Social Support is Key to Nursing Home Length of Stay Before Death

In a study of elderly Americans who moved to a nursing home for their final months or years of life, 65 percent died there within one year, according to an investigation by researchers at the San Francisco VA Medical Center and the University of California, San Francisco.

In the study, which appears in the online Early View section of the “Journal of the American Geriatrics Society,” the researchers found that length of stay before death in a nursing home was associated with differences in gender, net worth, and marital status.

Men had shorter lengths of stay before death than women, residents with higher net worth had shorter lengths of stay than those with lower net worth, and residents who were married or otherwise partnered had shorter lengths of stay before death than those who were single, says lead author Anne Kelly, MSW, a social worker at SFVAMC.

“It’s a matter of resources. People with more access to care and resources were able to stay in the community for longer before moving to a nursing home than those with less access,” explains Kelly. “One reason that men had shorter stays before death than women might be that women tend to outlive men, and so by the time a woman moves to a nursing home her partner is more likely to have died, whereas men are more likely to have a spouse or partner to care for them at home through the end of life.”

The association between social support and length of stay before death has broad social implications, says senior author Alexander K. Smith, MD, MS, MPH, a palliative medicine physician at SFVAMC and an assistant professor of medicine in the Division of Geriatrics at the University of California, San Francisco.

“One quarter of all deaths in the United States occur in nursing homes, and that figure is expected to rise to 40 percent by the year 2020,” says Smith. “At the same time, we know that nursing home care is incredibly expensive. This study suggests that if we can provide greater social support for patients who are less wealthy and have less caregiver support at home, we may be able to keep them out of nursing homes longer, which would probably have an impact on costs of care at the end of life.”

Smith describes the average and median length of stay before death as “surprisingly brief.” The implication, he says, is that “we need to engage nursing home residents in planning conversations about end-of-life care and treatment preferences very soon after they are admitted. We have only a brief amount of time to address their concerns before they become seriously ill.”

For the study, the authors analyzed data on 1,817 nursing home residents who died between 1992 and 2006. The residents were participants in the Health and Retirement Study, an ongoing nationally representative longitudinal study of health, retirement, and aging sponsored by the National Institute on Aging.

The average age of participants when they moved to a nursing home was about 83. The average length of stay before death was 13.7 months, while the median was five months. Fifty-three percent of nursing home residents in the study died within six months.

Men died after a median stay of three months, while women died after a median stay of eight months. Married participants died a median four months sooner than those who were unmarried. Participants in the highest quartile of net worth died a median six months sooner than those in the lowest quartile.

The differences in length of stay remained after the researchers adjusted for age, gender, marital status, health status, and other factors.

Smith cautions that the study did not examine quality of life for the nursing home residents in the study, or relate quality of life to length of stay, because those variables were not available to the study authors.

Co-authors of the study are Jessamyn Conell-Price, BA, of UCSF and Kenneth Covinsky, MD, MPH, Irena Stijacic Cenzer, MA, Anna Chang, MD, and W. John Boscardin, PhD, of SFVAMC and UCSF.

The study was supported by funds from the National Institute on Aging, the UCSF Clinical and Translational Science Institute, and the National Palliative Care Research Center. Some of the funds were administered by the Northern California Institute for Research and Education.

NCIRE - The Veterans Health Research Institute - is the largest research institute associated with a VA medical center. Its mission is to improve the health and well-being of veterans and the general public by supporting a world-class biomedical research program conducted by the UCSF faculty at SFVAMC.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.