End‐of‐life burdensome interventions among Medicare fee‐for‐service beneficiaries with no dementia, non‐advanced dementia, and advanced dementia

Abstract

BackgroundOlder adults with dementia have difficulties communicating their treatment preferences and experience end‐of‐life burdensome interventions with discomfort and limited benefits. This study compared utilization of burdensome interventions during the last 90 days of life among Medicare fee‐for‐service (FFS) beneficiaries with no dementia, non‐advanced dementia, and advanced dementia.MethodThis study utilized data from 2000‐2016 Health and Retirement Study (HRS) linked with Medicare and Medicaid claims, and HRS Exit Interviews. We quantified rates of imaging tests and life‐sustaining treatments during the last 90 days of life among those with no dementia, non‐advanced dementia, and advanced dementia. Life‐sustaining treatments include tube feeding, intensive care unit care, cardiopulmonary resuscitation, and invasive mechanical ventilation. Among patients with a claims‐based diagnosis of dementia, we classified them as having advanced dementia if they had three or more activities of daily living limitations and any diagnosis of malnutrition, pressure ulcer, incontinence, or aspiration pneumonia. We used logistic regression to examine factors associated with end‐of‐life imaging tests and life‐sustaining treatments.ResultA higher proportion of beneficiaries with non‐advanced dementia (68%) and advanced dementia (79%) had end‐of‐life imaging tests, compared to those without dementia (57%) (p<0.01). Beneficiaries with dementia were more likely than non‐dementia beneficiaries to receive these imaging tests, controlling for patient characteristics (non‐advanced dementia: OR = 2.2 [95% CI 2.0‐2.5]; advanced dementia: OR = 5.4 [4.5‐6.5]). The proportion of receiving end‐of‐life life‐sustaining treatments was lower among the non‐advanced dementia cohort (23%), compared to non‐dementia (27%) and advanced‐dementia (27%) individuals (p<0.01). After adjusting for patient characteristics, beneficiaries with dementia were more likely than those without dementia to receive at least one life‐sustaining treatment (non‐advanced dementia: OR = 1.1 [1.0‐1.2]; advanced dementia: OR = 1.9 [1.6‐2.3]). Younger age, survey self‐respondents, beneficiaries with fewer instrumental activities of daily living limitations and no advance care planning were more likely to have end‐of‐life imaging tests and life‐sustaining treatments.ConclusionOur findings suggest that older adults with dementia, especially advanced dementia, are more likely to receive end‐of‐life burdensome interventions compared to individuals without dementia. Advance care planning involving patients with dementia, their families, and physicians about end‐of‐life treatment may improve the quality of care.

Racial and ethnic differences in disease course Medicare expenditures for beneficiaries with dementia

“…2,25 Previous research documents end of life care differences by race and ethnicity, with less use of advance care planning, hospice services, and more use of inpatient admissions and life-sustaining treatments in the last 90 days of life among non-Hispanic Black and Hispanic compared to non-Hispanic White beneficiaries. 26,27 Dementia is a progressive disease that evolves over time, and the care needs of individuals with dementia change as the disease progresses. Medicare is the largest payer for healthcare services for individuals with dementia, and Medicare expenditures for care for these populations are high.…”

2024 Alzheimer's disease facts and figures

“…One group of researchers found that Medicare beneficiaries with advanced dementia who lived in the community were 1.8 times as likely to receive life-sustaining treatments in the last three months of life, compared with individuals without dementia living in the community. 941 Individuals with frequent transitions between health care settings are more likely to have feeding tubes at the end of life, even though feeding tube placement does not prolong life or improve outcomes. 942 The odds of having a feeding tube inserted at the end of life vary across the country and are not explained by severity of illness, restrictions on the use of artificial hydration and nutrition, ethnicity or gender.…”

“…943 However, individuals with advanced dementia are significantly more likely to receive tube feeding in the last three months of life compared with those without dementia. 941…”

“…Although these interventions may not be consistent with patient preferences, individuals with Alzheimer's may be at greater risk for receiving these treatments. One group of researchers found that Medicare beneficiaries with advanced dementia who lived in the community were 1.8 times as likely to receive life‐sustaining treatments in the last three months of life, compared with individuals without dementia living in the community 941 . Individuals with frequent transitions between health care settings are more likely to have feeding tubes at the end of life, even though feeding tube placement does not prolong life or improve outcomes 942 .…”

“…Finally, with the increased focus on the lack of evidence supporting feeding tube use for people with advanced dementia, the proportion of nursing home residents receiving a feeding tube in the 12 months before death decreased from nearly 12% in 2000 to less than 6% in 2014 943 . However, individuals with advanced dementia are significantly more likely to receive tube feeding in the last three months of life compared with those without dementia 941 …”