Self-Perceptions of Aging and Advance Care Planning: Longitudinal Evidence from a National Panel Study

Background and Purpose

Advance care planning (ACP), including formal documentation and conversations about end-of-life care, helps ensure medical treatment aligns with individuals’ values and preferences. Yet, many older adults do not engage in either. It is important to explore modifiable psychological factors that may facilitate ACP. Guided by Stereotype Embodiment Theory, which suggests that internalized age-related beliefs and attitudes could shape health behaviors. This study examines whether self-perceptions of aging (SPA), individuals’ beliefs and attitudes toward their own aging, have longitudinal associations with formal and informal ACP engagement. We also test the heterogeneous effects by sociodemographic characteristics and health conditions.

Methods

Data came from the Health and Retirement Study (HRS), a nationally representative panel of U.S. adults over age 50. The analytic sample included 7,691 respondents aged 65+ with SPA measured in 2008 or 2010 and ACP outcomes assessed four years later (2010 or 2014). ACP was categorized into four mutually exclusive groups: (1) both formal (e.g., advance directives) and informal (e.g., conversations) ACP (reference group), (2) formal only, (3) informal only, and (4) neither. SPA was assessed using an eight-item scale, where higher scores indicate more positive SPA. Multinomial logistic regression models estimated associations between SPA and ACP outcomes, adjusting for age, gender, race/ethnicity, education, marital status, cognitive function, depressive symptoms, and chronic conditions. Interaction terms and stratified models assessed moderation.

Results

Respondents with more positive SPA at baseline were significantly less likely to engage in formal-only ACP four years later (RRR = 0.897, p = .008), compared to engaging in both types. SPA was not significantly associated with informal-only or no ACP. Older respondents and women were less likely to report having neither form of ACP. Black and Hispanic older adults were over three times more likely than White peers to report having neither formal nor informal ACP (Black RRR = 3.53, p < .001). The protective effect of SPA against having no ACP was stronger among older respondents (SPA × age: RRR = 1.007, p < .001) and those with more education (SPA × education: RRR = 0.979, p = .045). Among those with greater ADL limitations, positive SPA was more strongly linked to informal ACP (SPA × ADL: RRR = 1.10, p = .034). Among those with worse self-rated health, positive SPA was associated with lower odds of having neither type (SPA × SRH: RRR = 0.94, p = .027). No significant moderation was found for gender, race/ethnicity, or other health measures.

Conclusions and Implications

Positive SPA encourages more comprehensive ACP and reduces the likelihood of individuals only having documentation without meaningful conversations. Its effects were more pronounced among individuals with higher education and poorer physical health. The longitudinal impact of older adults' beliefs and attitudes toward aging on ACP underscores SPA as a modifiable psychosocial factor for social workers to intervene that can promote more comprehensive ACP engagement, where tailored outreach could benefit those with low health literacy or functional limitations.