Advance Directives Among Nursing Home Residents with Mild, Moderate and Advanced Dementia (S715)

Abstract

•An understanding of which demographic factors are most likely to impact completion of advance directives in nursing home residents with dementia.•An understanding of which clinical stages of dementia are most likely to be associated with advance directives among nursing home patients. For nursing home residents with complex care needs, particularly those with dementia, advance directives (ADs) provide essential guidance around medical decision-making. Identifying factors affecting AD completion is crucial to improving patient-centered care and efficiency of care in this population. To describe the prevalence of ADs among nursing home residents with mild, moderate, or advanced stage dementia and resident factors associated with ADs. We constructed a cohort of nursing home residents from five states in the U.S. (Minnesota, Massachusetts, Pennsylvania, Florida, California) in 2007 and 2008. Residents were identified and assessed using the Minimum Data Set 2.0 (MDS) linked to Medicare claims (Parts A and D) and the Medicare denominator file. Eligible residents were aged 65 and older and had a duration of stay ≥90 days and a diagnosis of dementia and a Cognitive Performance Scale (CPS) score ≥ 1. Stage of dementia was classified using the CPS. ADs were defined as the presence of a living will; do-not-resuscitate order (DNR); or do-not-hospitalize (DNH) order, medication restriction, and feeding restriction. Logistic regression was used to identify resident characteristics associated with ADs. The final sample size was 226,926. Overall, forty percent (n=91,547) had no AD. Presence of DNR, DNH, feeding restriction and medication restriction orders increased with dementia severity. In adjusted analysis, older age, female sex, white race, higher education, and being married or widowed were associated with the presence of an AD (all p’s < .001). ADs are more common among nursing home residents with advanced stages of dementia. Presence of ADs is influenced by a number of demographic factors.