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Improving outcomes for older people with advanced kidney
disease
Professor Edwina Brown Imperial College Renal and Transplant Centre
Hammersmith Hospital, London
Dialysis population is old and ageing!
UK Renal Registry Reports 2007, 2014
2013 • Median age HD – 66.9 years • Median age PD – 63.7 years
2006 • Median age HD – 65.0 years • Median age PD – 59.9 years
Increasing prevalence of “old old” on RRT
UK Renal Registry
RRT prevalence by age (per million age related population)
75-84 yrs >85 yrs
2009 5463 1030
2014 6647 1507
↑ 22% 46%
Questions
• What are challenges of providing dialysis for the ‘old old’?
• How has your renal unit practice adapted to the ageing of the dialysis population?
Distribution of dialysis modality in prevalent RRT patients in UK
%% 8.5 10.5 13.3 14.4 15.6 15.2 20.5 17.7 %
UK Renal Registry 2014
% PD
Q. 3D HD is optimal dialysis modality for older patients
114 questionnaires, British Renal Society 2015
Questions
• How would you have answered BRS question?
• Should more ‘old old’ be on PD?
Rembrandt: Portrait of an Old Man in Red
Sorrowing Old Man (‘At Eternity’s Gates’) by van Gogh
Phases of old age 1. Independent
Phases of old age 1. Independent 2. Decline in physical
and/or cognitive function
Phases of old age 1. Independent 2. Decline in physical
and/or cognitive function
3. Frailty and end of life
Ageing
“Young men be not proud in the presence of a decaying old man; he was once that which you are, he is now that which you will be.”
Clement III (reigned 1187-1191) Returned Papacy to Rome by signing treaty with Roman citizens to allow them their own magistrates. Died age 61
Published 2014 by The King’s Fund
Components of care for older people
Components of care all relate to advanced kidney disease
• Live well with 1 or more long-term conditions
• Support for complex co-morbidities and frailty
• Accessible effective support in crisis
• High quality person-centred acute care
• Good discharge planning and post-discharge support
• Effective rehabilitation and re-ablement
• Person-centred dignified long-term care
• Support, control and choice at end of life
Outline of talk
• Frailty – diagnosis and assessment
• Impact of frailty on outcomes
• HD or PD
• Assisted PD outcomes
• Challenges of care for older patients – HD and PD
• Can we improve care?
Common clinical presentations of frailty
• Non-specific: extreme fatigue, unexplained weight loss and frequent infections
• Falls: balance and gait impairment important risk factors and are major features of frailty
• Delirium: rapid onset of fluctuating confusion when admitted to hospital. Associated with adverse outcomes
• Fluctuating disability: day to day instability resulting in good and bad days
Increased vulnerability
Clegg et al, Lancet 2012
Assessing frailty: should be routine nephrological care for older patients • History:
– daily activities of patient
– how much help with these?
– any change in physical activity?
– any weight loss?
– any falls?
• Examination:
– walking speed into clinic and use of aids
– muscle mass and strength
– obvious weight loss
Cognitive Function
• Do not rely on simple conversation – can hide significant cognitive dysfunction
• Cognitive impairment in CKD mostly related to vascular disease and affects executive function
• Simple memory tests, including MMSE, often normal
• Executive function tests include clock drawing (easy to do in clinic), Trail Making Tests, MOCA
Outline of talk
• Frailty – diagnosis and assessment
• Impact of frailty on outcomes
• HD or PD
• Assisted PD outcomes
• Challenges of care for older patients – HD and PD
• Can we improve care?
Cranach: Fountain of Youth
Implications of being ‘frail’
• Associated with worse physical function and quality of life
• High incidence of geriatric syndromes – falls, delirium, cognitive impairment, dementia
• Increased admissions to hospital and prolonged lengths of stay
• Increased mortality
True for all conditions – not just dialysis
FEPOD: Frailty is principal predictor of
outcomes and dialysis modality (aPD cf HD)
Iyasere O et al: CJASN 2016
Outcome Predictor Multiplicity
Adjusted P-value
Effect Size (95%
CI)
Illness Intrusion Age <0.01 0.98 (0.97 – 0.99)
SF12 PCS Frailty <0.01 0.90 (0.88 – 0.93)
SF12 MCS Frailty <0.01 0.94 (0.91 – 0.97)
Illness Intrusion Frailty <0.01 1.14 (1.09 – 1.24)
Barthel Index Frailty <0.01 0.89 (0.86 – 0.93)
Symptom burden Frailty <0.01 1.23 (1.13 – 1.33)
Renal Treatment
Satisfaction
HD vs PD 0.03 0.93 (0.89 – 0.98)
Admission ADL score predicts death in hospital and discharge to assisted care facility in dialysis patients
Sood et al, AJKD 2011
Outcomes for 390 patients starting HD 2009-2013 stratified by frailty score – Halifax, Canada
Alfaeedel TA et al, CJASN 2015
Outline of talk
• Frailty – diagnosis and assessment
• Impact of frailty on outcomes
• HD or PD
• Assisted PD outcomes
• Challenges of care for older patients – HD and PD
• Can we improve care?
