Disadvantaged older adults face greater risk of function, cognition decline after ICU admission

1. Disadvantaged older adults face greater risk of function, cognition decline after ICU admission

Abstract: https://www.acpjournals.org/doi/10.7326/M21-3086 

URL goes live when the embargo lifts

A retrospective analysis found that socioeconomically disadvantaged older adults face a greater risk of decline in function and cognition after an intensive care unit (ICU) hospitalization than socioeconomically advantaged older adults. These findings highlight the need to prioritize low-income seniors in rehabilitation and recovery efforts after critical illness. The study is published in Annals of Internal Medicine.

Older adults are more vulnerable to experiencing new or worsening impairments in function, cognition,and mental health after a critical illness, also known as post–intensive care syndrome (PICS). The number of older adults who survive an ICU stay is expected to rise in the aging population with improving survival after critical illness and the current pandemic. However, equity in patient outcomes after ICU stays has not been examined.

Researchers from Yale School of Medicine compared decline in function, cognition, and mental health between dual-enrolled Medicare and Medicaid recipients and their non-dual-eligible counterparts. Dual-enrolled older adults are known to have greater chronic disease burden and worse health outcomes for many conditions compared with non–dual-eligible Medicare beneficiaries. The authors analyzed data of 641 patients drawn from the National Health and Aging Trends Study (NHATS), a longitudinal national survey of Medicare beneficiaries aged 65 and older. After conducting statistical analyses, the authors found that socioeconomic disadvantage was associated with a decline in function and cognition but not with symptoms of depression and anxiety after discharge from an ICU. After accounting for risk factors including age, frailty, comorbidity, and pre-ICU disability, the authors found that dual-eligible beneficiaries developed a nearly 30% greater burden of disability than their non–dual-eligible counterparts. The authors also found that even after adjusting for confounders, dual-eligible beneficiaries had nearly 10-fold greater odds of cognitive decline after ICU hospitalization than non–dual-eligible beneficiaries. According to the authors, post-ICU mental health symptoms seemed driven by pre-ICU mental health, although symptoms were worse among dual-enrolled beneficiaries.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Snigdha Jain, MD, please contact Fred Mamoun at fred.mamoun@yale.edu.

-------------------------------------------------

2. Caring for detained immigrants and asylum seekers on hunger strike ethically complex for physicians

Authors offer advice for physicians caring for vulnerable and marginalized people

Abstract https://www.acpjournals.org/doi/10.7326/M21-4280

A commentary published in Annals of Internal Medicine offers advice to physicians caring for detained immigrants and asylum seekers on hunger strike and calls for medical professional associations to support these physicians. Given the vulnerability and lack of agency experienced by people in detention, the medical community is in a unique position to help them.

Hunger strikes by those detained at U.S. Immigration and Customs Enforcement (ICE) facilities are constitutionally protected. Their numbers have increased recently, as detained people protested ICE's lack of adequate pandemic precautions: About 2,500 detainees participated in a hunger strike during the First 6 months of the pandemic compared with 1,600 during a prior 3-year period. While pressure may mount to ‘force feed’ a starving detainee, it is important for the physician to first evaluate the individual’s mental state and capacity for decision-making. Physicians must never use their skills to punish, including by force feeding a patient who has decision making capacity. Detained individuals are human beings with dignity and rights, including the right not to be force-fed by their doctors. Instead, the authors advise doctors to establish trust and maintain standards of excellent care, despite the environment. Finally, the authors say that physicians should not have to face these challenges alone. They call upon professional societies to support physicians when their ethics are challenged.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Matthew Wynia, MD, MPH, please contact Mark Couch at mark.couch@cuanschutz.edu.

-------------------------------------------------

Also new in this issue:

Type 1 Diabetes Mellitus

Fatima Z. Syed, MD, MSc

In the Clinic

Abstract: https://www.acpjournals.org/doi/10.7326/M21-3984

New COVID-19 content in this issue:

Toward Unbiased Evaluation of Postacute Sequelae of SARS-CoV-2 Infection: Challenges and Solutions for the Long Haul Ahead
Lauren E. Wisk, PhD; Graham Nichol, MD, MPH; Joann G. Elmore, MD, MPH
Ideas and Opinions
Free content: https://www.acpjournals.org/doi/10.7326/M21-4664