Conventional dialysis in the elderly: How lenient should our guidelines be?

Dependency and frailty in the older haemodialysis patient

BACKGROUND

Frailty among older adults undergoing hemodialysis is increasingly prevalent, significantly impacting cognitive function, mobility, and social engagement. This study focuses on the clinical profiles of very older adults in hemodialysis, particularly examining the interplay of dependency and frailty, and their influence on dialysis regimens.

METHODS

In this observational, descriptive study, 107 patients aged over 75 from four outpatient centers and one hospital unit were examined over a year. Patient data encompassed sociodemographic factors, dialysis specifics, analytical outcomes, lifestyle elements, and self-reported post-treatment fatigue. Malnutrition-inflammation scale was used to measure the Nutritional status; MIS scale for malnutrition-inflammation, Barthel index for dependency, Charlson comorbidity index; FRIED scale for frailty and the SF12 quality of life measure.

RESULTS

The study unveiled that a substantial number of older adults on hemodialysis faced malnutrition (55%), dependency (21%), frailty (46%), and diminished quality of life (57%). Patients with dependency were distinctively marked by higher comorbidity, severe malnutrition, enhanced frailty, nursing home residency, dependency on ambulance transportation, and significantly limited mobility, with 77% unable to walk. Notably, 56% of participants experienced considerable post-dialysis fatigue, correlating with higher comorbidity, increased dependency, and poorer quality of life. Despite varying clinical conditions, dialysis patterns were consistent across the patient cohort.

CONCLUSIONS

The older adult cohort, averaging over four years on hemodialysis, exhibited high rates of comorbidity, frailty, and dependency, necessitating substantial support in transport and living arrangements. A third of these patients lacked residual urine output, yet their dialysis regimen mirrored those with preserved output. The study underscores the imperative for tailored therapeutic strategies to mitigate dependency, preserve residual renal function, and alleviate post-dialysis fatigue, ultimately enhancing the physical quality of life for these patients.

Motivations, psychosocial burdens, and decision-making modes of post-partum women with stress urinary incontinence engaging in pelvic floor physical therapy: a qualitative research

INTRODUCTION AND HYPOTHESIS

This qualitative research explores the motivations, psychosocial burdens, and decision-making modes of post-partum women with stress urinary incontinence (SUI) engaging in pelvic floor physical therapy (PFPT).

METHODS

This study was conducted face-to-face in a treatment room using qualitative semi-structured interviews with post-partum women who received PFPT for SUI between May and October 2022. Participant interviews were transcribed verbatim and thematically analyzed using NVivo software, which is most commonly used for qualitative data analysis.

RESULTS

Themes that impacted participants' decisions to receive PFPT included avoiding deterioration of SUI symptoms, believing that the sooner it is treated the better, being unable to adhere to home exercise programs, and dissatisfaction with quality of life. Some participants experienced psychosocial burdens when receiving PFPT, including impact on daily activities, worries about the baby, financial burdens, and uncertainty about the effect. There were two modes of decision making, which brought different experiences. Some participants preferred participant-provider shared decision making and reported effective doctor-patient communication, and striving for autonomous decisions. Other participants preferred their clinicians to decide on PFPT protocols in view of their trust in their midwives, institutional reputation, and lacking knowledge of PFPT.

CONCLUSIONS

We discovered that participants had both motivations and psychosocial burdens when receiving therapy. Some participants preferred participant-provider shared decision making, whereas others preferred their midwives to make decisions. Further more standardized studies with more robust samples are needed.

Dialysis modality utilization patterns and mortality in older persons initiating dialysis in Australia and New Zealand

AIM

The benefits of dialysis in the older population remain highly debated, particularly for certain dialysis modalities. This study aimed to explore the dialysis modality utilization patterns between in-centre haemodialysis (ICHD), peritoneal dialysis (PD) and home haemodialysis (HHD) and their association with outcomes in older persons.

