Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment
Intensity
Lauren Nicholas
Jack Iwashyna
Ken Langa
David Weir
University of Michigan
June 29, 2010
Lauren Nicholas Jack Iwashyna Ken Langa David Weir
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Motivation
Motivation
End-of-life care is a controversial policy topic: Should
Medicare pay for discussions about end-of-life treatment
preferences?
Help to ensure patients life-sustaining treatment requests
honored, but raises concern about treatment denials
Care for beneficiaries with chronic illnesses during the last two
years of their lives accounts for about one-third of all
Medicare spending (Dartmouth Atlas Project)
It is unknown whether high-intensity, lifesaving efforts reflect
patient preferences
Many patients reach end-of-life without advance directives
Cognitive impairment likely to inhibit patients’ abilities to
provide informed consent
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Motivation
Cognitive Impairment is Common Near the End-of-Life
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Motivation
End-of-Life Preferences Not Well Documented Prior to
End of Life
Advance Directive
AD- All Possible Care
AD- limit EOL Care
AD- refuse certain Treatments
AD- Palliative Care Only
R consulted others about EOL
R has Power of Attorney
R talk about EOL
EOL decisions needed
R Participate in EOL decisions
EOL decision all care possible
Normal Cog
0.47
0.03
0.91
0.83
0.93
0.28
0.54
0.61
0.41
0.45
0.18
Nicholas et al.
CIND
0.43
0.06
0.90
0.82
0.95
0.28
0.53
0.56
0.41
0.32
0.18
Dementia
0.40
0.03
0.93
0.82
0.95
0.26
0.56
0.48
0.42
0.18
0.18
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Empirical Approach
Research Questions
1
Does end-of-life treatment intensity vary for cognitively
impaired and unimpaired older adults?
Intensive Care Unit
Life-Sustaining Medical Treatment
Hospice Care
2
Are advance directives related to differential use of end-of-life
treatment options?
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Empirical Approach
Data
Health and Retirement Study
Longitudinal, nationally representative survey of older
Americans
Collect demographic, health characteristics of respondents
including cognitive functioning assessment
Conduct exit interviews with next-of-kin after death of a
respondent including end-of-life treatments and preferences
86% of eligible respondents consent to Medicare claims
linkage, providing administrative records of health care
utilization for those aged 65 and above or disabled
Study population includes 4,339 decedents with assessed
cognitive functioning and linked Medicare data 4,245 also
have exit interviews
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Empirical Approach
Data
Cognitive Functioning in the End-of-Life Period
Cognitive functioning was determined by using a 35-point
cognitive scale for self-respondents, assessments of memory
and judgment for respondents represented by a proxy
Sample limited to decedents with a completed interview in the
wave prior to death
Cognitive functioning data used to classify respondents as
normal cognition, cognitively impaired non-demented (CIND),
or cognitively impaired based on an algorithm mapping HRS
question responses to clinical dementia screenings conducted
in the Aging, Demographics, and Memory Study
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Empirical Approach
Data
Medicare Claims: End-of-Life Treatment Intensity
Limit sample to beneficiaries enrolled in Fee-for-Service
Medicare for all of the 6 months prior to death
Use MEDPAR inpatient hospitalization records to capture
measures of end-of-life treatment intensity following Barnarto
(2009):
Life-Sustaining treatments: intubation/mechanical ventilation,
tracheostomy, gastrostomy tubes, hemodialysis, enteral or
parenteral nutrition, CPR
Intensive Care Unit
Hospice claims provide information about whether and how
long decedent received palliative hospice care
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Empirical Approach
Methods
Analytic Methods
Multivariate logistic regression models of end-of-life
treatments on respondent cognitive functioning and
demographic characteristics
All-decedent models examine odds of any hospitalization and
hospice use in the last six months of life
ICU usage and life-sustaining treatments conditional on
hospitalization
CIND and dementia pooled in cognitively impaired category,
results are similar for demented-only vs. normal or with 3
categories
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Results
Descriptive Statistics
HRS Decedents, 1998 - 2007
Any EOL Hospitalizations
EOL Hospice
Age at Death
Female
Non-White
Years Education
Household Wealth ($)
Household Income ($)
Married
Divorced
Widowed or Single
Observations
Normal Cog
0.60
0.33
78.2
0.46
0.10
12.19
303,705
35,488
0.53
0.09
0.37
1,816
Nicholas et al.
