abedini et al w4

Clinical Investigation: The Relationship of Loneliness to End-of-Life Experience in Older Americans: A Cohort Study

Authors

  • Nauzley C. Abedini, MD, MSc

  • HwaJung Choi, PhD

  • Melissa Y. Wei, MD, MPH, MS

  • Kenneth M. Langa, MD, PhD

  • Vineet Chopra, MD, MSc

Objectives

  • Investigate the relationship between loneliness and end-of-life (EOL) experience, including:

    • Symptom burden

    • Intensity of care

    • Advance care planning
      among older adults.

Design

  • Study Type: Secondary analysis of the Health and Retirement Study (HRS)

  • Setting: Population-based

  • Participants: Decedents aged over 50 years who died between 2004-2014 (n = 8700)

    • Exclusions:

    • 2932 individuals ineligible for loneliness surveys

    • 2872 individuals with missing or incomplete loneliness or symptom data

Measurements

  • Loneliness determined via the three-item Revised UCLA Loneliness Scale from the most recent HRS survey before death

    • Outcomes reported by proxies for:

    • Total EOL symptom burden

    • Intensity of EOL care (e.g., late hospice enrollment, place of death, hospitalizations, use of life support)

    • Advance care planning

    • Results expressed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs)

Results

  • Loneliness Prevalence: One-third of the 2896 decedents (n = 942) were identified as lonely.

  • Impact on EOL Symptom Burden: After adjusting for demographics and various social factors:

    • Loneliness correlated with greater total symptom burden at EOL (ß = .13; P = .004).

  • Use of Life Support: Lonely decedents more likely to have used life support in the last two years:

    • 35.5% lonely decedents vs 29.4% nonlonely (aOR = 1.36; 95% CI = 1.08-1.71)

  • Place of Death: More lonely individuals died in nursing homes:

    • 18.4% lonely vs 14.2% nonlonely (aOR = 1.78; 95% CI = 1.30-2.42)

  • No Significant Differences: In other measures of intense care or likelihood of advance care planning.

Conclusion

  • Loneliness in older individuals can lead to increased symptom burden and exposure to more intense EOL care.

  • Calls for interventions to screen, prevent, and mitigate loneliness during the EOL phase.

Key Terms

  • Loneliness: Subjective feeling of isolation, lack of belonging, or companionship.

    • Affects approximately 40% of older adults and is linked to poor health outcomes:

    • Depression

    • Accelerated functional and cognitive decline

    • Early mortality.

  • Social Determinants of Health: Importance of loneliness emphasized in screening recommendations by:

    • National Academies of Sciences

    • Centers for Medicare & Medicaid Services.

Understanding Loneliness and EOL Outcomes

  • Common EOL challenges:

    • Role transitions

    • Shrinking social networks

    • Increased multimorbidity

  • Associated negative health outcomes may include:

    • Burden at EOL

    • Intense EOL care impact, potentially causing suffering for individuals and families.

Study Methodology

Data Source and Study Participants

  • HRS: Longitudinal survey for adults aged 51 and older, conducted biannually.

  • Sample: Individuals who died from 2004-2014; 2896 eligible decedents after exclusions.

Predictor Variable: Loneliness

  • Loneliness assessed via the 3-item Revised UCLA Loneliness Scale with responses indicating feelings of:

    • Being left out

    • Feeling isolated

    • Lacking companionship.

  • Classification of loneliness:

    • Nonlonely: Average score of 1.9 or less

    • Lonely: Average score of 2.0 or more.

    • Reliability: Cronbach's α = .81

Primary Outcome: Total Symptom Burden

  • Proxy reports on symptoms in the last year of life:

    • Items assessed included pain, difficulty breathing, severe fatigue, etc.

  • Composite scale created to evaluate total symptom burden, using:

    • Factor analysis (Eigenvalue > 1.0) and predictive regression models (Cronbach's α = .65).

Secondary Outcomes

  • Intensity of EOL care and advance care planning measured through:

    • Late hospice referral

    • Place of death (home, hospital, nursing home)

    • Use of life support and dialysis.

Covariates Considered

  1. Demographics: Age at death, sex, race, education, income, employment status

  2. Multimorbidity: Weighted index via self-reported chronic conditions

  3. Depressive Symptoms: Measured with CES-D with adjusted scoring

  4. Social Support: Relying on partner, children, friends for serious problems

Statistical Analysis

  • Utilized survey weights to adjust for design complexity during analyses.

  • Compared lonely and nonlonely participant characteristics using:

    • χ2 tests for categorical variables

    • t-tests for continuous variables

    • Statistical significance set at P < .05

  • Examinations: Loneliness related to individual symptoms via logistic regression and total symptom burden via multivariable regression.

Results Summary

  • Overall characteristics and differences between lonely and nonlonely decedents summarized (n = 2986 subject to various factors).

  • Notably higher symptoms reported by lonely decedents.

Discussion of Findings

  • Symptom Burden: Lonely individuals statistically associated with greater symptom burden.

  • EOL Care: Increased likelihood of aggressive interventions among lonely decedents without significant differences in advance care planning measures.

  • Policy Implications: Focus on identifying and addressing loneliness through screening and interdisciplinary interventions during EOL.

Limitations and Considerations

  • Reliance on proxies may introduce biases; variability in loneliness not accounted may influence findings.

  • Future studies needed to explore longitudinal interactions and refine loneliness measurements.