Perspectives and experiences of patients and healthcare professionals with geriatric assessment in chronic kidney disease: a qualitative study

Abstract

Background Older patients with end-stage kidney disease (ESKD) often live with unidentified frailty and multimorbidity. Despite guideline recommendations, geriatric assessment is not part of standard clinical care, resulting in a missed opportunity to enhance (clinical) outcomes including quality of life in these patients. To develop routine geriatric assessment programs for patients approaching ESKD, it is crucial to understand patients’ and professionals’ experiences with and perspectives about the benefits, facilitators and barriers for geriatric assessment. Methods In this qualitative study, semi-structured focus group discussions were conducted with ESKD patients, caregivers and professionals. Participants were purposively sampled from three Dutch hospital-based study- and routine care initiatives involving geriatric assessment for (pre-)ESKD care. Transcripts were analysed inductively using thematic analysis. Results In six focus-groups, participants (n = 47) demonstrated four major themes: (1) Perceived characteristics of the older (pre)ESKD patient group. Patients and professionals recognized increased vulnerability and (cognitive) comorbidity, which is often unrelated to calendar age. Both believed that often patients are in need of additional support in various geriatric domains. (2) Experiences with geriatric assessment. Patients regarded the content and the time spent on the geriatric assessment predominantly positive. Professionals emphasized that assessment creates awareness among the whole treatment team for cognitive and social problems, shifting the focus from mainly somatic to multidimensional problems. Outcomes of geriatric assessment were observed to enhance a dialogue on suitability of treatment options, (re)adjust treatment and provide/seek additional (social) support. (3) Barriers and facilitators for implementation of geriatric assessment in routine care. Discussed barriers included lack of communication about goals and interpretation of geriatric assessment, burden for patients, illiteracy, and organizational aspects. Major facilitators are good multidisciplinary cooperation, involvement of geriatrics and multidisciplinary team meetings. (4) Desired characteristics of a suitable geriatric assessment concerned the scope and use of tests and timing of assessment. Conclusions Patients and professionals were positive about using geriatric assessment in routine nephrology care. Implementation seems achievable, once barriers are overcome and facilitators are endorsed. Geriatric assessment in routine care appears promising to improve (clinical) outcomes in patients approaching ESKD.

Design of a consensus-based geriatric assessment tailored for older chronic kidney disease patients: results of a pragmatic approach

“…Rather, results are discussed in a multidisciplinary meeting, informing nephrology treatment decisions and follow-up interventions among which CGA and consultation of a geriatrician. The NGA could be conducted by a geriatric-trained nephrology nurse (practitioner) or by a partnership between geriatric medicine and nephrology (i.e., geriatrician co-management after screening for eligibility by geriatrician or triage nurse) as described elsewhere [18,20]. However, appropriate geriatric training for clinicians to assess and manage geriatric conditions is advocated [3,6,8,10,20,21].…”

“…Furthermore, although CGA has demonstrated benefits in other medical fields [15,16], studies on its effectiveness are lacking. Though, use of a geriatric assessment was suggested to identify often undiagnosed problems [6], raise awareness for these problems among health care professionals [3,18,20], and enables treatment adjustment or tailored supportive interventions [48]. Besides, the information derived from standardized geriatric assessment can potentially be used to stratify patients into risk categories to better predict their outcomes on kidney replacement therapy or conservative care [5].…”

“…Both patients with positive and negative experiences with NGA and with different (future) choices of treatment modality were invited, as were their caregivers. Detailed methods and overall results of these focus groups are published elsewhere [18]. Findings were included in the list of basic principles for geriatric assessment in nephrology which was presented and discussed in the expert meeting described below.…”

“…Table S1 presents the description of the generic purposes of the geriatric screening, criteria for selection of tests and questionnaires, criteria for feasibility, and duration of the assessment. Results of the focus group meetings [18] yielded five additional essential points: i.e., awareness of illiteracy, burden for patients, learning effect in case of repeated measurements over time, feasibility to conduct the NGA next to other local preferred instruments, and unpracticality of performing walking tests in the outpatient-clinic.…”

“…Such a modified nephrology-specific geriatric assessment could be conducted by a trained nephrology nurse and be discussed in a multidisciplinary meeting, informing nephrology treatment decisions and follow-up interventions among which geriatric assessment identifies those patients who may benefit from CGA. In this model, the geriatrician adds valuable expertise on clinical judgement of frailty and appropriate interventions for older patients in addition to the nephrologists' knowledge of the patient and the disease [18]. Clinicians have recognized that a standardized set of instruments could benefit these clinical purposes [5,19].…”