JAMDA 13 (2012) 82.e7e82.e11

JAMDA

journal homepage: www.jamda.com

Original Study

What Factors Are Associated With Having an Advance Directive Among OlderAdults Who Are New to Long Term Care Services?

Karen B. Hirschman PhD, MSWa,b,c,*, Katherine M. Abbott PhD, MGS a,b, Alexandra L. Hanlon PhD a,Janet Prvu Bettger ScD a,d, Mary D. Naylor PhD, RN a,b,c,e

a School of Nursing, University of Pennsylvania, Philadelphia, PAbNewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PAc Institute on Aging, University of Pennsylvania, Philadelphia, PAdDuke University School of Nursing, Durham, NCe Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA

Keywords:Nursing homeassisted livingadvanced care planningPACE

This study was supported by “Health-Related QuLong-Term Care” (National Institute on Aging/NaResearch R01 AG025524, PI: Mary D. Naylor) and thProgram, University of Pennsylvania.* Address correspondence to Karen B. Hirschman

Pennsylvania, School of Nursing, 3615 Chestnut Stre334, Philadelphia, PA 19104.

E-mail address: hirschk@nursing.upenn.edu (K.B. H

1525-8610/$ - see front matter Published by Elsevierdoi:10.1016/j.jamda.2010.12.010

a b s t r a c t

Objectives: To explore differences in having an advance directive among older adults newly transitionedto long term services and support (LTSS) settings (ie, nursing homes [NHs]; assisted living facilities[ALFs]; home and community-based services).Design: Cross sectional survey.Setting: LTSS in New York and Pennsylvania.Participants: Participants were 470 older adults who recently started receiving LTSS. Included in thisanalyses, N ¼ 442 (ALF: n ¼ 153; NH: n ¼ 145; home and community-based services: n ¼ 144).Measurements: Interviews consisted of questions about advance directives (living will and health carepower of attorney), significant health changes in the 6 months before the start of long term care supportservices, Mini-Mental State Examination, and basic demographics.Results: Sixty-one percent (270/442) of older adults receiving LTSS reported having either a living willand/or an health care power of attorney. ALF residents reported having an advance directive morefrequently than NH residents and older adults receiving LTSS in their own home (living will: c2[2]¼120.9; P < .001; health care power of attorney: c2[2]¼ 69.1; P < .001). In multivariate logistic regressionmodels, receiving LTSS at an ALF (OR ¼ 5.01; P < .001), being white (OR ¼ 2.87; P < .001), having morethan 12 years of education (OR ¼ 2.50; P < .001), and experiencing a significant health change in past 6months (OR ¼ 1.97; P ¼ .007) were predictive of having a living will. Receiving LTSS at an ALF (OR ¼ 4.16;P < .001), having more than 12 years of education (OR ¼ 1.74, P ¼ .022), and having had a significantchange in health in the last 6 months (OR ¼ 1.61; P ¼ .037) were predictive in having an health carepower of attorney in this population of LTSS recipients.Conclusions: These data provide insight into advance directives and older adults new to LTSS. Futureresearch is needed to better understand the barriers to completing advance directives before and duringenrollment in LTSS as well as to assess advance directive completion changes over time for this pop-ulation of older adults.

Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.

In the United States, approximately 10million people residing inthe community or in institutional settings report the need for long-term services and support (LTSS).1 Approximately 50% of this

ality of Life: Older Adults intional Institute on Nursinge Marian S. Ware Alzheimer

, PhD, MSW, University ofet, Ralston Penn-Center, Rm.

irschman).

Inc. on behalf of the American Me

population is age 65 and older.1 Presently about 14% of the USpopulation is age 85 and older, and it is expected to grow to morethan 21% by 2050,2 thus increasing the need for LTSS. Withadvances in medicine and improvements in the management ofchronic diseases, this population of older adults will live longer butwith increased complexity of care needs.3 As this population growsand the need for LTSS increases so does the need for understandingadvance care planning within this population.

