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.