The Relevance of Geriatric Impairments in Patients Starting Dialysis: A Systematic Review

Abstract

Background and objectives With aging of the general population, patients who enter dialysis therapy will more frequently have geriatric impairments and a considerable comorbidity burden. The most vulnerable among these patients might benefit from conservative therapy. Whether assessment of geriatric impairments would contribute to the decision-making process of dialysis initiation is unknown.Design, setting, participants, & measurements A systematic Medline and Embase search was performed on December 1, 2015 to identify studies assessing the association between risk of mortality or hospitalization and one or more geriatric impairments at the start of dialysis therapy, including impairment of cognitive function, mood, performance status or (instrumental) activities of daily living, mobility (including falls), social environment, or nutritional status.Results Twenty-seven studies were identified that assessed one or more geriatric impairments with respect to prognosis. The quality of most studies was moderate. Only seven studies carried out an analysis of elderly patients ($70 years old). Malnutrition and frailty were systematically assessed, and their relation with mortality was clear. In addition, cognitive impairment and functional outcomes at the initiation of dialysis were related to an increased mortality in most studies. However, not all studies applied systematic assessment tools, thereby potentially missing relevant impairment. None of the studies applied a geriatric assessment across multiple domains.Conclusions Geriatric impairment across multiple domains at dialysis initiation is related to poor outcome. However, information in the elderly is sparse, and a systematic approach of multiple domains with respect to poor outcome has not been performed. Because a geriatric assessment has proved useful in predicting outcome in other medical fields, its potential role in the ESRD population should be the subject of future research.

Geriatric Assessment in Elderly Patients with End-Stage Kidney Disease

“…First, in studies focusing on one or more geriatric domains in patients on dialysis, a reduced functional performance, cognitive impairment, depression and immobility were all associated with negative outcomes, such as (early) mortality and hospitalizations [16]. Furthermore, frailty in patients with ESKD is associated with worse quality of life, irrespective of dialysis or MCM [44].…”

“…Nevertheless, elderly patients may benefit from dialysis, and age on itself is not a good selection criterion. Previous studies in the ESKD population showed that frailty is related to mortality, hospitalizations and falls [3,16]. Therefore, understanding the burden of geriatric impairments could provide an opportunity to direct treatment decisions and to start preventive interventions.…”

Breaking the cycle of functional decline in older dialysis patients

“…31 Although these alternatives may not perform as well as CGA for identifying geriatric problems, some providers apply them to screen for patients who would benefit from CGA. 32…”

Depression and Physical Frailty Have Additive Effect on the Nutritional Status and Clinical Outcome of Chinese Peritoneal Dialysis

“…In addition to organ-system specific comorbid diseases, it is increasingly recognized that physical frailty, depression, and cognitive impairment are important contributing factors to the adverse clinical outcome of chronic kidney disease (CKD) and dialysis patients [4,5]. Frailty is defined as a clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems, such that the ability to cope with every day or acute stressors is comprised [6].…”