Advance Directives and Dementia Care

End-of-life care accounts for a large percent of all health spending.  Research in Health Affairs examines care and costs associated with cognitive impairment and dementia in community and nursing home settings.   (HA Article)  Survey data from the Health and Retirement Study was linked with Medicare claims data to study total Medicare spending in the 6 months before death, as well as number of in-hospital deaths, ICU stays and life-sustaining treatments.  Almost 4,000 beneficiaries were studied and 43% had mild dementia or cognitive impairment and 22% had severe dementia.  About 70% of patients with severe dementia were in nursing homes near the end-of-life, but 30% remained at home or in other community settings.  Only 36% of the patients with severe dementia had some form of advance directive, with more, about 40%, nursing home patients having them, than the respondents living in the community.  Severe dementia patients who were in nursing homes during the last 6 months of life were less likely to have an ICU stay and to die in a hospital than similar patients who lived in the community.  But there was no overall statistical difference in Medicare spending for the two groups.  For patients with more mild cognitive problems, however, a nursing home stay was associated with significantly higher Medicare spending, but these patients were also less likely to die in a hospital.  These patients with mild dementia showed no association between having an advance directive and higher Medicare spending, use of an ICU or in-hospital death.  For severe dementia patients, having an advance directive was associated with lower Medicare spending, less use of the ICU and other life-sustaining treatments and lower rates of in-hospital death.

The data support the notion that some degree of cognitive impairment is very common among the over-65 population.  Having an advance directive appears to help those with severe dementia avoid some treatments they apparently wished to avoid, and saves Medicare money.  This supports the goal of encouraging all Medicare-eligible people to establish advance directives, the earlier the better so that their care preferences are communicated before any cognitive decline sets in.