Homebound Status May Predict Mortality Among Older Adults

Among adults aged 65 years and older living in the community, homebound status is associated with greater risk of death, independent of functional impairment and comorbidities, according to findings published in the Journal of the American Geriatrics Society. Further, half of older adults studied were homebound in the year before death.

“Two-year mortality was greater than 40% in homebound individuals, and half of community-dwelling Medicare beneficiaries are homebound in the last year of life,” write the authors.

“Identifying homebound older adults and offering them medical care where they need it will only become more important as the population ages.” 

Investigators analyzed the in-person interview responses of community-dwelling older adults (n = 6,400) enrolled between 2011 and 2013 in NHATS (the National Health and Aging Trends Study), an examination of trends in late-life disability and functioning among a nationally representative cohort of Medicare beneficiaries. 

To date, definitions of older adults’ homebound status have been based on their use of Medicare home health services rather on the frequency with which they leave their house, the authors note. For the purposes of this study, participants living in home settings other than nursing homes were classified into one of the following three categories of homebound status:

1. Homebound: respondents who reported they left their home never or rarely within the past month
2. Semi-homebound: participants who left home, but with assistance or with difficulty doing so on their own 
3. Non-homebound: participants who left home without help or difficulty 

 “This article is the first, to the authors’ knowledge, to describe the effect of homebound status on mortality in a US population,” write the authors. They propose that gaining an accurate estimate of mortality risk associated with homebound status is “an important first step in differentiating homebound status from functional status in predicting mortality in older adults.” 

Overall Findings

• 50.9% of community-dwelling older adults were homebound in the last year of life. 
• At two-year follow-up, 40.3% of homebound participants and 21.3% of semi-homebound participants had died; only 5.8% of non-homebound participants had died. 

The finding that half of all participants were homebound in the year before death “suggests that half of Medicare beneficiaries will have difficulty accessing office-based care when they have the most need,” the authors observe. They suggest that older homebound patients’ restricted access to care could be addressed by increasing home-based palliative care, which has been shown to benefit patients through improved quality of life and decreased hospitalizations.

Non-Homebound vs Homebound

Compared with non-homebound individuals, the homebound and semi-homebound participants were:

• Older (84.0 and 80.6 years old, respectively, vs 76.5 years old)
• More likely to be female (73.0% and 66.3% vs 53.1%) 
• More likely to be nonwhite (32.4% and 23.7% vs 16.7%) 
• Burdened with more chronic diseases, including higher rates of probable or possible dementia (62.4% and 37.7% vs 14.0%) and depression (46.1% and 27.0% vs 10.1%) 
• More likely to be dependent in one or more self-care activities (65.5% and 40.2% vs 5%) and dependent in at least one household activity (78.4% and 55% vs 7%; all, P < 0.001)
 

Mortality Risk

• One-year mortality for homebound participants was 21%; two-year mortality was 40.3%. 
• In unadjusted analysis, both homebound and semi-homebound status were strongly predictive of two-year mortality (hazard ratio [HR] 8.85; 95% confidence interval [CI] 7.30–10.73 and HR 4.08; 95% CI 3.29–5.06, homebound and semi-homebound respectively). 
• After adjustment for factors such as demographics, functional status, comorbidities and social support, homebound status remained strongly associated with a greater likelihood of two-year mortality (HR 2.08; 95% CI 1.63–2.65; P < 0.001). 

“Homebound status is associated with greater risk of death independent of functional impairment and comorbidities,” the authors conclude. “To improve outcomes for homebound older adults and the many older adults who will become homebound in the last year of life, providers and policymakers need to extend healthcare services from hospitals and clinics to the homes of vulnerable individuals.” 

Source: : “Two-Year Mortality in Homebound Older Adults: An Analysis of the National Health and Aging Trends Study,” Journal of the American Geriatrics Society; January 2017; 65(1):123-129. Soones T, Federman A, Leff B, Sui AL, Ornstein K; Department of Geriatrics and Palliative Medicine; Division of General Internal Medicine, Department of Medicine; and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York City; Division of Geriatric Medicine, Department of Medicine; Department of Community and Public Health, School of Nursing; and Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore; and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York.