A critical first step is to better understand which older adultsnew to LTSS already have advance directives and what differencesexist among older adults new to LTSS. Advance directives,

dical Directors Association, Inc.

K.B. Hirschman et al. / JAMDA 13 (2012) 82.e7e82.e11 82.e8

specifically living wills and health care power of attorney(HCPOA), have received widespread attention since the PatientSelf-Determination Act (PSDA, Public Law No. 101e508) wasenacted in 1991. Advance directives allow an individual theopportunity to document their preferences for potentially life-saving medical treatment in the event he or she is unable tocommunicate. For older adults with multiple chronic illnesses,advance care planning, having health care preference discus-sions,4 and, specifically, putting preferences in writing, is criticalso that health care providers5 and family members,6 who are oftencalled upon to make decisions for their relatives, have someunderstanding of how to make decisions that best match thepatients’ preferences.

Among all older adults, the estimates of those with advancedirectives (ie, living wills or HCPOA) varies from 4% to 97%,7e10

depending on the sample of older adults and where those olderadults reside. For example, the prevalence of advance directivesamong older adults living at home and receiving community-basedservices (H&CBS), ranges from 1.5% to 20.0%.7 Among nursing home(NH) residents, the estimates of those with advance directives arehigher, ranging from 18% to 70%, depending on whether the dataare self-report or administrative (eg, Minimum Data Set).8e10

Limited data exist on the number of older adults with advancedirectives living in assisted living facilities (ALFs). The findings fromone survey of ALFs reported 48% to 69% of deceased ALF residentshad an advance directive, whereas family members reported muchhigher estimates (91% to 97%).11 There are no studies that haveestimated the prevalence of advance directives in ALFs based onresident self-report.

Although there is a growing body of literature that has esti-mated the prevalence of advance directives among older adultsliving in NHs and at home, little is known about advance directiveswhen older adults first transition into LTSS or the factors associatedwith having an advance directive for this population. No studies todate have compared older adults new to these 3 types of LTSS (eg,NH, ALF, and H&CBS) or compared the factors associated withhaving an advance directive among all 3 groups. The aim of thisstudy was to determine the factors associated with having anadvance directive among groups of older adults newly transitionedto receiving LTSS.

Methods

This study is part of a larger longitudinal study investigatingHealth-Related Quality of Life (HRQoL) in older adults new to LTSS.Data for this study come from the baseline interviews with newLTSS recipients.

The study was conducted in the Philadelphia, Pennsylvania, andNew York City, New York, metropolitan service areas. To be eligible,subjects werewithin 60 days of moving to an NH, ALF, or the start ofreceiving H&CBS; age 60 or older; could communicate in eitherEnglish or Spanish; and had a Mini Mental State Examination(MMSE) score of 12 or greater. Each study site had staff thatsystematically identified all potential subjects who were new totheir location (NH, ALF) or service (H&CBS) and referred the list ofnew LTSS members to an HRQoL study team member. A total of1311 (909 in Pennsylvania and 402 in New York) older adults werereferred by partnering agencies and approached to participatebetween March 2007 and July 2010.

An HRQoL study team member would approach the elder inperson, explain the study, and perform theMMSE. Older adults whoscored 23 or higher on the MMSE were considered capable toprovide written informed consent and eligible to enroll withoutproxy consent. For older adults who scored between 22 and 12 on

the MMSE, assent to participate was obtained from the LTSSrecipient and a legally authorized representative for the recipientwas contacted, the study was explained and written consent ob-tained for the LTSS recipient to participate. A total of 480 olderadults did not meet eligibility criteria primarily because of scoringlower than 12 on the MMSE and prior use of LTSS. Among thoseeligible to enroll (n ¼ 831), 308 (37.1%) declined to participate(reasons: lack of interest in research or did not want to spend timeparticipating) and 48 did not have a legally authorized represen-tative to co-sign or willing to co-sign the informed consent andwere not enrolled. Five individuals in the New York sample weredropped after enrollment for administrative reasons. A final sampleof 470 were enrolled into the HRQoL study (ALF: n ¼ 156; NH:n ¼ 158; H&CBS: n ¼ 156).

