IMPORTANCE: Little is known about functional trajectories of older persons in the year before and after admission to the intensive care unit (ICU) or how pre-ICU functional trajectories affect ...post-ICU functional trajectories and death. OBJECTIVES: To characterize functional trajectories in the year before and after ICU admission and to evaluate the associations among pre-ICU functional trajectories and post-ICU functional trajectories, short-term mortality, and long-term mortality. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 754 community-dwelling persons 70 years or older, conducted between March 23, 1998, and December 31, 2012, in greater New Haven, Connecticut. The analytic sample included 291 participants who had at least 1 admission to an ICU through December 2011. MAIN OUTCOMES AND MEASURES: Functional trajectories in the year before and after an ICU admission based on 13 basic, instrumental, and mobility activities. Additional outcomes included short-term (30 day) and long-term (1 year) mortality. RESULTS: The mean (SD) age of participants was 83.7 (5.5) years. Three distinct pre-ICU functional trajectories identified were minimal disability (29.6%), mild to moderate disability (44.0%), and severe disability (26.5%). Seventy participants (24.1%) experienced early death, defined as death in the hospital (50 participants 17.2%) or death after hospital discharge but within 30 days of admission (20 participants 6.9%). Among the remaining 221 participants, 3 distinct post-ICU functional trajectories identified were minimal disability (20.8%), mild to moderate disability (28.1%), and severe disability (51.1%). More than half of the participants (53.4%) experienced functional decline or early death after critical illness. The pre-ICU functional trajectories of mild to moderate disability and severe disability were associated with more than double (adjusted hazard ratio HR, 2.41; 95% CI, 1.29-4.50) and triple (adjusted HR, 3.84; 95% CI, 1.84-8.03) the risk of death within 1 year of ICU admission, respectively. Other factors associated with 1-year mortality included ICU length of stay (adjusted HR, 1.03; 95% CI, 1.00-1.05), mechanical ventilation (adjusted HR, 2.89; 95% CI, 1.91-4.37), and shock (adjusted HR, 2.68; 95% CI, 1.63-4.38). CONCLUSIONS AND RELEVANCE: Among older persons with critical illness, more than half died within 1 month or experienced significant functional decline over the following year, with particularly poor outcomes in those who had high levels of premorbid disability. These results may help to inform discussions about prognosis and goals of care before and during critical illness.
CONTEXT Disability among older persons is a complex and highly dynamic process, with high rates of recovery and frequent transitions between states of disability. The role of intervening illnesses ...and injuries (ie, events) on these transitions is uncertain. OBJECTIVES To evaluate the relationship between intervening events and transitions among states of no disability, mild disability, severe disability, and death and to determine the association of physical frailty with these transitions. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2008 of 754 community-living persons aged 70 years or older who were nondisabled at baseline in 4 essential activities of daily living: bathing, dressing, walking, and transferring. Telephone interviews were completed monthly for more than 10 years to assess disability and ascertain exposure to intervening events, which included illnesses and injuries leading to either hospitalization or restricted activity. Physical frailty (defined as gait speed >10 seconds on the rapid gait test) was assessed every 18 months through 108 months. MAIN OUTCOME MEASURE Transitions between no disability, mild disability, and severe disability and 3 transitions from each of these states to death, evaluated each month. RESULTS Hospitalization was strongly associated with 8 of the 9 possible transitions, with increased multivariable hazard ratios (HRs) as high as 168 (95% confidence interval CI, 118-239) for the transition from no disability to severe disability and decreased HRs as low as 0.41 (95% CI, 0.30-0.54) for the transition from mild disability to no disability. Restricted activity also increased the likelihood of transitioning from no disability to both mild and severe disability (HR, 2.59; 95% CI, 2.23-3.02; and HR, 8.03; 95% CI, 5.28-12.21), respectively, and from mild disability to severe disability (HR, 1.45; 95% CI, 1.14-1.84), but was not associated with recovery from mild or severe disability. For all 9 transitions, the presence of physical frailty accentuated the associations of the intervening events. For example, the absolute risk of transitioning from no disability to mild disability within 1 month after hospitalization for frail individuals was 34.9% (95% CI, 34.5%-35.3%) vs 4.9% (95% CI, 4.7%-5.1%) for nonfrail individuals. Among the possible reasons for hospitalization, fall-related injury conferred the highest likelihood of developing new or worsening disability. CONCLUSIONS Among older persons, particularly those who were physically frail, intervening illnesses and injuries greatly increased the likelihood of developing new or worsening disability. Only the most potent events, ie, those leading to hospitalization, reduced the likelihood of recovery from disability.
