Table 3.
Association between Proxy Perception of Prognosis and Use of Burdensome Interventionsa among Nursing Home Residents with Advanced Dementia
| Characteristic | Total No. (%) of Assessment Intervals with Characteristicb (N=2031) |
No. (%) of Assessment Intervals in Which Resident had Any Burdensome Interventions (N=1097) |
Likelihood of a Burdensome Intervention Odds Ratioc (95% Confidence Interval) |
||
|---|---|---|---|---|---|
| With Characteristic Present |
With Characteristic Absent |
Unadjusted | Adjusted | ||
| Proxy Estimated Resident had < 6 Months to Live | 251 (12.4) | 89 (4.4) | 1008 (49.6) | 0.47 (0.35, 0.62)d | 0.46 (0.34, 0.62) |
| Resident Covariates | |||||
| Age > 87 (median) | 954 (47.0) | 490 (24.1) | 607 (29.9) | 0.81 (0.64, 1.02)d | 0.77 (0.61, 0.97) |
| Female | 1691 (83.3) | 917 (45.2) | 180 (8.9) | 1.13 (0.83, 1.52) | |
| White | 1837 (90.5) | 970 (47.8) | 127 (6.3) | 0.58 (0.40, 0.86)d | |
| Alzheimer’s disease | 1472 (72.5) | 781 (38.5) | 316 (15.6) | 0.89 (0.69, 1.14) | |
| Chronic obstructive pulmonary disease | 217 (10.7) | 120 (5.9) | 977 (48.1) | 1.00 (0.69, 1.44) | |
| Congestive heart failure | 318 (15.7) | 203 (10.0) | 894 (44.0) | 1.63 (1.19, 2.22)d | 1.63 (1.19, 2.24) |
| Diabetes | 357 (17.6) | 243 (12.0) | 854 (42.1) | 1.94 (1.41, 2.67)d | 1.91 (1.39, 2.63) |
| TSI = 0e | 1053 (51.9) | 501 (24.7) | 596 (29.4) | 0.57 (0.46, 0.72)d | 0.66 (0.52, 0.86) |
| BANS-S > 21 (median)f | 808 (39.8) | 373 (18.4) | 724 (35.7) | 0.58 (0.46, 0.74)d | 0.68 (0.53, 0.88) |
| Any new major illness in prior 3 monthsg | 109 (5.4) | 82 (4.0) | 1015 (50.0) | 2.59 (1.70, 3.96)d | 2.83 (1.84, 4.35) |
| Proxy Covariates | |||||
| Age > 61 (median)h | 941 (46.3) | 481 (23.7) | 606 (29.8) | 0.78 (0.62, 0.98)d | |
| Female | 1288 (63.4) | 671 (33.0) | 426 (21.0) | 0.86 (0.68, 1.08) | |
| Child of resident | 1268 (62.4) | 709 (34.9) | 388 (19.1) | 1.22 (0.97, 1.55)d | |
| Asked their opinion about goals of care by a nursing home provider | 953 (46.9) | 501 (24.7) | 596 (29.4) | 0.88 (0.74, 1.04) | |
Burdensome interventions included any of the following: hospital transfer (hospitalization or emergency room visits), parenteral therapy, new feeding tube insertion, venipuncture, and bladder catheterizations.
Analyses were at the level of assessment intervals. Resident chart reviews and proxy interviews were done at baseline and quarterly for up to 12 months. Proxy prognosis was taken from the interview done at the start of the interval. The use of burdensome interventions reflected the residents experience during the 3-month interval following that interview. Dynamic covariates were drawn from the assessment that best reflected the resident’s status during the interval of interest (e.g., any new major illness). Static variables were brought forward from baseline.
Unadjusted and adjusted odds ratio accounted for clustering among resident/proxy dyads using generalized estimating equations.
Variables that were significant at P < 0.10 in bivariable analyses and entered into the multivariable model.
TSI = Test for Severe Impairment, range 0–24, lower scores indicate greater cognitive impairment.
BANS-S = Bedford Alzheimer’s Nursing Severity-Subscale, range 7–28, higher scores indicate more disability.
Any new major illness included hip fracture, stroke, myocardial infarction, major gastrointestinal bleed, pneumonia, and/or new diagnosis of cancer (other than localized skin cancer).
Age missing for 18 proxies.