Baseline interview data presented here is based on questionsabout advance directives, cognition, significant health changes inthe 6 months before receiving LTSS, and demographics.

LTSS recipients were asked if they had an advance directive (eg,living will and HCPOA) at the time of the interview. A definition ofthe document was provided for each document type. Living willwas defined as a legal document that allows persons to state thekind of health care they do or do not want under certain circum-stances if they are unable to make the decision for themselves. LTSSrecipients were also asked if they had an HCPOA (yes/no/unsure);the definition included phrasing that allowed for other legaldocuments that identify someone to make health care decisionsalso known as a “health care proxy.” For both variables, if theanswer was “unsure” we collapsed this small group into the “no”category for analyses.

MMSE12 is a widely used tool that measures orientation to timeand place, recall ability, short-term memory, and arithmetic abilityin elderly patients. In general, scores higher than 23 indicate intactcognition, 20 to 23 indicate mild cognitive impairment, 19 to 12indicate moderate cognitive impairment, and lower than 12 indi-cate severe cognitive impairment.12

Katz Index of Activities of Daily Living13 (ADL) measures indi-viduals’ abilities to perform activities of daily living. The index wasself-rated or used with LTSS staff if the older adult scored lowerthan 23 on the MMSE. This 6-item instrument assesses indepen-dence or dependence in the activities of bathing, dressing, toileting,transferring, continence, and feeding. Scores range from 0 to 6 withhigher scores indicating better functional status. Inter-rater reli-ability of 0.95 and correct classification of 96% of people has beenreported using the instrument.14

Older adults were asked if they had any significant health statuschanges in the past six months (yes/no). Significance was left to theinterpretation of the elder in this self-reported item.

Basic demographic information included race (white/other),gender (male/female), age (continuous), education (continuous),marital status (dichotomous married/not married), and income(ordinal). Finally, older adults were classified by the type of LTSSthey were receiving (categorical: home and community-basedservices ¼ 1, assisted living ¼ 2, nursing home ¼ 3).

Descriptive statistics are presented. Standard parametric testswere used to make comparisons to describe the sample (eg, chi-squares, 1-way analysis of variance [ANOVA]). Finally, univariateand multivariate logistic regression were used to describe therelationship between older adult characteristics and advancedirectives among this population newly transitioned to LTSS. Onlyvariables significant at P¼ .25 were included in the final model. Thevariable for living will was not includedwhenmodeling HCPOA andvice versa.

This study was reviewed and approved by the site InstitutionalReview Boards at the University of Pennsylvania and the VisitingNurse Service of New York.

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Results

Of the 470 enrolled older adults, 28 interviews had incompletedata in one or more independent variables and were excluded fromthese analyses. A final sample of 442 older adults newly enrolled inLTSS with complete data at the baseline interview are presented(ALF: n ¼ 153; NH: n ¼ 145; H&CBS: n ¼ 144) (Table 1).

On average, older adultswere 81 years old (range: 60e98), female(71.0%),white (52.0%), had12or fewer years of education (59.7%), hadsome cognitive impairment (MMSE; mean: 24), and had moderatedeficits in basic activities of daily living (mean: 4.3� 1.9, range: 0e6)(Table 1). Thirty-nine percent of older adults had a significant healthchange in the6monthsbefore the start of LTSS.Whenadjusted by thetype of long term care (LTC) service, ALF residents were significantlyolder (mean: 87 years) than NH residents (mean: 77 years) or olderadults receiving H&CBS (mean: 79 years) (1-way ANOVA: c2[2] ¼24.8, P < .001). A significant number of male older adults resided inNHs (42.8%) than in ALFs (16.3%) or in their own homes (28.5%)(c2[2] ¼ 25.3, P < .001). ALF residents were more likely to be white(93.5%) in comparison with NH residents (32.4%) and older adultsreceivingH&CBS (27.8%;c2[2]¼ 161.5, P< .001). ALF residents (66.7%)were more likely to have more than 12 years of education incomparison with NH residents (34.5%) and older adults receivingH&CBS (18.1%; c2[2]¼ 75.9, P< .001). NH residents had lower MMSEscores (mean: 22) than older adults receiving H&CBS (mean: 24) orALF residents (mean: 25) (1-way ANOVA: c2[2] ¼ 25.1, P < .001).Finally,NHresidentshadsignificantlymoredeficits in function (ADLs;mean: 3.5) than older adults receiving H&CBS (mean: 4.5) or ALFresidents (mean: 5.0) (1-way ANOVA: c2[2] ¼ 29.2, P < .001).

