Since the early 1990s, at least 45% of new patients entering the end-stage renal disease (ESRD) program in the U.S. each year have been more than 65 years old. This percentage is increasing; the figure for 2007 was 49%. The same trend appears in dialysis programs all over the world. Regardless of the treatment modality selected, some changes are required to adapt the therapy to the special needs of geriatric patients. As will become clear during the course of this chapter, besides presenting some limitations, older adult patients bring certain assets to their treatment regimens. All maintenance dialysis treatment modalities are available to the older adult patient, subject to the usual considerations, such as adequate vascular access or an intact peritoneal membrane.
Are the causes of chronic kidney disease different in elderly patients?
Not really. The most common cause is nephrosclerosis secondary to either diabetes or hypertension. Causes such as chronic glomerulonephritis and pyelonephritis are as common in older patients as in younger patients, although there may be slightly more older adult patients with an “unknown” renal diagnosis (biopsies are rarely done in elderly patients with renal failure of undetermined cause).
How do older patients differ from younger chronic kidney disease patients?
Comorbid conditions are much more common in older patients and can complicate the treatment of chronic kidney disease (CKD). Examples of significant comorbidities include an impaired cardiovascular system, osteoporosis, type 2 diabetes, delayed protein synthesis, reduced protein intake, impaired pulmonary function, impaired cognitive function, poor vision, poor mobility, and poor coordination.
Although not physical factors, adverse psychosocial and socioeconomic factors complicate treatment regimens for a larger proportion of older patients than younger patients.
Can elderly patients benefit from renal replacement therapy?
Many, perhaps most, elderly people can benefit from renal replacement therapy, often returning to a level of physical functioning and quality of life that is either equivalent to that of people their age without CKD or at least acceptable to the patient.
Some patients, usually but not necessarily elderly, may not benefit from treatment. Examples include those with irreversible dementia or extremely debilitating or imminently terminal comorbid conditions, such as cancer or advanced congestive heart failure. However, there are few firm medical or community standards with respect to withholding treatment, and decisions regarding initiating therapy vary with individual physicians or family members.
What is trial dialysis?
The concept of trial dialysis is gaining favor in some areas. A patient for whom the value of therapy is questionable may be given treatment (usually hemodialysis) for a clearly defined period to see whether explicitly described clinical goals can be achieved. Examples of such patients might include those with unexplained dementia, potentially reversible acute kidney injury, unexplained worsening of congestive heart failure, personality change, and adult failure-to-thrive syndrome. The duration of treatment, specific goals, and subsequent actions (continue or discontinue) are agreed to in advance by the medical team, family, and, in some cases, the patient. This allows the patient every opportunity to benefit from treatment, if that is possible; if it is not, trial dialysis provides the family and patient with time to adjust and the knowledge that every effort was made.
Can elderly patients be successfully transplanted?
Although the proportion of older adult CKD patients who qualify for transplantation is not as high as that of younger patients, graft survival in those who do receive transplants is about the same. Kidneys are becoming more available to elderly recipients because some transplant surgeons believe that organs donated by an older person should go to an older person. Elderly patients often require less intensive immunosuppressive therapy, due to the fact that their immune systems may already be compromised by age.
Although older adult patient survival is not as good as that of younger patients, because of an increased number and severity of complications, data show satisfactory results for transplantation in elderly patients. By the same token, dialysis is also safer than ever for the elderly, so making a decision between modes of therapy is not simple.
What are the advantages of peritoneal dialysis for elderly patients?
Peritoneal dialysis (PD), unlike hemodialysis at the present time, is a home dialysis therapy. Patients benefit from being at home in a number of ways. First, they are spared the considerable time, effort, and expense of being transported to and from a dialysis center. The transportation effort is, in itself, very debilitating for some older patients. Second, home dialysis patients are in full charge of administering their own therapy. This not only fosters independence but also preserves their usual lifestyle, allowing patients to perform exchanges at their convenience, within reason, rather than requiring them to conform to a rigid in-center schedule.
Patients on PD do not need a vascular access, with its attendant problems (although they must have a peritoneal access catheter, with its attendant problems), and many elderly patients have inadequate peripheral vessels. Because PD is a continuous—or at least daily—therapy, blood chemistries and fluid status approach a steady state; thus PD patients do not suffer the effects of the rapid biochemical and fluid changes common in hemodialysis. This can be a significant advantage because elderly patients are more prone to adverse reactions to these changes. For example, PD patients with diminished cardiac reserve experience less orthostatic hypotension or other cardiac symptoms in response to fluid removal. Slow, continuous therapy allows better correction of brain electrophysiologic and cognitive function abnormalities, which incurs less risk of destabilizing the fragile mental equilibrium of some elderly patients.
Another advantage of daily therapy is that dietary and fluid restrictions are less rigid, which can be important for those with diminished appetites or impatience with restrictions.
