Lower-income older adults suffer poorer health after critical illness

After patients are released from intensive care units (ICU) following treatment for illness, physicians know it’s critical to keep an eye out for new or worsening physical or mental impairments. This is particularly true for older adults, who are at greater risk for declines in physical function, cognition, and mental health after hospitalization.

Yale researchers have now found evidence that socioeconomically disadvantaged older adults are at even greater risk of worsening health following critical illness.

In a study published March 8 in Annals of Internal Medicine, the researchers report that following hospital admission with a stay in the ICU, older adults who were eligible for both Medicare and Medicaid — meaning they were over 65 years of age and met thresholds for low income — were far more likely to develop changes in physical function and were significantly more vulnerable to cognitive impairments than older adults not eligible for Medicaid.

“Increased disability and worsening cognitive function are two problems that separately or together may affect whether or not an older adult stays independent,” said Lauren Ferrante, an assistant professor of medicine (pulmonary and critical care medicine) and senior author of the study.

For the study, the researchers analyzed data from the National Health and Aging Trends Study, which included patients treated for critical illness in hospitals across the United States. Comparing health outcomes across hundreds of dual-eligible and non-dual-eligible patients, they looked for changes in physical function, cognitive function, and mental health.

To assess physical function, researchers asked patients or their proxies whether the patients needed help with eating, bathing, using the toilet, dressing, getting outside, getting around their home, or getting out of bed. “These activities are essential to independent living, so increased disability in these activities is problematic,” said Ferrante.

They found that in the year after a stay in the ICU, dual-eligible patients had scores for disability that were 28% higher than those of non-dual-eligible patients.

For cognitive function, the research team analyzed patients’ dementia status, based on cognitive assessment scores, interviews with their proxies, or diagnoses by a doctor. They found that dual-eligible patients were nearly 10 times more likely to develop probable dementia after a critical illness than their more socioeconomically advantaged counterparts.

The researchers also assessed symptoms of depression and anxiety but did not observe strong differences in mental health across the two patient groups.

Ferrante said the next step is to figure out what’s driving these disparities. “Why do we see an association with socioeconomic disadvantage when everyone is in the hospital together?”

Snigdha Jain, a postdoctoral fellow at the Yale School of Medicine and lead author of the study, said future work should look at the quality of care delivered in ICUs and after patients are discharged. There is evidence, she said, that socioeconomically disadvantaged patients may not receive the same level of care.

“When you look at the general quality of health care, we know that there are hospitals that cater to a larger proportion of the dual-eligible population that do worse on a lot of different quality measures,” Jain said. Similarly, home health agencies and nursing homes that serve more dual-eligible patients have lower rankings than those that do not, which means socioeconomically disadvantaged older adults may be receiving poorer rehabilitation and recovery care once they’re discharged from the hospital, she said.

To investigate these structural issues, Jain is now studying the role rehabilitation plays in the health outcomes of older patients. “Rehabilitation has been shown to be instrumental in improving function,” she said. “We’ll be looking into whether socioeconomically disadvantaged patients are getting adequate rehab and whether there are differences in rehab programs that may explain these health disparities.”

Uncovering and addressing the underlying causes is key, say the researchers. The elderly population is growing and the U.S. Census Bureau projects the United States will have more than 85 million people 65 years of age or older by 2050, almost double what it was in 2012 (43 million). Ferrante says that with more older adults and worsening income inequality, the disparities uncovered in this study could get worse and have severe downstream implications.

“If you come out of an ICU and you cannot recover your physical or cognitive function in the year afterwards, chances are that’s going to lead to loss of independence, more nursing home stays, increased health care costs, and, possibly, more readmissions and hospitalizations that are bad for the patient and bad for the health care system at large,” she said.

In the meantime, said Jain, hospitals should do more to ensure socioeconomically disadvantaged older adults have the support they need to recover after a critical illness. “We have identified this population that’s doing worse,” she said. “We need to pay attention to them.”