The effect of hemodialysis session on postural strategies in older end-stage renal disease patients

The Effect of Frailty on Quality of Life in Older Patients Receiving Hemodialysis and Associations With Fear of Falling

Purpose

This study investigated the effect of frailty and avoidance behavior due to fear of falling on the quality of life in older patients receiving hemodialysis treatment.

Methods

This study is cross‐sectional and descriptive. The study was conducted between January 2 and 31, 2022, with 154 individuals aged 65 years and over receiving treatment in dialysis centers. The study data were collected using the Patient Information Form, Edmonton Frail Scale, Fear of Falling Avoidance‐Behavior Questionnaire, and Quality of Life Scale (SF‐12).

Results

The Mean Edmonton Frail Scale score was found to be 8.7 ± 3.36, the mean Fear of Falling Avoidance‐Behavior Questionnaire score was found to be 33.17 ± 9.11, the mean SF‐12 physical component score was found to be 34.32 ± 8.51, and the mean mental component score was seen as 41.77 ± 8.35. The Fear of Falling Avoidance‐Behavior Questionnaire was an associated factor in the effect of the Edmonton Frail Scale on quality of life. It strengthened the negative impact of the Edmonton Frail Scale on quality of life. The predictive effect of these two variables in explaining quality of life was 59.3%.

Conclusion

It was found that the participants had moderate levels of frailty, moderate levels of activity limitation, and participation restriction due to fear of falling, and low levels of physical and mental quality of life. It was determined that frailty had a direct impact on quality of life. Also, the indirect effect of frailty on quality of life was determined through the role of avoidance behavior due to fear of falling.

Gait abnormalities and longitudinal fall risk in older patients with end-stage kidney disease and sarcopenia

BACKGROUND

Sarcopenia, gait disturbance, and intradialytic hypotension are among the various factors that contribute to fall risk. This study aimed to investigate the relationship between risk of sarcopenia, hemodialysis (HD) session, and long-term fall risk in older end-stage kidney disease (ESKD) patients by analyzing their spatiotemporal gait characteristics.

METHODS

We recruited 22 non-demented patients aged ≥ 65 years who were undergoing maintenance HD. Participants were divided into two groups based on their SARC-F score (< 4 and ≥ 4) to identify those with higher and lower risk of sarcopenia. Demographics, comorbidities, and renal parameters were compared between groups. Inertial measurement unit-based technology equipped with triaxial accelerometry and gyroscope was used to evaluate gait characteristics. The gait task was assessed both before and after dialysis using the Timed-Up and Go (TUG) test and a 10-meter walking test at a regular pace. Essential gait parameters were thoroughly analyzed, including gait speed, stride time, stride length, double-support phase, stability, and symmetry. We investigated the interaction between the dialysis procedure and gait components. Outcome of interest was any occurrence of injurious fall during follow-up period. Logistic regression models were employed to examine the relationship between baseline gait markers and long-term fall risk.

RESULTS

The SARC-F ≥ 4 group showed various gait abnormalities, including longer TUG time, slower gait speed, longer stride time, shorter stride length, and longer double support time compared to counterpart (SARC-F < 4). After HD sessions, the SARC-F ≥ 4 group showed a 2.0-second decrease in TUG task time, an 8.0 cm/s increase in gait speed, an 11.6% lower stride time, and a 2.4% increase in gait symmetry with significant group-time interactions. Shorter stride length and longer double support time were associated with injurious falls during the two-year follow-up.

CONCLUSION

Our study demonstrated the utility of triaxial accelerometers in extracting gait characteristics in older HD patients. High-risk sarcopenia (SARC-F ≥ 4) was associated with various gait abnormalities, some of which partially improved after HD sessions. These gait abnormalities were predictive of future falls, highlighting their prognostic significance.

Interventions to reduce falls among dialysis patients: a systematic review

INTRODUCTION

Despite all available evidence regarding increased morbidity and mortality among dialysis patients due to falls and their complications, and an increase in risk factors for falls, relatively little attention has been focused on evidence-based interventions that can reduce falls. We evaluated the effectiveness of fall prevention interventions among dialysis patients.

