"Effect of a Three-Component Geriatrics Bundle on Incident Delirium Among Critically Ill Older Adults: A Pilot Study." Annals of the American Thoracic Society, 0(ja), pp.

Rationale: Although mortality from COVID-19 increases with advanced age, most older adults survive a COVID hospitalization. Disability, or dependence in functional activities, is known to increase after a serious illness among older adults, with adverse consequences for patients, families, and society. Little is known about disability, and the factors associated with disability, after a COVID hospitalization among older adults. Methods: We enrolled 341 older (≥60 years) adults during their index COVID-19 hospitalization between 7/6/2020-6/24/2021 from five hospitals in the Yale-New Haven Health System. Upon enrollment, participants underwent an assessment of baseline (prehospitalization) disability, frailty, general health, social support, hearing, vision, mental health, and assessments of current (in-hospital) symptom burden and cognitive function. These assessments were linked to EMR data including demographics, SOFA score, comorbidities, biomarkers, respiratory support, pressors, length of stay, and COVIDspecific treatments. Disability was assessed at baseline and 1, 3, and 6 months by asking about dependence in 15 basic, instrumental, and mobility activities. The primary outcome was the disability count (0-15) over the 6 months after the COVID hospitalization. The analytic sample included 304 participants who survived their hospitalization and had at least one post-discharge follow-up. We determined the mean (SD) number of disabilities over the 6 months after discharge and evaluated 27 factors for their association with the 6-month disability count using backwards selection based on minimization of the Bayesian Information Criterion with a zero-inflated negative binomial distribution and adjustment for baseline disability count and months of follow-up. Results: The mean age was 71.2 years (SD 8.5), 158 (51.8%) were women, and 108 (35.5%) were of nonwhite race or Hispanic ethnicity (Table). The mean prehospitalization disability count was 2.2 (SD 3.4), and the mean disability count over the 6 months after the COVID hospitalization was 2.9 (SD 3.7). In the multivariable model, greater baseline disability, older age, higher BMI, higher comorbidity count, cognitive dysfunction, greater symptom burden during the hospitalization, and the need for advanced respiratory support were all associated with greater disability over the 6 months after a COVID hospitalization. Conclusions: Other than the need for advanced respiratory support, factors associated with disability after a COVID hospitalization among older adults reflect vulnerability at baseline (comorbidities, baseline disability, age, BMI) or during the hospitalization (symptom burden, cognitive dysfunction), rather than biomarkers or severity of illness. These factors may identify older adults for referral to Post-COVID clinic programs to improve the likelihood of functional recovery after discharge. (Table Presented).

Rationale: Socioeconomic disadvantage is associated with greater long-term mortality in older adults who survive critical illness.Whether socioeconomically disadvantaged older adults are at greater risk of development of functional decline compared to their less vulnerable counterparts is not known.We sought to examine the association between socioeconomic disadvantage and functional decline in a nationally representative sample of Medicare beneficiaries.Methods: We identified community-dwelling older adults in the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries ages ≥65, who underwent annual assessments of disability in 7 functional activities.ICU hospitalizations were identified using critical care revenue codes in linked Medicare claims.ICU survivors were eligible for the analysis and the unit of analysis was participant-ICU stays.We used a negative binomial Poisson model to evaluate the association between dualeligibility and the count of disabilities (range 0-7) assessed in the NHATS interview following discharge from the ICU hospitalization.Covariates in the model included age, gender, education, living alone, frailty, hospital length of stay, mechanical ventilation, and count of disabilities in the interview preceding ICU admission.Results: We identified 641 participant-ICU stays representing 3,767,695 ICU hospitalizations after survey-weighting.Dual eligible beneficiaries were more frequently males, of minority race, had less than high school level education, and lived alone, compared with those without Medicaid (Table 1).The median post-ICU disability count was 2.18 (IQR 0.00, 4.83) for dual-eligible participants and 0.01 (IQR 0.00, 2.47) for participants without Medicaid.Unadjusted, Medicaid eligibility was strongly associated with post-ICU disability with a 60% increase in post-ICU disability count compared to those who did not have Medicaid (unadjusted RR 1.60, 95% CI 1.29, 1.99).After covariate adjustment, Medicaid status was still positively associated with post-ICU disability with a 32% increase in post-ICU disability count relative to non-Medicaid beneficiaries (adjusted RR 1.32, 95% CI 1.04, 1.67).Conclusions: In this nationally representative sample of Medicare beneficiaries who survived ICU hospitalization, socioeconomic disadvantage was associated with greater risk of post-ICU disability after accounting for pre-ICU disability, frailty, and other relevant sociodemographic and clinical characteristics.This warrants investigation into factors underlying this disparity as well as consideration for post-ICU rehabilitation and recovery programs.

1 Postdoctoral Research Fellow, Section of Geriatrics, 2 Assistant Professor, Section of Pulmonary, Critical Care and Sleep Medicine, Department of InternalMedicine, Yale School ofMedicine, YaleUniversity, NewHaven, CT, USA ................................................................................................................................................................. Corresponding to: L. E. Ferrante Email: lauren.ferrante@yale.edu Accepted: 8 February 2019

As the population ages, so too does the intensive care unit (ICU) population. Already, it is estimated that greater than 50% of ICU admissions are patients aged 65 years and older, and this percentage is only expected to grow over time [1]. The growth of the ‘oldest old’, those above 80 years of age, is also expected to increase dramatically over the next three decades; in a study of European ICU admissions, some countries have seen the admission rate of patients in this demographic increase from 11% to 15% in a decade [2]. Older adults represent a unique population, with higher rates of preexisting comorbidities and vulnerabilities, and greater risk for developing ICU complications such as delirium. In this chapter, we discuss topics pertaining to care of the critically ill older patient, with a focus on new advancements in the last decade since Wunsch et al.’s excellent review published in 2009 [3], and a look to future studies that will help inform our day-to-day care of this sizeable, growing, and vulnerable population.