ANN ARBOR, Mich.—The inequalities that mark American life maintain their hold through age and even death, a new study shows.
Wealthier elders are significantly less likely than poorer ones to suffer pain at the end of their lives, according to a University of Michigan study forthcoming in the August issue of the Journal of Palliative Medicine.
Specifically, men and women age 70 or older whose net worth was $70,000 or higher were 30 percent less likely than poorer people to have felt pain often during the year before they died. This difference persisted after the researchers controlled for age, gender, ethnicity, education and diagnosis.
Wealthier elders also experienced a lower number of symptoms overall, the study found. Those in the wealthiest half of the elderly population not only had less pain, but were less likely to suffer from shortness of breath and depression.
Still, both rich and poor older Americans suffered more than expected in their last year of life, the researchers concluded.
"Regardless of wealth, older Americans carry an unacceptable burden of suffering in their last year of life," said Maria Silveira, a physician at the Veterans Affairs Ann Arbor Healthcare System, a research scientist at the U-M and the lead author of the study. "The older adults we studied who lived in the community suffered as much in their last year of life as do younger people who are severely ill and hospitalized."
Fatigue was the most common symptom, experienced by 57 percent of those who died. More than 50 percent experienced pain, and 59 percent of those who experienced pain were reported to have suffered pain at severe levels.
The study was based on an analysis of data on 2,604 men and women age 70 or older who died between 1993 and 2000. They were part of the Health and Retirement Study conducted by the U-M Institute for Social Research (ISR) and funded by the National Institute on Aging. The study interviews a nationally representative sample of 22,000 Americans age 50 and over every two years.
When a participant in the study dies, researchers interview surviving spouses or others to learn about their last months of life and the circumstances of their death. For the current study, Silveira and U-M colleagues Mohammed Kabeto and Kenneth Langa were especially interested in symptoms of pain, depression, and shortness of breath at the end of life. "These are treatable symptoms," Langa said, "and not an inevitable part of the dying process."
"Our current health system provides palliative care mostly through hospice and hospitals," Silveira said. "As a result, health care providers' radar may be set to miss older adults unless they have a reason to become hospitalized."
The authors offered several possible explanations for their "most unique and sobering finding"—that wealthier elders suffer less than poorer ones at the end of life.
When personal resources are limited, elders without coverage for prescription medications, including those on Medicare, may choose to sacrifice comfort in order to prolong their life or maintain their ability to function, the authors speculate, Silveira said.
"Elders with greater financial resources may express their symptoms more assertively and demand better care, the researchers suggest. They may have greater access to goods and services above and beyond what insurance provides, and to social support from family and friends. They may also reside in settings with better quality of care."
To break the connection between wealth and suffering at the end of life, the government might consider expanding Medicare to include medications, or expanding the criteria for hospice to include older adults with significant symptoms, regardless of their prognosis. Currently, hospice treatment is covered only for those whose physicians certify to have less than six months to live.
"This would enable older adults to access medications regardless of ability to pay," Silveira said. "It would also improve access to services for underserved and vulnerable populations."
Silveira is an M.D., M.P.H. and is an assistant professor of general medicine at the U-M Medical School and a member of the VA Center of Excellence at the VA Ann Arbor Healthcare System.
Langa is M.D., Ph.D. and is an assistant professor of general medicine at the U-M Medical School, a research investigator at the VA Ann Arbor Healthcare System, and a faculty associate at ISR.
Mohammed Kabeto is M.S., and is a research associate in general medicine at the Medical School.
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