METHODS

We searched Ovid-Medline, Ovid-Embase, PubMed, Cumulated Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials (Central) from inception to 19 July 2023 for studies that evaluated the effectiveness of fall prevention interventions among dialysis patients. The search, screening and extraction of data followed standardised processes and the methodological quality of studies was independently assessed by two reviewers. Data was analysed using a narrative synthesis approach.

RESULTS

Of the 18 studies that had full text review, five were eligible. Three studies were performed in the USA and one each in UK and Japan. Four studies were conducted in outpatient hemodialysis centres and one in a hospital-based nephrology unit. Reported sample sizes ranged from 51 to 96 participants per study with a follow-up period of 3 to 35 months. There was moderate-quality evidence that exercises reduce the rate of falls compared to usual care and low to moderate quality of evidence that multifactorial falls prevention interventions reduce the rate of falls. However, treatment effects could not be quantitatively estimated for all interventions due to substantial heterogeneity of included studies.

CONCLUSIONS

This systematic review reflects that there is insufficient evidence regarding falls prevention strategies specific to dialysis patients. Available data based on low to moderate quality studies, suggest that among dialysis patients, exercises may reduce falls and the effectiveness of multifactorial interventions such as staff and patient education still need to be explored using high-quality prospective studies.

Factors associated with postural balance in patients with end-stage renal disease on hemodialysis

BACKGROUND

Patients with end-stage renal disease on hemodialysis have postural balance impairments due to uremic syndrome and hemodialysis complications. This study evaluated the factors associated with postural balance in patients on hemodialysis.

METHODS

This cross-sectional study included patients on hemodialysis [n = 93, 62.0 (16.0) years]. Postural balance was evaluated using a force plate in a static position with eyes opened and eyes closed on a firm surface and with eyes opened on a foam surface to register the center of pressure path length. Physical function was assessed by isometric handgrip force, the 5-repetition sit-to-stand test, and gait speed. The level of physical activity and quality of life were evaluated by accelerometry and the 36-Item Short Form Health Survey, respectively.

FINDINGS

After adjustment for potential confounders, the multiple linear regression analysis showed that the presence of diabetes mellitus and neurological disease and gait speed were significantly associated with the center of pressure path length in the eyes opened test (R² = 0.263; p < 0.001). The center of pressure path length in the eyes closed test was significantly associated with the presence of neurological disease (R² = 0.177; p = 0.002). The center of pressure path length in the eyes opened on a foam surface test was significantly associated with the presence of diabetes mellitus (R² = 0.223; p < 0.001).

INTERPRETATION

Poor postural balance was associated with the presence of diabetes mellitus and neurological disease and a slower gait speed in patients on hemodialysis.

Association between fear of falling and a history of falls in patients with end-stage renal disease on hemodialysis

INTRODUCTION

Hemodialysis patients have complications that increase fear of falling (FOF). This study evaluated the association between FOF and a retrospective history of falls in hemodialysis patients and investigated the ability of the Fall Efficacy Scale-International (FES-I) to discriminate fallers from nonfallers.

METHODS

A retrospective study was conducted with 183 patients to investigate the history of falls in the last 12 months and to evaluate FOF by the FES-I.

RESULTS

The univariate linear regression model showed that the FES-I score was significantly associated with a history of falls (p = 0.01). After adjustment for potential confounders, this association remained significant (R²  = 0.19, p < 0.001). The FES-I score showed an area under the curve of 0.660 with a cutoff point of 25 (sensitivity-61.8%; specificity-62.2%).

CONCLUSION

FOF was associated with a history of falls in the 12-month period in hemodialysis patients, and FOF assessed by the FES-I was able to discriminate fallers from nonfallers.

Factors associated with falls in hemodialysis patients: a case-control study

OBJECTIVE

to identify possible associations between a higher probability of falls among hemodialysis patients and laboratory values, comorbidities, pharmacological treatment, hemodynamic changes, dialysis results and stabilometric alterations.

