Clin-STAR Journey Story

Older Adults in the ICU: Equitably Improving Long-term Outcomes

Snigdha Jain, MD, MHS, is an Assistant Professor in the Section of Pulmonary, Critical Care and Sleep Medicine at the Yale School of Medicine. Her medical school training drew her to work with critically ill patients in intensive care units. Motivated by the inherent challenge of the work, she quickly realized that most patients in intensive care units are over age 65, which led to her interest in geriatrics. “As I started caring for more older adults in the ICU,” she said, “I realized that to improve outcomes for these patients, I needed to better understand geriatric principles.” Because chronic conditions like frailty and multiple comorbidities make older adults more vulnerable to experiencing functional and cognitive decline in the ICU, she said that she “became interested in how we can deliver better care to improve long-term outcomes.”

Historically, patients did not survive the ICU experience, but the past couple decades have shown marked improvements in treating ICU patients with critical illnesses like sepsis and respiratory failure. “With those improvements,” she said, “we now face the burden of survivorship,” described as “the defining challenge of critical care in the 21st century.” As lead author of a 2023 Clin-STAR Corner publication in JAGS, she continued, “We think of the ICU as a quick in and out, but older persons often have long-term impairments in their function, cognition, and mental health, which can greatly reduce their quality of life.”

Along with her work in the ICU, Dr. Jain cares for patients at a post-ICU recovery clinic. Post-ICU recovery clinics have emerged throughout the United States, primarily at urban teaching hospitals, each with its own treatment focus based on local resources. Her experience in this setting spurred more research questions, not only about the type of care older adults need and receive after an ICU admission, but also about access for people in rural areas and for underserved populations and how to understand logistical barriers to follow-up.

Now a member of the Clin-STAR DEIA Research Interest Group and the AGS Diversity in Research Subcommittee, Dr. Jain has been concerned about these disparities since her clinical fellowship training at UT Southwestern in Dallas, where she worked at both the university hospital and the county hospital, which were mere blocks apart. She noticed vast differences in the resources that patients would have at their disposal after hospitalization. “I couldn’t turn a blind eye to what would happen to the patients’ recovery as a consequence,” she said. “The resources for recovery that patients had access to, say, to attend outpatient physical therapy, were different. So you could prescribe it, but the patient may never be able to make it happen.”

Understanding both in-hospital practices and follow-up care—the before and after—is the “missing piece of the puzzle for critical care physicians,” she said. To flesh out this picture, Dr. Jain turned to the longitudinal survey data from the National Health and Aging Trends Study, which resulted in a GEMSSTAR Award in 2022. Published in the Annals of Internal Medicine, her study showed that older adults who received Medicaid developed a greater burden of disability and were more likely to develop new dementia after an ICU admission, compared to older adults who did not receive Medicaid. “We know that everybody’s at risk for decline,” she said, “but what was new was that older adults who are poor are at risk for worse decline after ICU. I became interested in finding out what contributed to their worse outcomes, whether it was their individual resources or our healthcare system.”

The research related to her recent AGS New Investigator award dives deeper into this before-and-after scenario, specifically focusing on physical and occupational therapy. One project looks at the before scenario, which shows that hospitals that serve more socioeconomically disadvantaged older adults who receive Medicaid have a lower likelihood of delivering PT and OT during a critical illness hospitalization. Her other project covers the after scenario, which shows that older adults receiving Medicaid are less likely to get home health PT after an ICU hospitalization, even if they’re discharged with a referral. “I’m trying to draw attention to the difference in how rehab is delivered in the hospital and after hospitalization so maybe we can do better, provide more equitable care, and mitigate the disparity in the functional decline we see after ICU hospitalization.” In parallel work, she has discovered that symptoms restricting activity increase among older adults after critical illness and might be a target to enhance functional recovery. “Older adults from vulnerable backgrounds, such as those receiving Medicaid, must be a part of any intervention that we design, test, and implement to mitigate health disparities.”