Risk for poor outcomes greater among disadvantaged older adults after ICU admission, study finds

Medicare/Medicaid dual-eligible patients had a 28% increased risk of disability and 9.8-fold greater odds of being diagnosed with probable dementia after an ICU stay compared to non-dual-eligible older patients.

Socioeconomically disadvantaged older adults are at higher risk for decline in function and cognition after an ICU stay, a retrospective analysis found.

Researchers compared decline in function, cognition, and mental health between dual-enrolled Medicare and Medicaid recipients (considered socioeconomically disadvantaged) and their non-dual-eligible counterparts in the National Health and Aging Trends Study (NHATS). Function was defined as the count of disabilities in seven activities of daily living and mobility tasks, the cognitive outcome was defined as the transition from no or possible to probable dementia, and the mental health outcome was defined as Patient Health Questionnaire-4 score in the NHATS interview after ICU hospitalization. Results were published March 8 by Annals of Internal Medicine.

The cohort included 641 ICU hospitalizations for function, 458 for cognition, and 519 for mental health. After the researchers accounted for risk factors, including age, frailty, comorbidity, and pre-ICU disability, dual eligibility was associated with a significant increase in disability after an ICU stay (incidence rate ratio, 1.28; 95% CI, 1.00 to 1.64) and nearly 10-fold greater odds of transitioning to probable dementia (odds ratio, 9.79; 95% CI, 3.46 to 27.65). Dual eligibility was not associated with a significant increase in risk of depression and anxiety after ICU hospitalization (incidence rate ratio, 1.33; 95% CI, 0.99 to 1.79).

The study authors noted that cognitive and functional decline among older persons is associated with institutionalization, mortality, and increased caregiver burden. “The additional needs posed by decline in function and cognition can have devastating consequences for dual-eligible beneficiaries, who have greater baseline prevalence of dementia and disability and lower levels of social and financial support than nondual-eligible Medicare beneficiaries,” they wrote. In addition, they noted, worsening impairments after critical illness may also require hospital readmissions or long-term support services and further increase health care expenditures. “The downstream consequences of increased disability and dementia after ICU hospitalization can, therefore, worsen existing heath disparities for socioeconomically disadvantaged older adults,” the authors wrote.

Among other limitations, the administrative data source did not fully capture severity of illness, and while dual eligibility is a known proxy for socioeconomic disadvantage it does not distinguish individual social and economic risk factors, the authors noted. “These findings highlight the need to prioritize low-income seniors in rehabilitation and recovery efforts after critical illness,” they concluded. “Further research is needed to elucidate differences in acute and postacute care that contribute to disparities in functional and cognitive decline after ICU survivorship.”

An accompanying editorial stated, “Basic, translational, and clinical research studies are clearly needed to determine the biological mechanisms that underlie post-intensive care syndrome deficits, but it is not too early for health services research, clinical trials, and implementation science studies to examine the effectiveness of various approaches to care delivery after critical illness and to build an infrastructure that supports survivors' care needs effectively and equitably.”