Can elderly patients learn to do peritoneal dialysis?
Many older adult patients can do PD very well by themselves, and others can do PD with assistance from family members. In addition, several assistive devices are available that allow patients who are blind or who have limited dexterity to perform their own fluid exchanges. Automated, overnight dialysis systems eliminate all but a single connection and disconnection procedure.
What are the disadvantages of peritoneal dialysis for older patients?
The incidence of certain complications (dementia, hernias, Staphylococcus epidermidis peritonitis, abdominal and catheter leaks) is higher in elderly PD patients compared with younger PD patients and compared with elderly hemodialysis patients.
If the patient frequently requires significant ultrafiltration (UF), the resulting increased dialysate glucose concentration can significantly suppress the appetite, resulting in substantial malnutrition. This can be difficult to diagnose, at least initially, because dry weight may be stable or even increase (dextrose provides many calories but little nutrition). This can be a special problem with elderly patients, who are already at higher risk for malnutrition.
Loss of the opportunity to socialize during in-center therapy may also be a drawback to PD, because many elderly people are socially isolated.
What are the advantages of hemodialysis in treating elderly ckd patients?
Most hemodialysis in the U.S. is provided as an in-center therapy. There may be psychosocial advantages for elderly patients in the human interactions of dialysis center treatment, as mentioned earlier.
Another advantage is frequent observation by trained personnel. Elderly patients are more prone to complications of both CKD and dialysis. When they develop such complications, these patients often exhibit less obvious symptoms. Earlier recognition and intervention (with resulting reductions in patient discomfort and healthcare costs) is more likely in a dialysis center setting.
Modern hemodialysis equipment, with its sophisticated monitoring and UF control systems, is better able to provide controlled rates of biochemical and fluid removal and thus provide safe and comfortable treatments for a larger range of elderly patients than was possible in the past. Some patients prefer short, thrice-weekly treatments rather than continuously being on dialysis, as with PD. Treatment “burnout” is less common in the hemodialysis population. Also, many older adult patients grew up in an era when physicians and nurses—not patients—were expected to provide healthcare. Self-treatment, whether in a dialysis center or at home, is not acceptable to every older person. Most elderly dialysis patients in the U.S. are on hemodialysis.
Is hemodialysis more complicated for elderly patients?
Some practitioners claim that elderly patients are easier to dialyze. They tend to have lower fluid gains, lower creatinine, and lower urea generation rates; thus they do not necessarily require extremely aggressive treatment, with its higher risk of intradialytic complications. Also, older patients are generally more compliant with all facets of the treatment regimen and express higher life satisfaction than younger patients.
With one exception, the nature and frequency of intradialytic complications are similar to that of younger hemodialysis patients. The exception is hemodynamic instability, which is more common in elderly people; thus intradialytic cardiac arrhythmias and hypotensive episodes are likely in this group. In most cases, episodes of hemodynamic instability can be minimized, and often prevented, if staff members are properly trained in the methods to achieve this.
Measures to prevent hypotensive episodes include using an extracorporeal circuit with the smallest possible priming volume, equipment with a volumetric UF control system, and a bicarbonate dialysate with sufficiently high sodium, calcium, and dextrose levels to help maintain blood pressure during UF. UF and/or sodium modeling can help, as can using cool dialysate (35.5°C to 36.0°C). No patients, especially the elderly, should be allowed to eat during dialysis because blood is diverted from the peripheral circulation (where it maintains blood pressure) to the digestive organs immediately after a meal. As a result, hypotension is usually inevitable. There is now ample evidence that a brief episode of simple exercises, especially if performed during the last hour of dialysis, is an effective way to support blood pressure and minimize muscle cramping. Dietary sodium, protein, and fluid intake and an antihypertensive medication regimen should be reevaluated on a regular basis.
Arrhythmias are common in elderly hemodialysis patients and may not be associated with any detectable symptoms. They arise in conjunction with anemia, hypokalemia, hyperkalemia, acidosis, hypoxia, hypotension, hypertension, digoxin, or cardiac abnormalities due, for example, to metastatic calcifications, amyloid deposition, or cardiac hypertrophy. Arrhythmias that are associated with such symptoms as weakness or hypoxia should be reported to the physician, who may elect to adjust the patient’s diet, dialysate composition, or medication prescriptions. Nasal oxygen may provide symptomatic relief for hypoxia. Transfer to PD may be necessary, if feasible, for patients who do not respond to the aforementioned measures.
What are the disadvantages of hemodialysis for the elderly?
As mentioned, patients with significant cardiovascular disease do not tolerate the rapid biochemical and hemodynamic changes that accompany hemodialysis procedures and are at higher risk of intradialytic complications. As also mentioned, debilitated elderly people undergo considerable physical and emotional stress in relation to the thrice-weekly transportation to and from the dialysis center. Patients in either group would probably do better with a daily home dialysis regimen, such as PD or daily home hemodialysis, if that is feasible. Elderly patients may also experience more vascular access problems.
