We are no longer allowed to write ‘old age’ as a reason for dying on a death certificate. However, becoming frailer with age makes people more vulnerable to life ending threats.
People become more frail with age. The severity and timing of this process is unpredictable. It is largely determined by genes and lifestyle. Apoptosis is a process determined by genes at the time of conception. It regulates the rate that your body deteriorates.
We will all become more frail as we age no matter how much we exercise and eat the right food. It will be manifest by reduced muscle bulk and strength; vital organ function deterioration, such as heart, lungs, liver and/or kidney; and demineralisation of bones. This will, in turn, become evident in ways such as decreased grip strength, poor balance and decreased gait speed.
We will gradually be less able to undertake more vigorous exercise; we will move from running to walking; walking more slowly; needing assistance to walk; less ability to perform activities of daily living such as cleaning the house, personal showering and dressing; being chairbound; and eventually being bed bound.
These states can be measured by frailty scales, which track the deterioration and give some indication of coming to the end of life.
As well as deterioration, there can be a more obvious life threatening event such as a fall due to increasing frailty. It can result in death at the time by complications such as bleeding, fractured ribs and head injury. It can also be a predictor of increasing frailty and moving towards the end of life.
Another common life-threatening event is infection such as urinary tract infection or pneumonia. Infection is also related to frailty which is associated with increasing vulnerability to infection as well as a decreased chance of recovery.
The elderly can also die of specific concurrent diseases as they age such as heart attacks, strokes and cancer. Dementia is a terminal disease, but the exact end-of-life trajectory is highly variable and people with dementia may also die of other concurrent conditions.
Uncertainty is inherent in medicine and accurately predicting the end of life is often not possible. However, anticipating the impact of ageing and frailty on the end of life is important because it facilitates early support of both the person and their caregivers.