End-of-life experience for older adults in Ireland: results from the Irish longitudinal study on ageing (TILDA)

Abstract

Background: End-of-life experience is a subject of significant policy interest. National longitudinal studies offer valuable opportunities to examine individual-level experiences. Ireland is an international leader in palliative and end-of-life care rankings. We aimed to describe the prevalence of modifiable problems (pain, falls, depression) in Ireland, and to evaluate associations with place of death, healthcare utilisation, and formal and informal costs in the last year of life. Methods: The Irish Longitudinal Study on Ageing (TILDA) is a nationally representative sample of over-50-year-olds, recruited in Wave 1 (2009-2010) and participating in biannual assessment. In the event of a participant's death, TILDA approaches a close relative or friend to complete a voluntary interview on end-of-life experience. We evaluated associations using multinomial logistic regression for place of death, ordinary least squares for utilisation, and generalised linear models for costs. We identified 14 independent variables for regressions from a rich set of potential predictors. Of 516 confirmed deaths between Waves 1 and 3, the analytic sample contained 375 (73%) decedents for whom proxies completed an interview. Results: There was high prevalence of modifiable problems pain (50%), depression (45%) and falls (41%). Those with a cancer diagnosis were more likely to die at home (relative risk ratio: 2.5; 95% CI: 1.3-4.8) or in an inpatient hospice (10.2; 2.7-39.2) than those without. Place of death and patterns of health care use were determined not only by clinical need, but other factors including age and household structure. Unpaid care accounted for 37% of all care received but access to this care, as well as place of death, may be adversely affected by living alone or in a rural area. Deficits in unpaid care are not balanced by higher formal care use. Conclusions: Despite Ireland's well-established palliative care services, clinical need is not the sole determinant of end-of-life experience. Cancer diagnosis and access to family supports were additional key determinants. Future policy reforms should revisit persistent inequities by diagnosis, which may be mitigated through comprehensive geriatric assessment in hospitals. Further consideration of policies to support unpaid carers is also warranted.

Overprescribing among older people near end of life in Ireland: Evidence of prevalence and determinants from The Irish Longitudinal Study on Ageing (TILDA)

“…Our paper highlights that even in a setting with well-established palliative care services, the risk of inappropriate prescribing among people with limited life expectancy in significant. However, these deficiencies in patient experience must be understood in the context of other challenges; previous research in TILDA demonstrated strong evidence for undermanagement of illness symptoms near end of life, whereas overprescribing is a form of overtreatment [ 43 ].…”

Projecting future health and service use among older people in Ireland: an overview of a dynamic microsimulation model in The Irish Longitudinal Study on Ageing (TILDA)

“…TILDA-GRO linkage is scheduled for an update in 2022 and in future iterations we will update the model accordingly. TILDA collects usage across more than 20 categories of health care use 39 . We will incorporate all categories in future models, and then combine with unit costs for each category to model health care costs 40 .…”

Do Mini–Mental State Examination and Montreal Cognitive Assessment predict high‐cost health care users? A competing risks analysis in The Irish Longitudinal Study on Ageing

“…CAPI and SCQ follow‐up occurs at each Wave; health assessments were conducted again at Wave 3. In the event of a participant death, TILDA approaches a family member or close friend to complete a voluntary interview on end‐of‐life experience; full details including ethical procedures have been provided previously 3 . This study uses data up to and including Wave 5 (2018).…”

“…To identify additional predictors we drew on Andersen's model of predisposing, enabling, need characteristics and prior utilisation 16 ; and prior cost modelling using TILDA data 3 . The full list of predictors is provided in Table 1.…”

“…Health care costs are typically concentrated among a small minority of service users. [1][2][3] While health care use is associated with serious disease, functional impairment and proximity to death, high costs often reflect poor-quality and low-value care including unplanned hospital admissions and high-intensity care inconsistent with preferences. 4 The quality and value of care to this group might be achieved by better anticipation of complex needs and provision of new supports.…”