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 Care.
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."