By 2050, 83.7 million adults in the United States will be 65 or older (1). The Age-Friendly Health Systems initiative was launched to meet the needs of older adults by providing evidence-based quality care focusing on key health care domains (Figure 1) (2). A specific element, “What Matters,” aligns an individual's values and goals with his or her medical prognosis when formulating treatment plans, also known as shared decision-making (SDM) (3). Dialysis is an example of an intervention where SDM is imperative. For older adults, dialysis may prolong life but often at the cost of treatment burden, morbidity, cognitive decline, and loss of physical function. Unfortunately, most relevant decision aids are not designed for older adults and lack education on conservative kidney management (4).
Age-Friendly Health Systems initiative
Citation: Kidney News 15, 5
Reprinted from the Institute for Healthcare Improvement (2).A multicenter randomized controlled trial by Ladin et al. (5) shows that the Decision Aid for Renal Therapy (DART)—an online interactive decision aid specifically designed for older adults—has the potential to address this gap. In this trial, individuals aged 70 or older with chronic kidney disease (CKD) stage 4 or 5 were randomized to DART plus standard education or standard education alone. Standard education included in-person information from a nephrologist plus an educational booklet, called Choosing a Treatment for Kidney Failure (6), published by the National Kidney Foundation. The study showed statistically significant decreases in decisional conflict (mean difference on the decisional conflict scale score, −8.5; 95% confidence interval [CI], −12.0 to −5.0; p < 0.001), such as uncertainty about treatment choices and feeling unsupported in one's decision-making, whereas statistically significant increases were seen in “knowledge” at 3 months (mean difference, 7.2; 95% CI, 3.7–10.7; p < 0.001), with similar findings at 6 months in the DART group.
The study gives providers tools to meaningfully focus on what matters for older adults with CKD. One caveat is that although patient enrollment was geographically diverse, racial and ethnic diversity was limited. Furthermore, 79% of the participants completed high school or more and had the cognitive reserve to engage in the intervention, limiting the applicability of the tool. We are encouraged that Ladin et al. (5) have provided a key resource to empower older adults with CKD to consider what matters most, and we look forward to further diversification of the tool to expand applicability.
References
- 1. ↑
Ortman JM, et al. An aging nation: The older population in the United States: Population estimates and projections. US Census Bureau. May 2014; 1–28. https://www.census.gov/content/dam/Census/library/publications/2014/demo/p25-1140.pdf
- 2. ↑
Tinetti M; Institute for Healthcare Improvement. Age-Friendly Health Systems. What is an age-friendly health system? 2023. Accessed February 28, 2023. https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
- 3. ↑
Stevens LA, et al. Chronic kidney disease and end-stage renal disease in the elderly population: Current prevalence, future projections, and clinical significance. Adv Chronic Kidney Dis 2010; 17:293–301. doi: 10.1053/j.ackd.2010.03.010
- 4. ↑
Song MK, et al. Patient perspectives on informed decision-making surrounding dialysis initiation. Nephrol Dial Transplant 2013; 28:2815–2823. doi: 10.1093/ndt/gft238
- 5. ↑
Ladin K, et al. Effectiveness of an intervention to improve decision making for older patients with advanced chronic kidney disease: A randomized controlled trial. Ann Intern Med 2023; 176:29–38. doi: 10.7326/M22-1543
- 6. ↑
National Kidney Foundation. Choosing a Treatment for Kidney Failure. https://www.kidney.org/atoz/content/choosingtreat#:~:text=There%20are%20two%20treatment%20options%20for%20kidney%20failure%3A,a%20different%20type%20of%20treatment%20in%20the%20future
