Dying comfortably in very old age with or without dementia in different care settings – a representative “older old” population study

A new study from the University of Cambridge, supported by the CLAHRC EoE suggests that very old people are more likely to die comfortably if they die in a care home or at home, compared with dying in a hospital. Yet while the overwhelming majority of very old people reported symptoms at the end of life such as distress, pain and depression, the study found that these were not always treated effectively.

The researchers argue that their findings highlight the need to improve training in end-of-life care for all staff, in all settings, and in particular to address the current shortage of palliative care doctors in the NHS.

As life expectancy increases, so more and more people are dying at increasingly older ages, often affected by multiple conditions such as dementia, heart disease and cancer, which make their end-of-life care complicated. In the UK, in just a quarter of a century the proportion of deaths occurring at the age of 85 or older has risen steeply from around a fifth in 1990 to almost half of all current deaths.

Older people living with dementia commonly report multiple symptoms as they approach the end-of-life, and if these symptoms are not adequately controlled, they may increase distress and worsen an individual’s quality of life.

While some people close to the end-of-life may prefer to die at home, only a minority of the ‘oldest old’ (those aged 85 years and above) actually die in their own homes. In the UK, fewer older people die in hospices or receive specialist palliative care at home than younger age groups, and the trend for older deaths is gradually moving away from death in hospital towards long-term care facilities.

Little is known about symptom control for ‘older old’ people or whether care in different settings enables them to die comfortably. To address this gap in our knowledge, researchers from the Cambridge Institute of Public Health examined the associations between factors potentially related to comfort during very old people’s final illness: physical and cognitive disability, place of care and transitions in their final illness, and place of death. This involved a retrospective analysis of data for 180 study participants aged between 79 and 107 years.

The researchers found that just one in 10 participants died without symptoms of distress, pain, depression and delirium or confusion, and most people had in fact experienced combinations of two or more of these symptoms. Of the treatable symptoms reported, pain was addressed in the majority, but only effectively for half of these; only a fraction of those with depression received treatment for their symptom.

Compared with people who died in hospital, the odds of being reported as having died comfortably were four times as high for people whose end-of-life care had been in a care home or who died at their usual address, whether that was their own home or a care home.

People living in the community who relied on formal services for support more than once a week, and people who were cared for at home during their final illness but then died in hospital, were less likely to have reportedly died comfortably.

The open access paper can be accessed here

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