METHODS

Older persons (≥75 years) initiating dialysis in Australia and New Zealand from 1999 to 2018 reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry were included. The main aim of the study was to characterize dialysis modality utilization patterns and describe individual characteristics of each pattern. Relationships between identified patterns and survival, causes of death and withdrawal were examined as secondary analyses, where the pattern was considered as the exposure.

RESULTS

A total of 10 306 older persons initiated dialysis over the study period. Of these, 6776 (66%) and 1535 (15%) were exclusively treated by ICHD and PD, respectively, while 136 (1%) ever received HHD during their dialysis treatment course. The remainder received both ICHD and PD: 906 (9%) started dialysis on ICHD and 953 (9%) on PD. Different individual characteristics were seen across dialysis modality utilization patterns. Median survival time was 3.0 (95%CI 2.9-3.1) years. Differences in survival were seen across groups and varied depending on the time period following dialysis initiation. Dialysis withdrawal was an important cause of death and varied according to individual characteristics and utilization patterns.

CONCLUSION

This study showed that dialysis modality utilization patterns in older persons are associated with mortality, independent of individual characteristics.

The social construction of the patient-physician relationship in the clinical encounter: Media frames on shared decision making in Germany

The literature on healthcare management has noted that shared decision-making (SDM) - a practice of organizing joint decisions between healthcare professionals and patients - should improve healthcare outcomes through patient engagement and autonomy, fostering patient-centeredness. While SDM projects are implemented across Europe and the US, the diffusion of the practice remains partial, and its' conceptualization scattered. Healthcare management literature explores SDM on the underlying assumption that its limited diffusion results from an information problem, implying objective criteria and rational behavior. The purpose of this research is to study the social construction of SDM within the clinical setting and the underlying rationales using the case of one of the largest healthcare markets worldwide - Germany. To capture the complexity of SDM, a frame analysis is conducted on its medial representations. News media is both influential in shaping public opinion, as well as in generating public discourse. This analysis enables one to elaborate different facets of the construct of SDM, to capture inherent patterns of facilitating and obstructing aspects and to explore consequences for the diffusion of SDM. Three facilitating and three obstructive frames on the implementation of SDM were identified. The polarities of these frames range from the questioning of one's decision-making authority to the perception of individual competence and decision-making agency. Moreover, this study reflects on how physicians' and patients' role for SDM is conceived.

Kidney supportive care: an update of the current state of the art of palliative care in CKD patients

Chronic kidney disease (CKD) has become a public health burden worldwide for its increasing incidence and prevalence, high impact on the health related quality of life (HRQoL) and life expectancy, and high personal and social cost. Patients with advanced CKD, in dialysis or not, suffer a burden from symptoms very similar to other chronic diseases and have a life span not superior to many malignancies. Accordingly, in recent years, renal palliative care has been recommended to be integrated in the traditional care delivered to this population. This research provides an updated overview on renal palliative care from the relevant literature.

Risk factors for mortality in elderly haemodialysis patients: a systematic review and meta-analysis

Background

Older haemodialysis patients accompany a high burden of functional impairment, limited life expectancy, and healthcare utilization. This meta-analysis aimed to evaluate how various risk factors influenced the prognosis of haemodialysis patients in late life, which might contribute to decision making by patients and care providers.

Methods

PubMed, Embase, and Cochrane Central were searched systematically for studies evaluating the risk factors for mortality in elderly haemodialysis patients. Twenty-eight studies were included in the present systematic review. The factors included age, cardiovascular disease, diabetes mellitus, type of vascular access, dialysis initiation time, nutritional status and geriatric impairments. Geriatric impairments included frailty, cognitive or functional impairment and falls. Relative risks with 95% confidence intervals were derived.