Frailty is a strong indicator of vulnerability among older persons, but its association with ICU outcomes has not been evaluated prospectively (ie, with objective measurements obtained prior to ICU ...admission). Our objective was to prospectively evaluate the relationship between frailty and post-ICU disability, incident nursing home admission, and death.
The parent cohort included 754 adults aged ≥ 70 years, who were evaluated monthly for disability in 13 functional activities and every 18 months for frailty (1998-2014). Frailty was assessed using the Fried index, where frailty, prefrailty, and nonfrailty were defined, respectively, as at least three, one or two, and zero criteria (of five). The analytic sample included 391 ICU admissions.
The mean age was 84.0 years. Frailty and prefrailty were present prior to 213 (54.5%) and 140 (35.8%) of the 391 admissions, respectively. Relative to nonfrailty, frailty was associated with 41% greater disability over the 6 months following a critical illness (adjusted risk ratio, 1.41; 95% CI, 1.12-1.78); prefrailty conferred 28% greater disability (adjusted risk ratio, 1.28; 95% CI, 1.01-1.63). Frailty (odds ratio, 3.52; 95% CI, 1.23-10.08), but not prefrailty (odds ratio, 2.01; 95% CI, 0.77-5.24), was associated with increased nursing home admission. Each one-point increase in frailty count (range, 0-5) was associated with double the likelihood of death (hazard ratio, 2.00; 95% CI, 1.33-3.00) through 6 months of follow-up.
Pre-ICU frailty status was associated with increased post-ICU disability and new nursing home admission among ICU survivors, and death among all admissions. Pre-ICU frailty status may provide prognostic information about outcomes after a critical illness.
IMPORTANCE: Despite their importance to guiding public health decision-making and policies and to establishing programs aimed at improving surgical care, contemporary nationally representative ...mortality data for geriatric surgery are lacking. OBJECTIVE: To calculate population-based estimates of mortality after major surgery in community-living older US adults and to determine how these estimates differ according to key demographic, surgical, and geriatric characteristics. DESIGN, SETTING, AND PARTICIPANTS: Prospective longitudinal cohort study with 1 year of follow-up in the continental US from 2011 to 2018. Participants included 5590 community-living fee-for-service Medicare beneficiaries, aged 65 years or older, from the National Health and Aging Trends Study (NHATS). Data analysis was conducted from February 22, 2021, to March 16, 2022. MAIN OUTCOMES AND MEASURES: Major surgeries and mortality over 1 year were identified through linkages with data from the Centers for Medicare & Medicaid Services. Data on frailty and dementia were obtained from the annual NHATS assessments. RESULTS: From 2011 to 2017, of the 1193 major surgeries (from 992 community-living participants), the mean (SD) age was 79.2 (7.1) years; 665 were women (55.7%), and 30 were Hispanic (2.5%), 198 non-Hispanic Black (16.6%), and 915 non-Hispanic White (76.7%). Over the 1-year follow-up period, there were 206 deaths representing 872 096 survey-weighted deaths and 13.4% (95% CI, 10.9%-15.9%) mortality. Mortality rates were 7.4% (95% CI, 4.9%-9.9%) for elective surgeries and 22.3% (95% CI, 17.4%-27.1%) for nonelective surgeries. For geriatric subgroups, 1-year mortality was 6.0% (95% CI, 2.6%-9.4%) for persons who were nonfrail, 27.8% (95% CI, 21.2%-34.3%) for those who were frail, 11.6% (95% CI, 8.8%-14.4%) for persons without dementia, and 32.7% (95% CI, 24.3%-41.0%) for those with probable dementia. The age- and sex-adjusted hazard ratios for 1-year mortality were 4.41 (95% CI, 2.53-7.69) for frailty with a reduction in restricted mean survival time of 48.8 days and 2.18 (95% CI, 1.40-3.40) for probable dementia with a reduction in restricted mean survival time of 44.9 days. CONCLUSIONS AND RELEVANCE: In this study, the population-based estimate of 1-year mortality after major surgery among community-living older adults in the US was 13.4% but was 3-fold higher for nonelective than elective procedures. Mortality was considerably elevated among older persons who were frail or who had probable dementia, highlighting the potential prognostic value of geriatric conditions after major surgery.
