Geriatric Issues in the Elderly Dialysis Population

The United States ESRD population is aging. Patients over the age of 65 have the highest adjusted prevalence of ESRD (Figure 1) (1). As a result of these demographics, nephrology providers are now faced with the task of recognizing and treating not only the burdens of ESRD but also morbidities associated with geriatric syndromes (Table 1). Prognosis for the elderly encompasses survival as well as effects on quality of life (QOL), cognition, functional status, and time lost from being with family. Treatment choice and follow-up care should address these issues while considering the individual’s preferences, physiological state, and social support. Given that elderly dialysis patients will likely die while receiving dialysis, it would be beneficial to discuss end-of-life choices when dialysis is started.

Figure 1.

Adjusted prevalence of ESRD, per million, by age group, in the United States population, 1980 to 2012

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Reprinted with permission from US Renal Data System (1). The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the US government.

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Unique issues in older dialysis patients

Dialysis therapy does not seem to preserve functional status or independent living for many older patients, with the most vulnerable time being when it is first initiated (2, 3). Older patients receiving hemodialysis (HD) show a high prevalence of functional disability and dependence (3). The consequences of normal aging combined with dialysis-associated adverse events, such as posttreatment hypotension, place an already functionally challenged population at risk for falls. In patients over the age of 65, an accidental fall increases the risk of death in both HD (hazard ratio [HR] 1.78, 95% confidence interval [CI] 1.07–2.98) and peritoneal dialysis (PD) populations (HR 1.62, 95% CI 1.29–2.02) (4, 5). The American Geriatrics Society recommends that all older people be screened for falls (6). They endorse a multifactorial fall risk assessment if the screening results are positive. Empowering members of multidisciplinary dialysis teams to perform fall screenings and functional assessments is a simple way to identify patients appropriate for a more detailed geriatric assessment, and possibly improve QOL.

In addition to functional decline, many ESRD patients are also at risk for cognitive and executive function impairment (7). This deficiency can have an impact on complex thinking, compliance, QOL, and decision-making (7). In a recent study of HD patients, decreased executive function was associated with increased mortality, even with adjustment for comorbidities (7). PD has been shown to have a lower risk of dementia than HD (HR 0.74, 95% CI 0.64–0.86), although both groups have a higher incidence than age-matched control individuals not receiving dialysis (8). Identification of elderly patients with impaired cognition recognizes those who need assistance with decision-making, the responsibilities of dialysis, and caregivers who are at risk for burnout.

QOL, decision-making, and the individualized geriatric experience

As a result of multi-morbidity, the ESRD experience for the elderly is variable. Unfortunately, current guidelines are disease oriented and with a “one size fits all” approach that pays little attention to QOL. Nephrology providers are challenged to integrate the individual patient’s experience into appropriate clinical management.

There is no right answer for an elderly patient. A highly comorbid individual may want a trial of dialysis to enable living to a family milestone. An institutionalized patient requiring rehabilitation may be given more free time with PD. If a patient is interested only in survival, recent work from Korea showed an advantage with HD versus PD for the elderly, particularly those with diabetes mellitus or a longer dialysis vintage (9). However, this contrasts with older data that showed no difference in survival and, perhaps more importantly, no difference in QOL (10). For those with a high comorbidity burden, including ischemic heart disease, observational data have shown that dialysis does not confer a survival advantage when compared with conservative management with the incorporation of palliative care (11). Additionally, a recent single-center study demonstrated that integrating palliative care with conservative management led to improved or stable symptom control and QOL metrics at 12 months in a majority of patients (11). The individualized nature of this decision emphasizes the importance of communication; yet, older ESRD patients report feeling unprepared for the HD experience (12). Unfortunately, the burdens of dialysis and the option of conservative management are often excluded from conversations about treatment decisions (13).

Goal-directed therapy: time-limited trials

Given the risk of further suffering from geriatric syndromes in patients receiving dialysis, it is important to check in with patients regularly to assess their dialysis experience. A time-limited trial begins with the identification of patient-specific goals, often relevant to QOL and geriatric syndromes, with planned re-evaluations to assess the patient’s perceptions of the benefits and burdens of dialysis (14). This continuous dialogue also allows for a fluid transition into advance care planning. Advance care planning with dialysis patients can promote the use of hospice, a benefit often underused in this population (15). In the general population advance care planning is associated with fewer intensive procedures at the end of life, death at the location of choice, increased patient satisfaction, and increased use of hospice (16).

In summary, the current demographics of ESRD necessitate a cultural shift in care to an individualized approach that incorporates basic principles of geriatric medicine and palliative care. How to best achieve this goal with use of our own dialysis centers’ interdisciplinary teams is currently not clear. Although more research and education are needed, it appears obvious that the implementation of geriatric and palliative care principles will enhance current practice and allow the patients’ experience to be the largest factor.

References

1. U.S. Renal Data System. USRDS 2014 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014.

2. Jassal SV, Chiu E, Hladunewich M. Loss of independence in patients starting dialysis at 80 years of age or older. N Engl J Med 2009; 361:1612–1613.

3. Cook WL, Jassal SV. Functional dependencies among the elderly on hemodialysis. Kidney Int 2008; 73:1289–1295.

4. Li M, et al. Geriatric comorbidities, such as falls, confer an independent mortality risk to elderly dialysis patients. Nephrol Dial Transplant 2008; 23:1396–1400.

5. Farragher J, et al. Accidental falls and risk of mortality among older adults on chronic peritoneal dialysis. Clin J Am Soc Nephrol 2014; 9:1248–1253.

6. American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011; 59:148–157.

7. Drew DA, et al. Cognitive function and all-cause mortality in maintenance hemodialysis patients. Am J Kidney Dis 2015; 65:303–311.

8. Wolfgram DF, et al. Risk of dementia in peritoneal dialysis patients compared with hemodialysis patients. Perit Dial Int 2015; 35:189–198.

9. Han SS, et al. Dialysis modality and mortality in the elderly: a meta-analysis. Clin J Am Soc Nephrol 2015; 10:983–993.

10. Harris SA, et al. Clinical outcomes and quality of life in elderly patients on peritoneal dialysis versus hemodialysis. Perit Dial Int 2002; 22:463–470.

11. Brown MA, et al. CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life. Clin J Am Soc Nephrol 2015; 10:260–268.

12. Schell JO, et al. Discussions of the kidney disease trajectory by elderly patients and nephrologists: a qualitative study. Am J Kidney Dis 2012; 59:495–503.

13. Song MK, et al. Patient perspectives on informed decision-making surrounding dialysis initiation. Nephrol Dial Transplant 2013; 28:2815–2823.

14. Schell JO, Cohen RA. A communication framework for dialysis decision-making for frail elderly patients. Clin J Am Soc Nephrol 2014; 9:2014–2021.

15. Schmidt RJ, Weaner BB, Long D. The power of advance care planning in promoting hospice and out-of-hospital death in a dialysis unit. J Palliat Med 2015; 18:62–66.

16. Luckett T, et al. Advance care planning for adults with CKD: a systematic integrative review. Am J Kidney Dis 2014; 63:761–770.