Results

Functional impairment (OR = 1.45, 95% CI: 1.20–1.75), cognitive impairment (OR = 1.46, 95% CI: 1.32–1.62) and falls (OR = 1.14, 95% CI: 1.06–1.23) were significantly and independently associated with increased mortality in elderly haemodialysis patients. Low body mass index conferred a mortality risk (OR = 1.43, 95% CI: 1.31–1.56) paralleling that of frailty as a marker of early death. The results also confirmed that the older (OR = 1.43, 95% CI: 1.22–1.68) and sicker (in terms of Charlson comorbidity index) (OR = 1.41, 95% CI: 1.35–1.50) elderly haemodialysis patients were, the more likely they were to die. In addition, increased mortality was associated with early-start dialysis (OR = 1.18, 95% CI: 1.01–1.37) and with the use of a central venous catheter (OR = 1.53, 95% CI: 1.44–1.62).

Conclusions

Multiple factors influence the risk of mortality in elderly patients undergoing haemodialysis. Geriatric impairment is related to poor outcome. Functional/cognitive impairment and falls in elderly dialysis patients are strongly and independently associated with mortality.

Survival advantage of initiating dialysis in elderly and non-elderly incident end-stage kidney disease patients

AIM

Many patients, especially the elderly, who require renal replacement therapies (RRT) have delayed or rejected dialysis for various reasons. Current dialysis guidelines may not be relevant for the elderly or frail patients. We aim to determine survival advantage of initiating dialysis in patients deemed to require RRT.

METHODS

This was an observational cohort on incident end-stage kidney disease (ESKD) patients from January 1, 2007 to December 31, 2008. The primary outcome was all-cause mortality. Patients contributed person-time from the date of ESKD diagnosis until death, transplant or end of study on December 31, 2014, whichever occurred first. An extended Cox regression model with time-varying exposure to dialysis was used to account for immortal time bias.

RESULTS

Of 3990 incident ESKD patients included, 70.2% patients initiated dialysis; 78.8% with haemodialysis (HD) while the remaining 21.2% with peritoneal dialysis (PD). Dialysis reduced hazard of death in both elderly and non-elderly patients even after controlling for comorbidities (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.50, 0.68 and HR 0.76, 95% CI 0.69, 0.85, respectively). HD was protective in both the elderly and non-elderly (HR 0.53, 95% CI 0.45, 0.63 and HR 0.71, 95% CI 0.64, 0.80, respectively). PD significantly reduced risk of death compared to no dialysis in the elderly but not in the non-elderly.

CONCLUSION

Dialysis improved survival in all incident ESKD patients. The findings suggested a larger protection offered by HD. Although improvement in survival from initiating dialysis was large, its true benefit should take overall quality of life into account. SUMMARY AT A GLANCE This observational study showed that initiation of dialysis improves the survival of end-stage kidney disease (ESKD) patients of all age groups, but the quality of life is an important aspect that has not been explored.

Incremental hemodialysis, a valuable option for the frail elderly patient

Management of older people on dialysis requires focus on the wider aspects of aging as well as dialysis. Recognition and assessment of frailty is vital in changing our approach in elderly patients. Current guidelines in dialysis have a limited evidence base across all age group, but particularly the elderly. We need to focus on new priorities of care when we design guidelines "for people not diseases". Patient-centered goal-directed therapy, arising from shared decision-making between physician and patient, should allow adaption of the dialysis regime. Hemodialysis (HD) in the older age group can be complicated by intradialytic hypotension, prolonged time to recovery, and access-related problems. There is increasing evidence relating to the harm associated with the delivery of standard thrice-weekly HD. Incremental HD has a lower burden of treatment. There appears to be no adverse clinical effects during the first years of dialysis in presence of a significant residual kidney function. The advantages of incremental HD might be particularly important for elderly patients with short life expectancy. There is a need for more research into specific topics such as the assessment of the course of frailty with progression of chronic kidney disease and after dialysis initiation, the choice of dialysis modality impacting on the trajectory of frailty, the timing of dialysis initiation impacting on frailty or on other outcomes. In conclusion, understanding each individual's goals of care in the context of his or her life experience is particularly important in the elderly, when overall life expectancy is relatively short, and life experience or quality of life may be the priority.