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The Roger C. Lipitz Center for Integrated Health Care

Posted Date: April 29, 2014

Advance Directives, Severe Dementia, and End-of-Life Care
in the Community vs. Nursing Home

Susan Murrow, Lauren H. Nicholas,
and Emily Van Oeveren

 

More than 70 percent of elderly Medicare beneficiaries experience cognitive impairment or severe dementia near the end-of-life and may be unable to participate in health care decisions regarding their care. A new study published in the April 7 issue of Health Affairs  by Dr. Lauren Hersch Nicholas and colleagues, is believed to be the first to estimate the pervasiveness of cognitive impairment and dementia at the end-of-life and examine the aggressiveness of end-of-life care provided to these patients when they remain in the community versus living in a nursing home. 

Using data from the Health and Retirement Study (HRS) linked to Medicare claims, the authors discovered differences between care given to dementia patients in nursing homes and care given to patients remaining in their communities.1 Memory impaired patients living in the community were more likely to receive aggressive end-of-life care and potentially inappropriate care than those residing in nursing homes. Results suggest that advance directives may have an especially crucial role in treatment decisions for patients with severe dementia remaining in their communities.

In the study, aggressiveness of care was measured by the following three outcomes: in hospital death, intensive care unit (ICU) stays, and life-sustaining treatments. These treatments are often expensive,  and are associated with lower quality of life without improvements in survival for patients with dementia.

Advance directives were associated with receiving significantly less aggressive care at the end of life for community-dwelling older adults.2 These findings highlight the value of initiating advance care planning when cognitive impairment is first diagnosed and patients can still communicate their preferences if planning has not already occurred. 

Exhibit 1

Medicare Utilization In The Last Six Months Of Life Among Community-Based And Nursing Home Patients With Normal Cognition, Cognitive Impairment Without Dementia (CIND)/Mild Dementia, And Severe Dementia Who Died In The Period 1998–2007

 

Patients in:

 
 

Community (n = 2,064)

Nursing home (n = 1,812)

Difference (community−nursing home)

In-hospital death (%)

Normal cognition

35.2

23.8

11.3****

CIND/mild dementia

30.5

22.5

7.9****

Severe dementia

26.5

18.6

7.8***

ICU use (%)

Normal cognition

25.2

20.4

4.7**

CIND/mild dementia

20.2

17.3

2.8

Severe dementia

17.1

10.3

6.8***

   SOURCE Authors’ analysis of Health and Retirement Study core and exit interviews linked to Medicare claims
·       ↵** p<0.05 
·         ↵*** p<0.01
·         ↵**** p<0.001

Exhibit 2

Advance Directives And Medicare Utilization In The Last Six Months Of Life Among Patients With Normal Cognition, Cognitive Impairment Without Dementia (CIND)/Mild Dementia, And Severe Dementia Who Died In The Period 1998–2007

 

Patients in:

 

Community

Nursing home

 

Normal cognition

CIND/mild dementia

Severe dementia

Normal cognition

CIND/mild dementia

Severe dementia

In-hospital death (%)

No advance directive

35.8

32.7

31.8

27.2

23.8

20.6

Advance directive

35.2

27.5

13.9

17.9

19.3

14.6

Difference (percentage points)a

0.54

−5.2

−17.9****

−9.3***

−4.5

−6.0**

ICU use (%)

No advance directive

26.2

21.9

19.6

19.9

16.8

10.8

Advance directive

28.2

20.5

10.2

17.9

14.7

7.1

Difference (percentage points)a

2.0

−1.4

−9.4***

−2.0

−2.2

−3.7

 SOURCE Authors’ analysis of Health and Retirement Study core and exit interviews linked to Medicare claims.
·         ↵a AD−no AD.
·         ↵**p<0.05
·         ↵***p<0.01
·         ↵****p<0.001

REFERENCES

Nicholas LH, Bynum JPW, Iwashyna TJ, Weir DR, and Langa KM.  2014.  Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia.  Health Aff (Millwood), 33(4):667-674.