It is important to realize that older adult patients whose comorbidities are no more severe than those seen in younger patients do as well as those younger patients.
What special precautions should be taken with respect to monitoring the nutrition of elderly patients?
All patients lose nutrients during dialysis, whether hemodialysis or PD. Compared with the general dialysis population, elderly patients are at higher risk of malnutrition, in addition to being less likely to replace the nutrients lost during treatment. For this reason, staff must be able to recognize, and indeed regularly probe for, factors that signal poor nutrition.
In addition to the usual impediments to good nutrition, elderly people experience a number of losses that interfere with their ability to achieve good nutrition. There are physical losses, such as loss of teeth and loss of senses of taste and smell that make eating difficult or uninteresting, or loss of mobility, which makes it difficult to get to the grocery store or to prepare meals.
Mealtime, often an occasion of social interaction, can remind older adults of their social losses, such as loss of a spouse, companions, or access to community support. Some patients have psychologic conditions, such as dementia, depression, or simply mental inertia, that can impede their will to eat. Financial constraints can be a factor because many elderly live on fixed incomes and may have to make choices between paying for heat or for food, for example. Medical factors, such as anorexia, constipation, and medication effects, can interfere with eating. Even with adequate meals there can still be nutritional losses due to vomiting, diarrhea, or loss of protein through persistent exudates from wounds or sores. Some of the factors that impede good nutrition can be corrected if they are recognized.
You should suspect malnutrition if the patient has an increase in episodes of intradialytic hypotension or symptomatic congestive heart failure, develops depression or dementia, reports episodes suggestive of hypoglycemia (when not on hypoglycemic agents), experiences a steady decline in dry weight, or shows symptoms of adult failure-to-thrive syndrome.
A low predialysis blood urea nitrogen (BUN) is always due to poor nutrition, not to great dialysis. Resist the temptation to decrease dialysis; such patients usually need more dialysis, not less. By the same token, patients who are unstable during dialysis should not be taken off treatment early. This leads to underdialysis, which decreases appetite, leading to lower plasma protein levels and, shortly, to even greater intradialytic instability.
The physician or dietitian should be contacted if any of the situations discussed in this section are identified.
What are the problems with medications in elderly chronic kidney disease patients?
Dialysis patients, especially elderly ones, are likely to take a great many drugs. Geriatric patients are much more susceptible to drug reactions and interactions. Thus the dose of each drug must be carefully calibrated by the physician, taking into consideration many factors, such as the poor intestinal absorption, impaired hepatic clearance, and alteration in distribution space, common in the elderly. Various elements can alter the patient’s response to the prescribed dosage or combination of drugs; therefore any unexplained change in physical or mental condition should be reported to the physician.
However, the main issue for staff is to check with the patient on a regular basis (1) to determine whether the patient is having problems taking all of the prescribed medications and (2) to be alert to the possibility of polypharmacy, which is the tendency of some elderly people to see several physicians and, unknown to the physicians, acquire multiple prescriptions from each.
Does exercise play a role in the treatment of elderly chronic kidney disease patients?
It certainly does. Properly prescribed exercise can play a significant role in the rehabilitation and subsequent preservation of the ability to perform the normal activities of daily life. This not only provides a better quality of life for the patient but also reduces the need for expensive hospitalizations and/or home health aides.
Of special importance to hemodialysis staff is the ample evidence that a brief period (i.e., 10 minutes) of exercise, such as pedaling a stationary bicycle, especially during the last hour of hemodialysis, can reduce the incidence and severity of muscle cramps and hypotension. A special device can be constructed from a bicycle wheel and pedals that allows the patient to remain seated in the dialysis chair while exercising.
What are the outcomes of the various chronic kidney disease treatment modalities in elderly patients?
In terms of treatment selection, the most recent information available (U.S. Renal Data System, 2009) offers the following statistics as of the end of 2007: 80% of U.S. patients ages 65 or older were receiving in-center hemodialysis, less than 1% were on home hemodialysis, 4% were on PD, and 14% had a functioning transplant.
Mortality rates for prevalent dialysis patients ages 65 and older are almost seven times higher than those for the general population. The rates have been decreasing over the past five years, which is not surprising.
One-year mortality was 31.3% for patients ages 65 to 74 years and 45.5% for those older than 74 years. This is an improvement over earlier years (in 1984, for example, the mortality figures were 38% and 53%, respectively) and may reflect not only an improvement in maintenance dialysis therapies over that period but also increasing experience with treating elderly CKD patients. The mortality rate of elderly CKD patients is noticeably greater than that seen in younger CKD patient age groups (18.4% for 45- to 64-year-olds; 10.7% in 20- to 44-year-olds; and 5.3% in 0- to 19-year-olds), a trend noted in the non-CKD population as well.