There are estimated 2 million Americans who are homebound, based on the National Health and Aging Trends Study (NHATS), a cross-sectional, nationally representative sample of community-dwelling, non-institutionalized Medicare beneficiaries ages 65 or older(1). Cognitive and/or physical functional limitations contribute to the homebound continuum, ranging from independence, needing assistance to leave the home, to rarely/never leaving the home (homebound)(1). Medicare’s definition of homebound, associated with eligibility to receive home health services, means one requires physical or personal assistance to leave the home and that it requires a “taxing effort”(2), which aligns with both assisted and homebound categories within NHATS(1). Homebound status in older adults indicates vulnerability to worse healthcare outcomes: it is independently associated with more than twice the risk of death, in addition to more comorbidities, more functional impairment, and dementia(1)−(3).
The prevalence of Alzheimer’s disease and related dementias (ADRD) is particularly high in older adults who are homebound. ADRD prevalence is strongly correlated with degree of homebound status: 80% of those who were homebound had dementia, versus 57% of those who needed assistance and 14.8% of those who were independent(1).
In 2018, ADRD cost $277 billion in the US, and this could rise to $1.1 trillion by 2050, not including care provided by unpaid caregivers, valued at over $232 billion(4). Those with dementia have three times the healthcare cost compared to those without dementia, largely due to increased hospitalizations(5) in this multi-morbid population, where 35% have five or more chronic conditions(6).
Older age, being female or Hispanic, social isolation, smoking, having dementia, history of falls, use of walking assistive devices, and depression/anxiety are all associated with increased risk of becoming homebound(7),(8),(9). Longitudinal studies show conflicting data as to whether barriers at entry of the home were associated with becoming homebound(10),(11). Other factors that are highly prevalent in the homebound population such as sensory impairment(12), pain(13),(14), and sleep(13) have not been examined as potential risk factors for homebound progression. Current epidemiologic studies of homebound people do not distinguish those who are homebound due to physical vs cognitive impairment(7), (15), (16), (17). Therefore, it is essential to differentiate between individuals with dementia and those with normal cognition who are homebound, to achieve a more personalized approach to their clinical care. The purpose of this study was to determine which potentially modifiable factors contribute to homebound progression (from independent living to needing assistance to homebound), stratified by dementia status.