CIND
0.62
0.31
82.6
0.51
0.19
10.73
209,757
28,078
0.44
0.07
0.49
1,199
Dementia
0.56
0.32
85.7
0.59
0.21
9.68
149,104
21,558
0.36
0.06
0.58
1,324
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Results
Descriptive Statistics
Utilization at the End of Life
.4
.2
0
0
.2
.4
.6
Life-Sustaining Treatment
Cognitively Impaired and Unimpaired Decedents
.6
End of Life Hospitalization
Cognitively Impaired and Unimpaired Decedents
no CI
CI or CIND
no CI
CI or CIND
.4
.2
0
0
.2
.4
.6
Any Hospice
Cognitively Impaired and Unimpaired Decedents
.6
Any ICU Stay
Cognitively Impaired and Unimpaired Decedents
no CI
CI or CIND
Nicholas et al.
no CI
CI or CIND
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Results
Descriptive Statistics
Advance Directives and Treatment Intensity
Life-Sustaining Treatment
0
.1
.2
.3
.4
Cognitively Impaired and Unimpaired Decedents
no CI
CI or CIND
No AD
Nicholas et al.
no CI
CI or CIND
AD
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Results
Multivariate Results
Risk-Adjusted End-of-Life Treatment Intensity:
1998 - 2007
Any Hospitalization
Hospice
Cog. Impaired
0.95
[0.83,1.08]
0.94
[0.81,1.08]
Female
1.08
[0.95,1.22]
1.14
[0.99,1.30]
Non-White
1.12
[0.94,1.33] 0.60** [0.49,0.73]
Age < 70
1.35* [1.05,1.75]
0.71*
[0.54,0.94]
Age 75-80
1.25
[0.98,1.58]
0.94
[0.73,1.21]
Age 80-85
1.21
[0.96,1.52]
0.93
[0.73,1.18]
Age 85-90
1.33* [1.05,1.67]
0.95
[0.74,1.21]
Age 90+
1.06
[0.84,1.33]
1.15
[0.90,1.46]
Odds ratios and 95% confidence intervals
* (p<0.05), ** (p<0.01)
4,339 decedents enrolled in FFS Medicare.
Models include controls for year of death.
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Results
Multivariate Results
Risk-Adjusted End-of-Life Treatment Intensity:
Hospitalized Decedents 1998 - 2007
Intensive Care Unit
Inpatient Death
Life-sustaining
Cog Impair 0.68** [0.57,0.81]
0.98
[0.82,1.16]
0.82*
[0.67,0.99]
Female
1.14
[0.97,1.34]
1.03
[0.88,1.21]
0.99
[0.82,1.19]
Non-White 1.52** [1.22,1.89] 1.45** [1.15,1.81] 2.53** [2.01,3.19]
Age < 70
1.23
[0.89,1.71]
0.96
[0.69,1.34] 2.07** [1.46,2.94]
Age 75-80
1.15
[0.85,1.57]
1.09
[0.80,1.49]
1.24
[0.88,1.75]
Age 80-85
0.96
[0.71,1.28]
1
[0.74,1.34]
1.02
[0.73,1.42]
Age 85-90
0.77
[0.57,1.04]
0.98
[0.73,1.33]
0.88
[0.62,1.24]
Age 90+
0.58** [0.42,0.79]
0.82
[0.60,1.11]
0.63*
[0.44,0.90]
Odds ratios and 95% confidence intervals, * (p<0.05), ** (p<0.01)
2,579 decedents enrolled in FFS Medicare.
Models include controls for year of death.
