Long-term functional outcomes and mortality after hospitalization for extracranial hemorrhage

Abstract

Background: The effects of extracranial hemorrhage (ECH), or bleeding outside the brain, are often considered transient. Yet, there are few data on the long-term and functional consequences of ECH.

Objective: Define the association of ECH hospitalization with functional independence and survival in a nationally representative cohort of older adults.

Design: Longitudinal cohort study.

Settings and participants: Data from the Health and Retirement Study from 1995 to 2016, a nationally representative, biennial survey of older adults. Adults aged 66 and above with Medicare linkage and at least 12 months of continuous Medicare Part A and B enrollment.

Intervention: Hospitalization for ECH.

Main outcomes and measures: Adjusted odds ratios and predicted likelihood of independence in all activities of daily living (ADLs), independence in all instrumental activities of daily living (IADLs) and extended nursing home stay. Adjusted hazard ratio and predicted likelihood for survival.

Results: In a cohort of 6719 subjects (mean age 77, 59% women) with average follow-up time of 8.3 years (55,767 person-years), 736 (11%) were hospitalized for ECH. ECH was associated with a 15% increase in ADL disability, 15% increase in IADL disability, 8% increase in nursing home stays, and 4% increase in mortality. After ECH, subjects became disabled and died at the same annual rate as pre-ECH but never recovered to pre-ECH levels of function. In conclusion, hospitalization for ECH was associated with significant and durable declines in independence and survival. Clinical and research efforts should incorporate the long-term harms of ECH into decision-making and strategies to mitigate these effects.

Figure 1. Longitudinal likelihood of ADL independence and association with extracranial hemorrhage

Legend- ADL, activity of daily living; ECH, extracranial hemorrhage. This graph is produced from the regression model results (Appendix Text 1, Appendix Table 3).The blue line represents the predicted likelihood of the outcome assuming no one has an ECH, and the red line represents the predicted likelihood of the outcome assuming all have an ECH at 5.2 years, the median time to ECH in the cohort. The blue line represents the predicted loss of independence where there are no ECH admissions in the cohort (i.e., the baseline rate of function loss). The red line represents a scenario where everyone in the population has an ECH: (1) the red line from 0 to 5.2 years represents the baseline rate of function loss pre-ECH; (2) at 5.2 years, the difference between the blue and red lines represents the change in function associated with ECH (3) after 5.2 years, the red line describes the change in baseline rate of function loss post-ECH. Functional trajectory is displayed through 12 years, the 75th percentile of follow up time. The analysis is based on 6719 participants; we excluded 333 person waves (1.2%) with missing ADL outcome data, 400 person-waves (1.5%) with missing IADL outcome data, 268 person-waves (0.98%) with missing nursing home outcome data.

Figure 2. Longitudinal likelihood of mortality and association with extracranial hemorrhage

Legend ECH, extracranial hemorrhage. This graph is produced from the regression model results (Appendix Text 2, Appendix Table 4).The blue line represents the predicted likelihood of the outcome assuming no one has an ECH, and the red line represents the predicted likelihood of the outcome assuming all have an ECH at 5.2 years, the median time to ECH in the cohort. The blue line represents the predicted survival where there are no ECH admissions in the cohort (i.e., the baseline mortality rate). The red line represents a scenario where everyone in the population has an ECH: (1) the red line from 0 to 5.2 years represents the baseline survival rate pre-ECH; (2) at 5.2 years, the difference between the blue and red lines represents the mortality associated with ECH (3) after 5.2 years, the red line describes the change in baseline mortality rate post-ECH. Survival trajectory is displayed through 12 years, the 75th percentile of follow up time. The analysis is based on 6719 participants; none were missing mortality data.