Do Older Adults have Advance Directives When they StartReceiving LTSS?

Sixty-one percent of older adults receiving LTSS reported havingan advance directive (either a living will, HCPOA, or both). Most ALFresidents reported having an advance directive when they wereinterviewed (ALF: have a living will: 84.3%; have an HCPOA: 79.7%)in comparison with fewer than half of NH residents (NH: havea living will: 39.1%; have an HCPOA: 40.7%) or older adults receivingH&CBS (H&CBS: have a living will: 22.9%; have an HCPOA: 36.1%)(living will: c2[2] ¼ 120.9; P< .001; HCPOA: c2[2] ¼ 69.1; P < .001).Forty-one percent of older adults receiving LTSS had both types ofadvance directives, most commonly in the ALF group (112/153,73.2%). Thirty-nine percent of older adults had neither type ofdocument, with the H&CBS group having the greatest percentage ofindivduals who had neither document (92/144, 63.9%).

What Factors are Associated with Having an Advance DirectiveAmong LTSS Recipients?

Univariate analyses identified several factors associated witholder adults reporting having a living will. First, the type of LTSS

Table 1Demographics and Characteristics of Long-Term Services and Support Recipients (N ¼ 4

All N ¼ 442

Age, y, mean � SD (range) 81.0 � 8.8 (60e98)MMSE Score, mean � SD (range) 24.1 � 4.2 (12e30)Functional Status (Katz), mean � SD (range) 4.3 � 1.9 (0e6)Male, n (%) 128 (29.0%)Education, >12 y, n (%) 178 (40.3%)White, n (%) 230 (52.0%)Significant change in health in past 6 months, n (%) 172 (38.9%)

See Methods section for inclusion and exclusion criteria. Subjects had to score 12 or higMMSE, Mini Mental State Examination.

was significant, with the odds of an older adult having a living willbeing 18.08 times higher if the older adult was receiving LTSS in anALF than at home (95% Confidence Interval [95% CI]: 10.08e32.40,P � .001). The odds of having a living will were 2.18 times greaterfor older adults receiving LTSS in an NH than at home (95% CI:1.31e3.64, P ¼ .003). For age, the odds of having a living willincreased by a factor of 1.06 for each 1-year increase in the age ofthe LTSS recipient (95% CI: 1.03e1.08, P � .001). Older adults withmore than 12 years of education had an odds of having a living will5.33 times higher than older adults with 12 or fewer years ofeducation (95% CI: 3.51e8.09, P� .001). For each 1-point increase inMMSE score, the odds of having a living will increased by a factor of1.07 (95% CI: 1.03e1.12, P¼ .002). Being white increased the odds ofhaving a living will by 7.43 in comparison with non-white olderadults new to LTSS (95% CI: 4.87e11.32, P � .001). Older adultsreceiving LTSS who reported having a significant change in healthstatus in the past 6 months had an odds of having a living will 2.14times higher than older adults who did not report a significantchange in the past 6 months (95% CI: 1.45e3.17, P � .001). Func-tional status (odds ratio [OR] ¼ 1.09, 95% CI: 0.99e1.21, P ¼ .087),although not significant at .05, was significant at the P is less than orequal to .25 level for reporting having a living will andwas includedin the building of the final model. Gender was not significant inunivariate analyses for having a living will.