METHOD

this was a retrospective case-control study with hemodialysis patients. Patients in a hemodialysis unit who had suffered one or more falls were included in the case group. Patients from the same unit who had not suffered falls were the controls. Data were gathered from the patients' clinical history and also from the results of a balance test conducted six months before the study.

RESULTS

thirty-one patients were included (10 cases and 21 controls). Intradialytic body weight change was significantly greater among cases (p <0.05). Patients in the case group also presented greater lateral instability after dialysis (p <0.05). Other factors such as high blood pressure, antihypertensives, beta-blockers, and lower heart rates were also associated with falls.

CONCLUSION

a greater intradialytic weight change was associated with an increase in risk of falls. Nursing staff can control these factors to prevent the incidence of falls in dialysis patients.

Haemodialysis patients have worse postural balance with an associated risk of falls

INTRODUCTION

Postural balance is the result of a complex interaction of sensory input which keeps us upright. Haemodialysis patients have alterations which can lead to postural instability and a risk of falls. Our objective was to analyse postural stability and its relationship with the risk of falls in haemodialysis patients using a force platform.

MATERIAL AND METHODS

This was a prospective cross-sectional study. Postural balance was recorded using a force platform in prevalent haemodialysis patients. We collected epidemiological, dialysis, analytical and treatment data. The incidence of falls was recorded over the 6 months following the tests. The postural stability analysis was performed with a portable strain gauge platform (AMTI AccuGait®) and a specific software unit for stabilometry (Balance Trainer® program). We measured 31 balance parameters; the balance variables used were: Area95; AreaEffect; VyMax; Xrange and Yrange. The stabilometry studies were performed in 3 situations: with eyes open; with eyes closed; and with the patient performing a simultaneous task. We performed one study at the start of the dialysis session, and a second study at the end. Stabilometry was measured in a control group under similar conditions.

RESULTS

We studied 32 patients with a mean age of 68 years old; of this group, 20 subjects were male and 12 were female. Their mean weight was 74kg, with a mean BMI of 27.6kg/m². In the controls, there were no significant differences in the stabilometry between the 3 situations studied. Both pre- and post-haemodialysis, patients with closed eyes showed greater imbalance, and there were significant differences with the other situations and controls. We found a significant increase in instability after the haemodialysis session, and greater instability in the 13 patients with diabetes (P<.05). The 4 patients with hyponatraemia (Na<136mmol/l) had worse balance in the simultaneous task situation (P=.038). Various drugs, such as insulin (P=.022), antiplatelet agents (P=.036) and beta-blockers (P=.029), were associated with imbalance. The 10 patients who suffered falls had greater imbalance, Yrange, Xrange, Area95 and AreaEffect, both pre- and post-haemodialysis (P<.05) than those without falls.

CONCLUSIONS

Haemodialysis patients have alterations which can lead to postural instability and a risk of falls. Prevention programmes which include specific exercises to improve balance could be beneficial in reducing the risk of falls in this population.

Discussions during shared decision-making in older adults with advanced renal disease: a scoping review

OBJECTIVES

This review summarises the information available for clinicians counselling older patients with kidney failure about treatment options, focusing on prognosis, quality of life, the lived experiences of treatment and the information needs of older adults.

DESIGN

We followed the Joanna Briggs Institute Methodology for Scoping Reviews. The final report conforms to the PRISMA-ScR guidelines.

DATA SOURCES

PubMed, PsycINFO, CINAHL, Embase, Scopus, Web of Science, TRIP and online repositories (for dissertations, guidelines and recommendations from national renal associations).

ELIGIBILITY CRITERIA FOR INCLUSION

Articles in English studying older adults with advanced kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m2); published between January 2000 and August 2018. Articles not addressing older patients separately or those comparing between dialysis modalities were excluded.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened articles for inclusion and grouped them by topic as per the objectives above. Quantitative data were presented as tables and charts; qualitative themes were identified and described.

RESULTS

248 articles were included after screening 15 445 initial results. We summarised prognostic scores and compared dialysis and non-dialytic care. We highlighted potentially modifiable factors affecting quality of life. From reports of the lived experiences, we documented the effects of symptoms, of ageing, the feelings of disempowerment and the need for adaptation. Exploration of information needs suggested that patients want to participate in decision-making and need information, in simple terms, about survival and non-survival outcomes.

