Remaining in the Community: End-of-Life Experiences Among Homebound Older Adults Living Alone

Background and Objectives: About one third of the nearly 7 million homebound older adults in the US live alone. Among the homebound, we examined factors associated with entering a facility in the last year of life and compared end-of-life experiences for those who lived alone versus with others. Methods: Using the National Health and Aging Trends Study (NHATS), we identified 1317 decedents who were homebound (i.e., rarely/never left home or left with difficulty or assistance) in the year before death. We used descriptive analyses and multivariable models to examine likelihood of entering a facility (e.g., nursing home) and end-of-life experiences (e.g., hospice use, symptom burden). Results: In the last year of life, 20% of our sample lived alone and only 6% entered a facility. Having dementia (odds ratio [OR] 1.78, 95% confidence interval [CI] 1.03–3.11) and living alone (OR 2.01, 95% CI 1.14–3.47) were associated with facility entry. Among those who remained in the community, those who lived alone (versus with others) were less likely to die at home (40.4% vs. 50.3%, p = 0.019) or use hospice (49.4% vs. 60.5%, p = 0.002). In the last month of life, they were less likely to be pain free (21.7% vs. 31.0%, p = 0.006) and less likely to have always had their personal care needs met (76.6% vs. 83.7%, p = 0.003). Conclusions: Many homebound older adults remain in the community through the end of life. Identification of care needs and earlier referral to hospice, palliative care, and/or other supportive services may improve end-of-life experiences, especially for those who live alone.