Univariate analyses for HCPOA revealed that the type of LTSSincreased the odds of having an HCPOA but only for those olderadults in ALFs as compared with older adults receiving services athome (H&CBS: reference group; ALF: OR¼ 6.96, 95% CI: 4.14e11.72,P � .001; ALF: OR ¼ 1.21, 95% CI: 0.76e1.95, P ¼ .424). For age, each1-year increase in the age of the LTSS recipient increased the oddsof having an HCPOA by a factor of 1.05 (95% CI: 1.03e1.08, P � .001).Among LTSS recipients with more than 12 years of education theodds of having an HCPOA was 3.13 times higher than those LTSSrecipients with 12 or fewer years of education (95% CI: 2.10e4.68,P � .001). Being white increased the odds of having an HCPOA by3.41 in comparison with non-white older adults new to LTSS (95%CI: 2.31e5.04, P � .001). Among LTSS recipients who reporteda significant change in health status in the past 6 months, the oddsof having an HCPOA was 1.74 times higher than recipients who didnot report a significant change in health in the past 6 months (95%CI: 1.18e2.56, P ¼ .005). For each 1 point increase in MMSE score,the odds of having an HCPOA increase by a factor of 1.05 (95% CI:1.01e1.10, P ¼ .022). Being male (OR ¼ 1.17, 95% CI: 0.77e1.77,P¼ .46) and functional status (OR¼ 1.09, 95% CI: 0.99e1.21, P¼ .08),although not significant at .05, were significant when the P is lessthan or equal to .25 level for reporting having an HCPOA and wereincluded in the building of the final model.

In univariate analyses, the odds of having either type of writtenadvance directive were 17.56 times greater for ALF residents (95%CI: 9.20e33.52; P � .001) and 2.12 times greater for NH residents(95% CI: 1.32e3.39; P ¼ .002) in comparison with older adultsreceiving LTSS in their own home (H&CBS ¼ reference group). The

42)

Assisted LivingFacility n ¼ 153

Nursing Homen ¼ 145

Home & CommunityBased Services n ¼ 144

86.3 � 6.0 (62e98) 76.7 � 9.1 (60e97) 79.1 � 7.7 (63e97)25.4 � 3.8 (13e30) 22.3 � 4.9 (12e30) 24.7 � 3.2 (14e30)5.0 � 1.4 (0e6) 3.5 � 2.1 (0e6) 4.5 � 1.7 (0e6)25 (16.3%) 62 (42.8%) 41 (28.5%)

102 (66.7%) 50 (34.5%) 26 (18.1%)143 (93.5%) 47 (32.4%) 40 (27.8%)68 (44.4%) 69 (47.6%) 35 (24.3%)

her on the MMSE to enroll.

K.B. Hirschman et al. / JAMDA 13 (2012) 82.e7e82.e11 82.e10

odds of having either written advance directive increased bya factor of 1.05 for each 1-year increase in the age of the LTSSrecipient (95% CI: 1.03e1.08, P < .001). Among LTSS recipients withmore than 12 years of education, the odds of having either writtenadvance directive was 4.41 times higher than those LTSS recipientswith 12 or fewer years of education (95% CI: 2.83e6.85, P � .001).Among white LTSS recipients, the odds of having a written advancedirective were 4.46 times greater than non-white LTSS recipients(95% CI: 2.96e6.74, P < .001); reporting a significant change inhealth in the past 6 months increased the odds of having any formof written advance directive by a factor 1.85 (95% CI: 1.23e2.77,P ¼ .003).

