Acceleration of health deficit accumulation in late-life: Evidence of terminal decline in frailty index three years before death in the US Health and Retirement Study

Erwin Stolz, Hannes Mayerl, Emiel O Hoogendijk, Joshua J Armstrong, Regina Roller-Wirnsberger, Wolfgang Freidl

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Background: Little is known about within-person frailty index (FI) changes during the last years of life. In this study, we assess whether there is a phase of accelerated health deficit accumulation (terminal health decline) in late-life. Material and methods: A total of 23,393 observations from up to the last 21 years of life of 5713 deceased participants of the AHEAD cohort in the Health and Retirement Study were assessed. A FI with 32 health deficits was calculated for up to 10 successive biannual, self- and proxy-reported assessments (1995–2014), and FI changes according to time-to-death were analyzed with a piecewise linear mixed model with random change points. Results: The average normal (preterminal) health deficit accumulation rate was 0.01 per year, which increased to 0.05 per year at approximately 3 years before death. Terminal decline began earlier in women and was steeper among men. The accelerated (terminal) rate of health deficit accumulation began at a FI-value of 0.29 in the total sample, 0.27 for men, and 0.30 for women. Conclusion: We found evidence for an observable terminal health decline in the FI following declining physiological reserves and failing repair mechanisms. Our results suggest a conceptually meaningful cut-off value for the continuous FI around 0.30.

Original languageEnglish
Pages (from-to)156-161
Number of pages6
JournalAnnals of epidemiology
Early online date1 Apr 2021
Publication statusPublished - Jun 2021


  • aged
  • aged 80 and over
  • death
  • frailty
  • geriatrics
  • repeated rounds of survey

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