A total of 321 people participated in surveys less than a year before they died aged at least 85 years, comprising 80% of participants still alive at survey (median time of last interview before death = 28 weeks, interquartile range = 16–41 weeks). Death certificate residence data were available for all but one participant (analysis sample n = 320). outlines their sociodemographic characteristics. Half these ‘oldest old’ participants were aged 85–89 years, and half were aged at least 90 years at death. Overall, two-thirds were female (male:female ratio 2:3 in the 85–89 years age-band, 1:4 in the older group). There were no demographic differences between those who were or were not interviewed in their last year of life.
Sociodemographic profile of the sample.
How this fits in
Numbers of deaths are rising fastest in many developed countries among ≥85 year olds. Current policy is to enable people to be cared for until death where they would prefer. However, not only are preferences difficult to assess, but even data on the transitions in place of care of the oldest old at the end of life are scarce. This study found that only 7% of individuals aged ≥85 years in a population-based sample changed their address in their last year of life, yet more than half died somewhere other than their usual address at the time of death. Over two-thirds were living in the community when last interviewed less than 12 months before death, but fewer than one-third who had lived at home died there. Of the individuals who died in acute hospitals, 15% came from care homes, predominantly residential homes. The findings will help planning to implement the End of Life Care Strategy.
Address less than a year before death
Just over two-thirds of participants were community dwelling when last surveyed (), including 17% in sheltered housing. Excluding these partially supported settings, more males still lived at home than females (70% versus 44%). Twice as many ≥90 year olds were living in care (38%: 27% in residential homes, 9% in nursing homes) as 85–89 year olds (19%: 16% in residential homes and 3% in nursing homes).
Usual address at death
details what proportions were subsequently in different accommodation according to death certification — usual address at death and place of death — but these changes are best understood in conjunction with the individual-level data illustrated in . By the time of death the percentage living in care homes was virtually unchanged among those in their late 80s, but had risen to 44% of those dying in their 90s or older (from 38% when interviewed), with a further 5% whose ‘usual address’ was a long-stay hospital (). Living in residential care was twice as common at death for older males than for 85–89 year-old males (18% versus 9%), and higher for females, but the age-band difference was less marked (32% versus 21%). There was a three- to four-fold increase in the need for long-term nursing care by the time of death for both sexes, from just a few per cent aged <90 years whose usual address was a nursing home, compared with 14% of ≥90 year olds (25% including long-stay wards: males 17%, females 24%).
Usual address at time of death and place of death by age and sex.
Figure 3 Movements between residential or care settings during the last year of life (n = 320 people who died aged ≥85) from their place of residence when interviewed less than a year before death, to their ‘usual address’ registered at (more ...)
Place of death
Just over half the sample died in hospital (10% on long-stay wards, 41% in acute settings). shows age and sex differences. Almost half those dying in their late 80s were in acute settings, compared with one-third of the older group; overall 50% of males and 37% of females died in acute hospitals; 7% more died in long-stay hospitals than had these units recorded as their usual address. Only 2% died in hospices.
Transitions before death
represents the movements between different places of residence or care during the last year of life from where participants lived when last interviewed, to where their usual address when they died and where they actually died. The direction of movement is predominantly up the ‘ladder of care’, with only a handful of exceptions: a few transfers from long-stay hospital to care homes and one person who moved from residential care to her son's home. Compared with death certificate-recorded ‘usual address’, community addresses appear considerably less frequently as the registered ‘place of death’. Only 16% of all deaths were at home: fewer than one-third of the 50% of participants who still lived in their own or a relative's home died there. People whose usual address at death was in sheltered housing (15%) were even less likely to die there: less than one-fifth. The 19% dying in residential care was only slightly less than the 22% with a residential home as their ‘usual address’. However, as shows, these were not all the same people: 16/71 (23%) people living in residential homes died in acute hospitals and 7/62 (11%) people who died in residential care usually lived at home. Settings that provided nursing care transferred fewer people to other institutions. Similar numbers died in nursing homes as were living there. Long-stay hospital deaths included all those usually resident, but also included less permanent patients, presumably more recently admitted. Care homes were the usual address of most people dying there (77% in residential homes, 87% in nursing homes) but 15% of deaths in acute hospital came from (predominantly residential) care homes. Overall, whereas only 7% had a ‘usual address’ recorded on their death certificate that differed from where they lived when interviewed less than a year before, for 52% the registered place of death was not their usual address (see and, for details by age-band and sex, ). Individuals in their 90s or 100s were more likely to have died at their usual address than 85–89 year olds, as were females, regardless of age.
Deaths at usual address by age and sex.
Age and time
As the study findings draw on interview data spanning over two decades, a check was carried out for temporal trends, stratifying by age to avoid confounding. plots proportions for earlier and later study periods of (a) study participants living in different settings at death, and (b) their place of death, showing separately 85–89 year olds and ≥90 year olds. Percentages of community dwellers and home deaths have declined in both age-bands. While it has become slightly more common to live, and die, in sheltered housing before the age of 90 years, this is increasingly uncommon for anyone older. Nursing home residence has risen steeply in both age-bands, as have nursing home deaths but in residential care homes, the number of residents aged ≥90 years has risen only slightly, and deaths of individuals aged ≥90 years have shown no increase. Acute hospitals have remained the location with the highest proportion of deaths across the years for very old people dying before or after 90 years of age.
Study participants' usual address at death and place of death by age-band.