Incorporating Geriatric Assessment into a Nephrology Clinic: Preliminary Data from Two Models of Care

Abstract

Older adults with advanced chronic kidney disease (CKD) experience functional impairment that can complicate CKD management. Failure to recognize functional impairment may put these patients at risk of further functional decline, nursing home placement, and missed opportunities for timely goals of care conversations. Routine geriatric assessment could be a useful tool for identifying older CKD patients who are at increased risk of functional decline and provide contextual information to guide clinical decision-making. We implemented two innovative programs in the Veterans Health Administration that incorporate geriatric assessment performed concurrently with a nephrology visit. In one program, standardized geriatric assessment tools were performed on CKD patients ≥ 70 years by a geriatrician embedded in a nephrology clinic (Comprehensive Geriatric Assessment for CKD) (CGA-4-CKD). In the second program, a nephrology clinic employed comprehensive appointments for patients ≥ 75 years to conduct both geriatric assessments and CKD care (Renal Silver). We report data on 68 Veterans who had geriatric assessments through these programs between November 2013 and May 2015. In CGA-4-CKD, difficulty with one or more ADLs, history of falls, and cognitive impairment were each found in 27.3% of patients. ADL difficulty, falls and cognitive impairment were found in 65.7%, 28.6%, and 51.6% of patients in Renal Silver. Geriatric assessment guided care processes in 45.4% (n=15) and 37.1% (n=13) of Veterans in the CGA-4-CKD and Renal Silver programs, respectively. Findings suggest there is a significant burden of functional impairment in older adults with CKD. Knowledge of this impairment is applicable to CKD management.

Exercise and cognitive function in patients with end‐stage kidney disease

“…It is encouraging that these interventions can indeed have such a profound effect on health and quality of life, as was demonstrated in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial, an ongoing multi‐center trial of healthy community‐dwelling older adults followed for 20+ years . The likelihood of success among patients with ESKD may be especially hopeful given the high burden of cognitive impairment, and therefore, greater room for improvement in the face of these interventions; cognitive screening as part of a comprehensive geriatric assessments may help identify those ESKD patients who may benefit most from ET and/or CT …”

Reply to: Comment on: “Incorporating Geriatric Assessment into a Nephrology Clinic: Preliminary Data from Two Models of Care”

“…2 We were unable to report the same details for Renal Silver clinic patients as for Comprehensive Geriatric Assessment for Chronic Kidney Disease (CGA-4-CKD) clinic patients because we did not systematically document medication changes for Renal Silver patients. More than 75% of Renal Silver patients had two or more of the following chronic conditions: diabetes, hypertension, congestive heart failure, cerebrovascular disease and coronary artery disease.…”

Geriatric Assessment in Advanced Kidney Disease

“…Its role in chronic disease settings is less well established. There are reports of its use in advanced kidney disease (7,8), where it has the potential to inform shared decision-making about modality choice and maximize opportunities for rehabilitation and maintenance of independence, which are known priorities for patients with advanced CKD (9). Use of the CGA can also ensure better coordination of management for multimorbid conditions and, where appropriate, enable smooth transition into palliative modes of care.…”