The Burden of Frailty on Mood, Cognition, Quality of Life, and Level of Independence in Patients on Hemodialysis: Regina Hemodialysis Frailty Study

Abstract

Background: The prevalence of frailty is disproportionately increased in patients with chronic kidney disease (CKD) in comparison with non-CKD counterparts and is the highest in patients on hemodialysis (HD). While the cross-sectional measurement of frailty on HD has been associated with adverse clinical events, there is a paucity of data on longitudinal assessment of frailty and its relationship to outcomes. Objective: The objectives were to (1) evaluate changes in frailty status, level of independence, mood, cognition, and quality of life (QoL) over a 12-month period and (2) explore the relationship between frailty status and level of independence, mood, cognition, and QoL at 2 different time points (at baseline and at 1 year). Design: This is a prospective cohort study involving 100 prevalent HD patients. Setting: Regina General Hospital and Wascana Dialysis Unit in Regina, Saskatchewan, Canada, between January 2015 and January 2017. Patients: One hundred prevalent HD patients underwent frailty assessments using the Fried criteria at baseline and 1 year later. Measurements: Frailty was assessed using the Fried criteria, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), and questionnaires for physical activity and self-perceived exhaustion. Cognition, mood, and QoL were measured using questionnaires (Montreal Cognitive Assessment [MoCA], Geriatric Depression Scale [GDS], and EuroQol [EQ-5D] utility scores and visual analog scale [VAS], respectively). Methods: Frailty status was reported as a binary variable: frail vs. nonfrail (prefrail and robust). Differences across baseline and 1-year groups were assessed using McNemar’s test or Wilcoxon signed-rank test, as appropriate. We assessed the differences between frail and nonfrail groups using the Mann–Whitney U test or chi-square test/Fisher’s exact test where appropriate. Results: Ninety-seven of the 100 patients had complete initial assessments. The median (interquartile range [IQR]) duration of dialysis at baseline was 35.5 (13.75-71.75 months). One year later, 22 had died, 10 refused assessments, and 3 had relocated. In comparison with baseline vs 1 year, the number of frail patients was 68.1% vs. 67.7%; prefrail 26.8% vs. 26.1%; robust 5.1% vs. 6.2%; MoCA ≥24, 69% vs. 64.5%; GDS score ≥ 2, 52.8% vs. 47.7%; median EQ-5D utility score 0.81 vs. 0.77; and median EQ-VAS 60 vs. 50. Similarly, in comparison with baseline vs. 1 year, the number of independent patients was 82% vs. 63%, independent with support 17% vs. 31%, and long-term care home 0% vs. 3.1%. Eighteen of the 22 patients (82%) who died were frail. At 1 year, the median (IQR) MoCA was 24 (19-25) vs. 25 (21-26; P = .039) and median (IQR) GDS was 2 (1-3) vs. 1(0-2; P = .034). Likewise, median (IQR) EQ-5D utility score was 0.78 (0.6-0.82) vs. 0.81 (0.78-0.85; P = .023). There were significant changes in self-care (27% vs. 0%), P = 0.006, and daily activities (68.2% vs. 38.1%), P = 0.021. Limitations: This is a single-center study, so direct inferences must be interpreted in the context of the demographics of the study population. Patients were undergoing dialysis for a median of 36 months before undergoing initial assessment. Conclusions: Frailty and prefrailty in our dialysis patients is near-ubiquitous and will need to be proactively addressed to improve subsequent health care outcomes.

The Impact of Malnutrition, Inflammation on Cognitive Impairment in Hemodialysis Patients: A Multicenter Study

“…In this study, the predictive capability of MIS on cognitive impairment of HD patients has been evaluated in a large sample and multicenter cohort. Our data have demonstrated that 19.5% of HD patients have cognitive impairment with MMSE<27, which is similar with the results of previous (8.3-51%) [30][31][32][33]. The different prevalence rates of cognitive impairment in HD patients have been reported in past researches in terms of different population demographics, sample sizes, and measurements for assessment.…”

“Together We Stand”: A Pilot Study Exploring the Feasibility, Acceptability, and Preliminary Effects of a Family-Based Psychoeducational Intervention for Patients on Hemodialysis and Their Family Caregivers

“…Chronic kidney disease has also been considered a model of accelerated aging, leading to reduced cognitive and physical functioning, which increases frailty and the risk of loss of independence [56,57], compromising participation in psychoeducational interventions. Therefore, studies are needed to design and test the effectiveness of interventions to specifically support patients with cognitive impairment undergoing dialysis as well as their family caregivers who may be at increased risk of depression and burden [62].…”

Effects of Intradialytic Cognitive and Physical Exercise Training on Cognitive and Physical Abilities in Hemodialysis Patients: Study Protocol for a Randomized Controlled Trial

“…Cognitive functions will be assessed with tests previously used in HD patients ( Costa et al, 2014 ; San et al, 2017 ; Zimmermann and Fimm, 2017b ; Jafari et al, 2020 ), including Montreal Cognitive Assessment (MoCA), Trail Making Test A and B (TMTA and TMTB), Symbol Digit Modalities Test (SDMT), and computerized Test of Attentional Performance (TAP).…”