Final models were constructed to predict having a living will, anHCPOA, or either advance directive (Table 2). Factors associatedwith having a living will in the multivariate logistic regressionmodel were living in an ALF (OR ¼ 7.48, 95% CI: 3.71e15.04,P < .001), more than 12 years of education (OR ¼ 2.50, 95% CI:1.51e4.16, P < .001), being white (OR ¼ 2.87, 95% CI: 1.65e4.99,P < .001), and having had a significant change in their health in thepast 6 months (OR ¼ 1.97, 95% CI: 1.20e3.24, P ¼ .007). In multi-variate logistic regression for HCPOA, only living in an ALF(OR ¼ 4.10, 95% CI: 2.15e7.80, P < .001), more than 12 years ofeducation (OR ¼ 1.74, 95% CI: 1.08e2.78, P ¼ .022), and having hada significant change in health in the past 6 months (OR ¼ 1.61, 95%CI: 1.03e2.51, P ¼ .037) were significant factors in having an HCPOAin this population of new LTSS recipients. In multivariate logisticregression for having any advance directive, living in an ALF(OR ¼ 5.25, 95% CI: 2.49e11.05, P < .001) or an NH (OR ¼ 1.75, 95%CI: 4.39e19.31, P ¼ .024) and more than 12 years of education(OR ¼ 2.22, 95% CI: 1.34e3.66, P ¼ .002) were significant factors inhaving any type of advance directive in this population of new LTSSrecipients.

Discussion

The aim of this study was to determine the factors associatedwith having an advance directive among groups of older adults newto long-term services and supports. Although 61.1% (270/442) ofolder adults receiving LTSS reported having a living will, a durablepower of attorney for health care, or both, most of these olderadults live in ALFs (139/153, 90.8%). This study highlights that someolder adults new to LTSS do have advance directives, but there aresignificant differences with respect to education, race, type of LTSS,and health status changes in the past 6 months associated withhaving an advance directive. These data shed light on 3 important

Table 2What Factors Are Associated with Having an Advance Directive? Multivariate Logistic Re

Multivariate

Living Will

OR (95% CI)

LTSSHome & Community Based Services ref groupAssisted Living Facilities 7.48 (3.72e15.04)z

Nursing Homes 1.49 (0.82e2.71)Age, y 0.99 (0.96e1.02)MMSE score 0.99 (0.93e1.05)Education, >12 y 2.50 (1.51e4.16)z

White 2.86 (1.65e4.99)z

Significant change in health in past 6 months 1.97 (1.20e3.24)y

Functional Status (Katz) 0.95 (0.83e1.08)

CI, confidence interval; HCPOA, Health Care Power of Attorney; LTSS, Long-Term Service*P < .05.yP < .01.zP < .001.

insights into predictors of having an advance directive among olderadults new to long-term support services.

First, older adults receiving LTSS in their own homes are lesslikely at the start of LTSS to have any written advance directives incomparison with older adults receiving LTSS in an NH or ALF. Thismay be in part because NH and ALF residents may be seeing healthcare providers more frequently in the setting in which they residein comparison with older adults who receive LTSS at home. Find-ings from this study reveal that older adults living in ALFs areputting together advance directives in significantly greaterpercentages than their peers in NHs or H&CBS. It is possible that theALF group plans over an extended period of time before tran-sitioning to the ALF setting than those individuals who receive LTSSin NHs or in their own home. In addition, this population wassignificantly older than the NH and H&CBS groups but age was notsignificant in multivariate models. Findings from interventionstudies with older adults in the primary care setting indicate thatolder age was associated with greater advance directive comple-tion.15,16 However, once age was controlled for in the multivariatemodel it was no longer a significant predictor of having an advancedirective at the start of LTSS for this population. Overall, the reportof having an advance directive was higher than previously reportedpercentages for these populations. One potential reason for thishigher percentage may be that LTSS organizations are requiringadvance directives as part of the admission to an ALF or NH or aspart of the H&CBS enrollment. Another reason may be that theseolder adults report having put documents together but have notprovided copies to the LTSS provider as has been found in otherresearch.11 This was unknown for these sites and population anda limitation of the study. Finally, further investigation into simi-larities and differences between LTSS recipients’ advance directivecompletion in other areas of the United States as well as the char-acteristics of those LTSS is needed.

