminal drop hypothesis: Fact or artifact? Experimental Aging Research 1975;1(1):169-85. doi: 10.1080/03610737508257957

7. Diehr P, Williamson J, Burke GL, et al. The aging and dying processes and the health of older adults. J Clin Epidemiol 2002;55(3):269-78. [published Online First: 2002/02/28]

8. Ravindrarajah R, Hazra NC, Hamada S, et al. Systolic Blood Pressure Trajectory, Frailty and All-Cause Mortality Over 80 Years of Age. Cohort Study Using Electronic Health Records. Circulation 2017 doi: 10.1161/circulationaha.116.026687

Competing interests: No competing interests

12 September 2017
Rathi Ravindrarajah
Research Associate
Professor Martin Gulliford
King's College London