CONCLUSION

When discussing treatment options, validated prognostic scores are useful. Older patients with multiple comorbidities do not do well with dialysis. The modifiable factors contributing to the low quality of life in this cohort deserve attention. Older patients suffer a high symptom burden and functional deterioration; they have to cope with significant life changes and feelings of disempowerment. They desire greater involvement and more information about illness, symptoms and what to expect with treatment.

Thoracic vertebral fractures and hyperkyphosis in elderly patients with end-stage kidney disease; do these patients have different clinical outcomes?

BACKGROUND AND OBJECTIVES

Elderly patients with end-stage kidney disease (ESKD) are at high risk for fractures. However, the prevalence of vertebral fractures and hyperkyphosis is not studied well. This is relevant, because in the general population, both vertebral fractures and hyperkyphosis are associated with poor outcome. Therefore, the primary aim of our study was to assess the prevalence of vertebral fractures and hyperkyphosis in the ESKD population. The secondary aim was to assess if patients with vertebral fractures and/or hyperkyphosis more often have poor outcome after starting dialysis, such as accidental falling, functional decline and mortality compared to the patients without vertebral fractures and/or hyperkyphosis.

DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS

This study included patients ≥65 years with ESKD who were enrolled in the Geriatric assessment in Older patients starting Dialysis (GOLD) study of whom a lateral chest radiograph was available. Chest radiographs were scored independently by two observers for vertebral fractures (Genant ≥1) and hyperkyphosis (≥50 degrees). The relation between vertebral fractures and hyperkyphosis with clinical outcomes (falls, decline in ADL and IADL, mortality) was studied using the Chi-square test.

RESULTS

Of the 196 enrolled patients, chest radiographs were available for 160 patients. Mean age was 75.3 (SD ±6.9), and 35% were female. The prevalence of vertebral fractures was 43% and of hyperkyphosis 22%. Patients with hyperkyphosis had a higher one-year mortality compared to patients without hyperkyphosis (20% vs. 8%, p = 0.04). No differences were observed between patients with and without hyperkyphosis, vertebral fractures and the remaining outcomes after six months of follow-up.

CONCLUSIONS

In patients ≥65 years old with ESKD starting dialysis, vertebral fractures are highly prevalent. In contrast to the general population, patients with vertebral fractures did experience poor outcome as often as patients without vertebral fractures. Remarkably, patients with hyperkyphosis did have a higher one-year mortality. However, these patients did not experience more functional decline or accidental falls.

Dialytic hemodynamics are associated with changes in gait speed

INTRODUCTION

Functional impairment and reduced mobility are prevalent in patients on chronic hemodialysis (HD). The impact of HD on physical performance and mobility needs evaluation.

METHODS

We measured gait speed in a cohort of chronic HD patients both pre and post an HD session. We collected demographic and laboratory data and dialytic hemodynamic parameters for the HD session. Participants completed the Falls Efficacy Scale International (FES-I) survey to assess concern for falling. We used linear regression analysis to tests for associations between our predictor variables of intra-dialytic hemodynamic change and change in gait speed from pre to post HD (primary outcome) and FES-I score (secondary outcome).

FINDINGS

Twenty-eight participants completed the study. The mean (SD) age was 64.0 (10.5) years. The majority were male (71.4%), had hypertension (85.7%) and diabetes (57.1%). The mean (SD) change in gait speed from pre to post dialysis was -0.06 (0.08) m/s. A greater decrease in gait speed was associated with greater decrease in SBP and DBP from pre to post HD (p = 0.02 and p = 0.04, respectively) and greater maximum drop in SBP and DBP during HD (p = 0.01 and p <0.01, respectively). The association between maximum drop in SBP and DBP and gait speed remained significant after adjustment for covariates. There was no association between BP change and FES-I score.

DISCUSSION

Our results suggest that HD patients who have greater decrease in BP during HD are at risk for decreased gait speed post HD.