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Results
Multivariate Results
Life-Sustaining Treatments in the Last Six Months of Life:
Hospitalized Decedents 1998 - 2007
Cognitively Impaired
Non-White
Intubation/Ventilation
0.8
[0.63,1.01]
2.15** [1.64,2.82]
Tracheostomy
0.72
[0.39,1.31]
1.24
[0.60,2.59]
CPR
0.85
[0.54,1.33]
1.87*
[1.12,3.10]
Hemodialysis
1.09
[0.72,1.64]
3.06** [2.02,4.64]
Gastrostomy
1.11
[0.76,1.62]
2.45** [1.66,3.62]
Any Feeding Tubes
1.02
[0.76,1.37]
2.19** [1.59,3.00]
Odds ratios and 95% confidence intervals, * (p<0.05), ** (p<0.01)
2,579 decedents enrolled in FFS Medicare.
Models include controls for year of death, age and sex.
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Results
Multivariate Results
Decedent Preferences and End-of-Life Treatment Intensity:
1998 - 2007
Any Hospitalization
Hospice
Cog. Impaired
0.91
[0.79,1.05]
1.06
[0.91,1.24]
<HS EDU
1.21*
[1.02,1.44]
0.99
[0.83,1.19]
HS grad
1.17
[0.98,1.38]
1.03
[0.86,1.23]
Advance Directive
0.71** [0.58,0.86]
1.19
[0.97,1.46]
R consult others EOL
1.46** [1.20,1.77] 1.48** [1.21,1.81]
Power of Attorney
1.01
[0.87,1.18] 1.32** [1.12,1.55]
R talk about EOL wishes 1.21** [1.05,1.39]
1.18*
[1.02,1.37]
Odds ratios and 95% confidence intervals
* (p<0.05), ** (p<0.01)
4,245 decedents enrolled in FFS Medicare with exit interviews.
Models control for age, race, sex, wealth, year of death.
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Results
Multivariate Results
Decedent Preferences and End-of-Life Treatment Intensity:
Hospitalized Decedents 1998 - 2007
Cog. Impaired
< HS EDU
HS grad
Advance Directive
Power of Attorney
R talk EOL wishes
Intensive Care
0.63**
[0.53,0.76]
1.29*
[1.03,1.62]
1.1
[0.87,1.37]
0.71*
[0.54,0.94]
0.9
[0.74,1.09]
0.91
[0.76,1.08]
Inpatient Death
0.92
[0.76,1.11]
0.99
[0.79,1.23]
0.96
[0.77,1.20]
0.76*
[0.58,0.98]
0.81*
[0.66,0.98]
0.85
[0.71,1.01]
Life-Sustaining
0.75** [0.61,0.93]
0.98
[0.76,1.27]
0.87
[0.67,1.12]
0.66**
[0.48,0.90]
0.98
[0.78,1.22]
0.9
[0.74,1.10]
Odds ratios and 95% confidence intervals, * (p<0.05), ** (p<0.01)
2,535 decedents enrolled in FFS Medicare with exit interviews.
Models control for age, race, sex, wealth, year of death.
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Conclusions and Policy Implications
Summary of Findings
58% of older adults hospitalized in the last 6 months of life
are moderately or severely cognitively impaired
Only 40% of this group has an advance directive
More than 41 of this group receive life-sustaining treatment
and 40% treated in ICU
Odds of aggressive treatment receipt are much higher for
minority seniors
Cognitively impaired and unimpaired face same odds of any
admission and in-hospital death
Power of attorney and associated with higher odds of hospice
use, less inpatient treatment intensity
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity
Cognitive Impairment and End-of-Life Treatment Intensity
Conclusions and Policy Implications
Policy Implications
Large proportion of decedents reach EOL without documented
treatment preferences and possible incapacity for informed
consent
Physician discussions earlier in life potentially helpful to create
awareness, decisions while unimpaired, emphasize advance
directives
Increased distribution of advance directives in outpatient
setting
Change default treatment options, less care rather all care
possible as automatic
Recognition of cognitive impairment as a terminal illness
Nicholas et al.
Cognitive Impairment and End-of-Life Treatment Intensity