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. 2025 Dec 9.
doi: 10.1007/s11606-025-10073-z. Online ahead of print.

Effects of Functional Impairments and Frailty on the Association of Cognitive Impairment with Total Healthcare Costs: A Prospective Multi-cohort Study

Howard A Fink  1   2   3   4 , Kerry M Sheets  5   6 , Lisa Langsetmo  7   5   8 , John T Schousboe  9   10 , Allyson M Kats  8 , Kristine E Ensrud  7   5   8
Affiliations

Effects of Functional Impairments and Frailty on the Association of Cognitive Impairment with Total Healthcare Costs: A Prospective Multi-cohort Study

Howard A Fink et al. J Gen Intern Med. .

Abstract

Background: Cognitive impairment is associated with higher total healthcare costs (THC) after accounting for demographic factors and comorbidity burden.

Objective: Determine the proportion of incremental THC associated with cognitive impairment that is accounted for by functional impairments and frailty.

Design: Four prospective cohort studies of community-dwelling older adults are linked with each other and Medicare claims.

Participants: Eight thousand one hundred sixty-five community-dwelling, fee-for-service Medicare beneficiaries (mean age 79 years, 53% women, 79% non-Hispanic White).

Main measures: Cognitive impairment was defined by either abnormal cognitive tests or self-or-proxy report of a clinician diagnosis of dementia. Comorbidity was the count of claims-based chronic conditions. Functional impairments were self-reported difficulty performing four activities of daily living. Frailty was defined by the Cardiovascular Health Study phenotype or a claims-based deficit accumulation index (CFI). Annualized THC were ascertained for 36 months following an index exam. Incremental THC of cognitive impairment were mean THC in women (men) with cognitive impairment minus the mean THC in women (men) without cognitive impairment.

Key results: Incremental THC of cognitive impairment after adjustment for age, race, geographic region, and comorbidities was $6883 (95% CI, 3461-10,305) in women and $7276 (3298-11,254) in men. A substantial proportion of incremental THC of cognitive impairment were attributable to functional impairment, phenotypic frailty, or CFI individually (range 31.1-40.2% in women and 27.6-40.1% in men), while the combination of these three domains accounted for the majority of incremental THC (63.4% in women and 58.2% in men).

Conclusions: For both women and men, after accounting for demographics and comorbidity, approximately 60% of incremental THC associated with cognitive impairment was attributable to functional impairments and frailty. Investigation is warranted to determine if addressing these geriatric syndromes will mitigate their impact on THC among community-dwelling older adults with cognitive impairment.

Keywords: Cognitive impairment; Dementia; Frailty; Functional status; Health care costs.

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Conflict of interest statement

Declarations. Ethics Approval and Consent to Participate: The University of Minnesota human subjects committee approved the study; informed consent was waived because it was a secondary analysis of de-identified data. Conflict of interest: Dr. Sheets reports grant support from the NIH and honorarium from the International Antiviral Society for an invited manuscript. Dr. Ensrud reports honorarium from the American College of Physicians for an invited manuscript and serves or has served as chair on NIH DSMBs (but declined any honoraria). The other authors have nothing to disclose.

References

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