Second, older adults experiencing a significant health change inthe last 6 months was predictive of having either a living will or anHCPOA after controlling for other independent variables. This couldindicate that many of these older adults are experiencing healthstatus changes, which may have precipitated their transition toreceiving LTSS, and could have been the catalyst in the completionof an advance directive.17 It is possible that the discussions withhealth care professionals, either during or after a hospital stay orduring a primary care visit, could be influencing the completion ofadvance directives for this population. Alternatively, it may be thatthe population completing an advance directive has multiplehealth problems and planning has been part of the health care and

gression

HCPOA Advance Directive (Any vs None)

OR (95% CI) OR (95% CI)

ref group ref group4.10 (2.15e7.80)z 9.20 (4.39e19.31)z

0.98 (0.57e1.69) 1.75 (1.08e2.85)*1.00 (0.98e1.04) 1.00 (0.97e1.03)1.00 (0.94e1.06)1.74 (1.08e2.79)* 2.21 (1.34e3.66)y

1.29 (0.77e2.17) 1.53 (0.92e2.56)1.61 (1.03e2.51)* 1.48 (0.93e2.35)0.99 (0.88e1.11)

s and Support; MMSE, Mini Mental State Examination;OR, odds ratio.

K.B. Hirschman et al. / JAMDA 13 (2012) 82.e7e82.e1182.e11

life process. Because we do not know at what point in time theadvance directive was created, only that they report having anadvance directive, future research into this relationship is needed.

Third, after controlling for demographics, several patient char-acteristics were predictive of having an advance directive. Educa-tionwas significant regardless of type of advance directive and racewas significant for having a living will. This finding is similar toother research on living will completion, which shows that whiteolder adults are more likely to complete a living will10,18 and olderadults with less than a high school education are less likely tocomplete a living will.19 The finding that location of LTSS (NH, ALF,or H&CBS) and education were the only significant predictors ofhaving any type of advance directive would appear to indicate thata communal setting (ie, ALF or NH) and having more than 12 yearsof education are predictive of having an advance directive at thestart of LTSS. This population of older adults receiving LTSS at homemay put together these documents over time as they begin toreceive services. Future longitudinal research to assess the naturaltrajectory of changes in advance directive completion over time forH&CBS recipients is needed. Regardless of previous findings onadvance directive completion, these are the first data, to ourknowledge, to compare having an advance directive in multipleLTSS populations at the start of receiving services.

Finally, an additional limitation for this study is the inclusion ofolder adults with “moderate” cognitive impairment as is defined byMMSE cut points (MMSE: 12e19). Becausewe included older adultswith moderate cognitive impairment, it is possible that their recallin having a living will or HCPOA was inaccurate. Unfortunately, wewere unable to verify their self-report data with the actual copy ofthe advance directive to confirm or negate the information. Anal-yses were run with only those subjects with MMSE scores higherthan 20 (mild cognitive impairment to normal cognition) in themultivariate logistic regression models and the results were thesame. Therefore, we feel confident in our results with this broaderpopulation. In addition, LTSS recipients with normal cognition andmany with mild impairment can still fully contribute to discussionsabout health care preferences, thus leaving time for conversationsto occur and documentation to be put into place. LTC providers (eg,physicians, nurses, social workers) play a critical role in elicitingand discussing the health care preferences of these older adults andrevisiting these discussions with LTSS recipients and their familymembers, as needed.

Conclusion

These data provide insight into advance directives and olderadults new to LTSS and further highlight that non-white olderadults with a high school education or less are less likely to havea living will at the start of LTSS. Recent research supports thecontinued use of advance directives20 as a way to either documenthealth care preferences (ie, living will) or convey health carepreferences to a proxy decision maker (ie, HCPOA) and can helpproviders guide care at the end of life. Education of older adultsreceiving LTSS, proxy decisionmakers, and LTC service providers onadvance directive types and usefulness before the older adult can

no longer participate in the preference discussion is key. This willhelp LTSS recipients and proxy decision makers, most often familycaregivers, make end-of-life decisions based on what the patientwould have wanted.

Acknowledgments

The authors thank the older adults participating in the HRQoLstudy, the HRQoL study staff, as well as the HRQoL advisorycommittee, consisting of staff from the various long term care site/organizations that have provided guidance throughout the dura-tion of the study.

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