Psychological Resilience and End-of-Life Symptom Burden: Evidence From a National Cohort Study

Distressing symptoms are common in the last year of life and contribute substantially to suffering for older adults and their families. While psychological resilience has been linked to better aging outcomes, its association with end-of-life symptom burden is not well characterized.

We conducted a retrospective cohort study using nationally representative data from the Health and Retirement Study (2006-2022). The cohort included 4466 decedents aged ≥ 50 years with next-of-kin-reported symptoms in the last year of life and psychological resilience assessed on average 2 years before death. Psychological resilience was measured using a validated 12-item scale and categorized into quartiles. Outcomes included 12 end-of-life symptoms grouped into physical, neuropsychiatric, and functional domains. The primary outcome was high symptom burden, defined as seven or more symptoms. Associations were estimated using survey-weighted Poisson regression with robust standard errors, adjusting for sociodemographic, clinical, and functional covariates.

Decedents were on average 76 years old, 50% female, and 16% non-White. Resilience scores averaged 8.4 (SD, 1.91; median, 8.5). Higher resilience was associated with lower prevalence of end-of-life symptom burden. In adjusted models, high symptom burden was present in 31.1% (95% CI, 28.0-34.2) of those in the lowest resilience quartile and 19.6% (95% CI, 16.8-22.4) of those in the highest (P for trend < 0.001). Predicted probabilities demonstrated notable gradients of symptom prevalence across quartiles for depression (57.9% vs. 36.5%), severe fatigue (66.1% vs. 56.7%), incontinence (45.0% vs. 35.0%), and pain (56.1% vs. 47.4%). Associations were absent for symptoms such as appetite loss and vomiting.

In this nationally representative cohort, high psychological resilience measured before death was associated with lower symptom burden across multiple domains in the last year of life. Resilience assessment may help identify individuals at risk for distressing end-of-life experiences and inform interventions to bolster late-life resilience.