University of Massachusetts Medical School Faculty Publications


Advance Directives among Nursing Home Residents with Mild, Moderate, and Advanced Dementia

UMMS Affiliation

Department of Quantitative Health Sciences

Publication Date


Document Type



Geriatrics | Health Services Administration | Mental Disorders | Nervous System Diseases | Palliative Care


OBJECTIVE: To describe prevalence and content of AD documentation among NH residents by dementia stage.

BACKGROUND: The prevalence of advance directives (ADs) among nursing home (NH) residents with mild, moderate, and advanced dementia remains unclear.

METHODS: Population-based, cross-sectional study of all licensed NHs in five U.S. states. Subjects included all long-stay ( > 90 day) NH residents with dementia, aged > /=65 years, and a Cognitive Performance Scale (CPS) score > /=1 from the 2007 to 2008 Minimum Data Set 2.0 (n = 180,621). Dementia severity was classified as follows: mild (CPS 1-2), moderate (CPS 3-4), and advanced (CPS 5-6).

MEASUREMENTS: ADs were defined as the presence of a living will, do-not-resuscitate order, do-not-hospitalize order, medication restriction, or feeding restriction).

RESULTS: Overall, 59% of residents had any AD and 17% had a living will. Prevalence of any AD increased by dementia severity: mild (51.2%), moderate (58.2%), and advanced (61.5%) (p < 0.001). In adjusted analysis, resident characteristics associated with any AD documentation included older age, female gender, being white, and having more severe dementia. Having a living will was associated with higher education ( > /=high school graduate vs. some high school or less) and being married.

DISCUSSION: While dementia severity was associated with greater likelihood of having documented any AD, almost 4 in 10 residents with dementia lacked any AD. Effective outreach may focus efforts on subgroups with lower odds of any AD or living wills, including non-white, less educated, and unmarried NH residents. A greater understanding of how such factors impact care planning will help to address barriers to patient-centered care for this population.


advance directives, dementia, nursing home

DOI of Published Version



J Palliat Med. 2017 Aug 3. doi: 10.1089/jpm.2016.0473. [Epub ahead of print] Link to article on publisher's site

Related Resources

Link to Article in PubMed

Journal/Book/Conference Title

Journal of palliative medicine

PubMed ID