Handedness is often thought of as a hand “preference” for specific tasks or components of bimanual tasks. Nevertheless, hand selection decisions depend on many factors beyond hand dominance. While ...these decisions are likely influenced by which hand might show performance advantages for the particular task and conditions, there also appears to be a bias toward the dominant hand, regardless of performance advantage. This study examined the impact of hand selection decisions and workspace location on reaction time and movement quality. Twenty-six neurologically intact participants performed targeted reaching across the horizontal workspace in a 2D virtual reality environment, and we compared reaction time across two groups: those selecting which hand to use on a trial-by-trial basis (termed the choice group) and those performing the task with a preassigned hand (the no-choice group). Along with reaction time, we also compared reach performance for each group across two ipsilateral workspaces: medial and lateral. We observed a significant difference in reaction time between the hands in the choice group, regardless of workspace. In contrast, both hands showed shorter but similar reaction times and differences between the lateral and medial workspaces in the no-choice group. We conclude that the shorter reaction times of the dominant hand under choice conditions may be due to dominant hand bias in the selection process that is not dependent upon interlimb performance differences.
Little is known about the deleterious effects of injurious falls relative to those of other disabling conditions or whether these effects are driven largely by hip fractures. From a cohort of 754 ...community-living elders of New Haven, Connecticut, we matched 122 hospitalizations for an injurious fall (59 hip-fracture and 63 other fall-related injuries) to 241 non-fall-related hospitalizations. Participants (mean age: 85.7 years) were evaluated monthly for disability in 13 activities and admission to a nursing home from 1998 to 2010. For both hip-fracture and other fall-related injuries, the disability scores were significantly greater during each of the first 6 months after hospitalization than for the non-fall-related admissions, with adjusted risk ratios at 6 months of 1.5 (95% confidence interval (CI): 1.3, 1.7) for hip fracture and 1.4 (95% CI: 1.2, 1.6) for other fall-related injuries. The likelihood of having a long-term nursing home admission was considerably greater after hospitalization for a hip fracture and other fall-related injury than for a non-fall-related reason, with adjusted odds ratios of 3.3 (95% CI: 1.3, 8.3) and 3.2 (95% CI: 1.3, 7.8), respectively. Relative to other conditions leading to hospitalization, hip-fracture and other fall-related injuries are associated with worse disability outcomes and a higher likelihood of long-term nursing home admissions.
Factors common to socioeconomically disadvantaged neighborhoods, such as low availability of transportation, may limit access to restorative care services for critical illness survivors. Our primary ...objective was to evaluate whether neighborhood socioeconomic disadvantage was associated with an increased disability burden after critical illness. Our secondary objective was to determine if the effect differed for those discharged to the community compared with those discharged to a facility.
Longitudinal cohort study with linked Medicare claims data.
United States.
One hundred ninety-nine older adults, contributing to 239 ICU admissions, who underwent monthly assessments of disability for 12 months following hospital discharge in 13 different functional tasks from 1998 to 2017.
Neighborhood disadvantage was assessed using the area deprivation index, a 1-100 ranking evaluating poverty, housing, and employment metrics. Those living in disadvantaged neighborhoods (top quartile of scores) were less likely to self-identify as non-Hispanic White compared with those in more advantaged neighborhoods. In adjusted models, older adults living in disadvantaged neighborhoods had a 9% higher disability burden over the 12 months following ICU discharge compared with those in more advantaged areas (rate ratio, 1.09; 95% Bayesian credible interval, 1.02-1.16). In the secondary analysis adjusting for discharge destination, neighborhood disadvantage was associated with a 14% increase in disability burden over 12 months of follow-up (rate ratio, 1.14; 95% credible interval, 1.07-1.21). Disability burden was 10% higher for those living in disadvantaged neighborhoods and discharged home as compared with those discharged to a facility, but this difference was not statistically significant (interaction rate ratio, 1.10; 95% credible interval, 0.98-1.25).
