Long-Term Outcomes of Advance Care Planning Among Older Adults with Cognitive Impairment and their Care Partners

Key Message : This session presents findings from a randomized controlled trial evaluating the long-term effect of advance care planning (ACP) conversations with cognitively impaired older adults and their care partners after 24 months. Findings underscore the importance of an iterative approach to ACP for better provider communication and increased readiness to engage.

Abstract:

Background: Advance care planning (ACP) that engages care partners of older adults with Alzheimer's disease and related dementias is important to ensure values and treatment preferences are discussed before cognitive impairment worsens(1-2). Little is known about the long-term effects of ACP in this population.

Objectives: To determine the sustained effect of facilitated ACP on quality of communication (QoC) about end-of-life care and readiness to engage in ACP at 24-months.

Methods: Patient-care partner dyads were randomized 1:1 to either an ACP intervention (SHARE) or usual care (N=273). This multicomponent communication intervention to engage and support ACP was delivered between baseline and 6 months to cognitively impaired adults 80+ and their family care partners(3). Outcomes were followed to 24 months. Group differences were compared using ANCOVA, adjusting for baseline scores and cognitive impairment level. Primary outcomes were care partner-reported QoC and readiness to engage in ACP collected at 6, 12, and 24 months(4).

Results: In total, 42% of dyads (n-114) completed 24-month assessments. Patients were average 87.1 years old and 63% had moderate or severe cognitive impairment at baseline. Care partners were mostly women (91.2%), average 65.5 years old, and predominantly adult children (66.7%). On average, they provided 19.3 hours of care weekly and accompanied patients to doctor visits for 8.1 years. QoC scores were low across intervention and control groups for care partners (3.34 vs. 3.18) and patients (2.86 vs. 2.18). Readiness to engage in ACP was slightly higher for care partners in the intervention group (26.63 vs. 25.64), while patient scores were similar (17.21 vs.17.55). No statistically significant differences were observed.

Conclusion: ACP conversations with cognitively impaired older adults and their care partners did not significantly affect long-term QoC or readiness to engage in ACP in this randomized trial. ACP within primary care for this population may require an iterative approach for ongoing benefit.

References: 1. Manly JJ, Jones RN, Langa KM, et al. Estimating the Prevalence of Dementia and Mild Cognitive Impairment in the US: The 2016 Health and Retirement Study Harmonized Cognitive Assessment Protocol Project. Archives of neurology (Chicago). 2022;79(12):1242–1249. doi:10.1001/jamaneurol.2022.3543

2. Sudore RL, MD, Lum, Hillary D., MD, PhD, You JJ, MD, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. Journal of pain and symptom management. 2016;53(5):821–832.e1. doi:10.1016/j.jpainsymman.2016.12.331

3. Wolff JL, Cagle J, Echavarria D, et al. Sharing health care wishes in primary care (SHARE) among older adults with possible cognitive impairment in primary care: Study protocol for a randomized controlled trial. Contemporary clinical trials. 2023;129:107208. doi:10.1016/j.cct.2023.107208

4. Wolff JL, Cagle JG, Hanna V, et al. Sharing health care wishes among older adults with cognitive impairment in primary care: Results from a randomized controlled trial. Alzheimer's & dementia. 2024;20(10):7263–7273. doi:10.1002/alz.14210