Advance care planning in adults ages 80 years and older with impaired cognition: Using actual conversations to examine best practices

Introduction: Recommendations for advance care planning (ACP) in persons with cognitive impairment are based on expert input without insight from actual ACP conversations.

Methods: We used thematic analysis to analyze transcripts of ACP conversations for 88 older adults with normal cognition (n = 15), mild cognitive impairment (n = 13), and scores consistent with dementia (n = 60).

Results: Patients with dementia were least verbally active; however, some shared values and identified surrogates. We identified three themes: (1) cognitive impairment inhibits participation in ACP, but individuals with dementia are able to contribute; (2) care partners have a key role in supporting ACP across the spectrum of cognitive impairment; and (3) structured questions about values and tailored communication strategies can facilitate engagement of older adults with dementia.

Discussion: Our findings reinforce best practice recommendations for early ACP and identify strategies to increase patient engagement among older adults with cognitive impairment with support of care partners.

Highlights: Data from actual ACP conversations involving older adults with a range of cognitive function and their care partners reinforce best practice recommendations and suggest practical implications for education and training. Family involvement in ACP was valued by older adults and improved engagement. ACP initiatives should prioritize eliciting values of older adults with dementia and improving skills for communication to increase engagement.