Neighborhood socioeconomic disadvantage is associated with a higher disability burden in the 12 months after a critical illness. Future studies should evaluate barriers to functional recovery for ICU survivors living in disadvantaged neighborhoods.
IMPORTANCE Although a serious fall injury is often a devastating event, little is known about the course of disability (ie, functional trajectories) before a serious fall injury or the relationship ...between these trajectories and those that follow the fall. OBJECTIVES To identify distinct sets of functional trajectories in the year immediately before and after a serious fall injury, to evaluate the relationship between the prefall and postfall trajectories, and to determine whether these results differed based on the type of injury. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study conducted in greater New Haven, Connecticut, from March 16, 1998, to June 30, 2012, in 754 community-living persons aged 70 years or older who were initially nondisabled in their basic activities of daily living. Of the 130 participants who subsequently sustained a serious fall injury, 62 had a hip fracture and 68 had another fall-related injury leading to hospitalization. MAIN OUTCOMES AND MEASURES Functional trajectories, based on 13 basic, instrumental, and mobility activities assessed during monthly interviews, were identified in the year before and the year after the serious fall injury. RESULTS Before the fall, 5 distinct trajectories were identified: no disability in 16 participants (12.3%), mild disability in 34 (26.2%), moderate disability in 34 (26.2%), progressive disability in 23 (17.7%), and severe disability in 23 (17.7%). After the fall, 4 distinct trajectories were identified: rapid recovery in 12 participants (9.2%), gradual recovery in 35 (26.9%), little recovery in 26 (20.0%), and no recovery in 57 (43.8%). For both hip fractures and other serious fall injuries, the probabilities of the postfall trajectories were greatly influenced by the prefall trajectories, such that rapid recovery was observed only among persons who had no disability or mild disability, and a substantive recovery, defined as rapid or gradual, was highly unlikely among those who had progressive or severe disability. The postfall trajectories were consistently worse for hip fractures than for the other serious injuries. CONCLUSIONS AND RELEVANCE The functional trajectories before and after a serious fall injury are quite varied but highly interconnected, suggesting that the likelihood of recovery is greatly constrained by the prefall trajectory.
Older adults admitted to an intensive care unit (ICU) are at risk for developing impairments in function, cognition, and mental health. It is not known whether socioeconomically disadvantaged older ...persons are at greater risk for these impairments than their less vulnerable counterparts.
To evaluate the association between socioeconomic disadvantage and decline in function, cognition, and mental health among older survivors of an ICU hospitalization.
Retrospective analysis of a longitudinal cohort study.
Community-dwelling older adults in the National Health and Aging Trends Study (NHATS).
Participants with ICU hospitalizations between 2011 and 2017.
Socioeconomic disadvantage was assessed as dual-eligible Medicare-Medicaid status. The outcome of function was defined as the count of disabilities in 7 activities of daily living and mobility tasks, the cognitive outcome as the transition from no or possible to probable dementia, and the mental health outcome as the Patient Health Questionnaire-4 score in the NHATS interview after ICU hospitalization. The analytic sample included 641 ICU hospitalizations for function, 458 for cognition, and 519 for mental health.
After accounting for sociodemographic and clinical characteristics, dual eligibility was associated with a 28% increase in disability after ICU hospitalization (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 symptoms of depression and anxiety after ICU hospitalization (incidence rate ratio, 1.33; 95% CI, 0.99 to 1.79).
Administrative data, variability in timing of baseline and outcome assessments, proxy selection.
Dual-eligible older persons are at greater risk for decline in function and cognition after an ICU hospitalization than their more advantaged counterparts. This finding highlights the need to prioritize low-income seniors in rehabilitation and recovery efforts after critical illness and warrants investigation into factors leading to this disparity.
National Institute on Aging.
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