Wealth Disparities in End-of-Life Symptom Burden Among Older Adults.

Importance: Understanding how wealth influences the end-of-life experience is crucial for improving patient care and policy, particularly with regard to symptom burden. Objective: To examine the prevalence of 12 end-of-life symptoms by wealth categories; the association between wealth and a composite measure of high symptom burden; and whether this association is mediated by multimorbidity, functional impairment, or dementia. Design, Setting, and Participants: This cohort study used data from the Health and Retirement Study (HRS), a nationally representative survey of older adults in the US, on decedents who died between January 1, 2000, and February 28, 2021, from proxy-reported exit interviews through February 28, 2021. Decedents were HRS participants aged 65 years or older who had completed a core interview within 24 months before death and had a proxy-reported exit interview. The data analysis was performed from October 6, 2023, through November 26, 2024. Exposures: Wealth (assets opposed to income) was categorized into low (bottom quartile, <$6000), medium (middle 2 quartiles, $6000-$120 000), and high (top quartile, >$120 000). Main Outcomes and Measures: The presence of 12 individual end-of-life symptoms and a composite measure of high symptom burden (≥7 symptoms) were analyzed using modified Poisson regression. Mediators included multimorbidity, functional impairment, and dementia. Models were adjusted for age, sex, marital status, race and ethnicity, education, childhood socioeconomic status, HRS proxy respondent relationship, location of death, survey timing, year of death, and private insurance. Results: Of 8976 decedents (mean [SD] age, 81.3 [8.6] years; 4927 women [55.1%] women) in the cohort, 2197 (22.5%) were included in the low wealth category, 4534 (50.5%) in the medium wealth category, and 2245 (27.1%) in the high wealth category. Decedents with lower wealth had a higher prevalence of end-of-life symptoms. High symptom burden was most common in the low wealth group (800 decedents [37.0%]) vs the medium (1301 decedents [28.0%]) and high wealth (512 decedents [23.2%]) groups. Low wealth was associated with a significantly increased risk of high symptom burden vs medium wealth (adjusted risk ratio, 0.79; 95% CI, 0.73-0.87) and high wealth (adjusted risk ratio, 0.71; 95% CI, 0.63-0.79). Multimorbidity, functional impairment, and dementia were more common in the low wealth group and mediated this association, with functional impairment being the strongest mediator. Conclusions and Relevance: This cohort study found that lower wealth was associated with a higher symptom burden at the end of life, mediated in part by higher rates of multimorbidity, functional impairment, and dementia. These findings highlight the need for policies and programs to support patients with lower financial resources to improve end-of-life experiences and mitigate wealth disparities.