Choice of dialysis modality
• No difference in survival on HD compared to PD
• Decision should therefore be made with patient dependent on patient goals, lifestyle and medical concerns
• Availability of assistance enables older patients to have dialysis at home – assisted PD considered first line treatment for older frail patients in France
Need for patient-centred care
• What matters to patient?
– Travel?
– Caring for spouse?
– Grandchildren care?
– Length of life or quality of life?
– End of life priorities?
HD or PD in elderly: patient perspective
HD or PD in elderly: patient perspective HAEMODIALYSIS
• Hospital based treatment – Not dependent on patient ability
– Can provide social structure for frail elderly
– Transport (journey and waiting time) needs to be added into treatment time
– Often feel washed out for hours after HD session
• Interferes with social and family life
• Increased hospitalisation for vascular access problems
• Difficult to travel for holidays or visiting family
PERITONEAL DIALYSIS • Home based treatment
– Patient independence
– Fits in with work and social activities
– Can be done by carer (paid assistant or family)
• Less visits to hospital
• Flexibility of manual exchanges (3-4/day) or automated cycling machine over night
• Treatment burden related to daily and repetitive nature of performing exchanges
• Easier to travel to go on holiday or visit family nationally or overseas
HD or PD in elderly: doctor perspective
HD or PD in elderly: doctor perspective HAEMODIALYSIS
• Familiar with HD; complications regarded as part of treatment
• Well-established pathways so easy to organise
• Very few medical contraindications so less need to assess patient for medical and psycho-social eligibility
• Many older patients find it difficult to make decisions and too many barriers to education so takes less time just to put patient on to HD – or keep patient on HD if presenting acutely
PERITONEAL DIALYSIS • Often not familiar with PD
and only see patients with complications
• Perception that older patients cannot do PD so not offered
• Takes time to have discussions about treatment choices and give information so PD not offered or discussed
Benefits of PD for older patients • Treatment is at home
• Flexibility of treatment round social activities (CAPD) or at night with day-time freedom (APD)
• Enables travel
• Preservation of residual renal function – enables days off dialysis
• No haemodynamic swings and no periods of feeling “washed out” (as on HD)
• Simple procedure – so can be done by family member or paid assistant
BOLDE: Adjusted Illness Intrusion Ratings Scores for PD and HD
Significantly less illness intrusion in PD
P=0.032
Brown EA et al, NDT 2010
Potential obstacles to PD for older patients: age-related
POTENTIAL OBSTACLE POTENTIAL SOLUTION
Poor manual dexterity Assisted PD
↓physical function; difficulty in lifting bags
Assisted PD
Impaired vision Assisted PD
Impaired hearing Visual aids for training
Cognitive dysfunction Assisted PD; can be contraindication if advanced
General frailty Assisted PD
Late presentation (more common)
Acute start PD + assisted PD
Potential obstacles to PD for older patients: PD-related
POTENTIAL OBSTACLE POTENTIAL SOLUTION
Prior lower abdominal surgery Surgically placed catheter: PD can be contra-indicated
Severe obesity Surgically placed catheter; PD can be contra-indicated
Housing – no storage space More frequent so smaller deliveries
Depression / anxiety Assisted PD; can be contra-indication
Eligibility, choice and use of PD according to availability of home care
19 (37) 39 (47) Received PD
19(58) 39 (59) Choose PD if eligible
.06 33 (65) 66 (80) Eligible for PD
2 3 PD barriers, median
35 (42) 29 (57) Hospital start
21 (78) 60 (74) Predialysis care
.04 35 (68) 42 (51) Male
.02 66 75 Age, median
51 83 Patients
P No home care Home care
Oliver MJ et al: Kidney International (2007) 71, 673–678
Outline of talk
• Frailty – diagnosis and assessment
• Impact of frailty on outcomes
• HD or PD
• Assisted PD outcomes
• Challenges of care for older patients – HD and PD
• Can we improve care?
•Retrospective study of 1613 patients >75 years old who
started dialysis between 1.1.2000 and 31.12.2005
•Mean age at dialysis initiation was 81.9 ± 4.5 years
•89% on CAPD
•81.8% required assistance
Copyright restrictions may apply.
Castrale, C. et al. Nephrol. Dial. Transplant. 2009 0:gfp375v1-375; doi:10.1093/ndt/gfp375
Kaplan-Meier curves of patient survival according to the modality of assistance for elderly patients on peritoneal dialysis (log rank test: P < 0.001 for the autonomous versus the family-
assisted group and for the autonomous versus the nurse-assisted group, P < 0.001)
Median survival:
Autonomous – 48m
Family assisted – 26m
Nurse assisted – 24m
UK Renal Registry 11th Annual Report
10 year survival of incident RRT patients, 1997-2006 cohort
Median survival
75 yrs+: 22 mths
Outcome data for assisted PD
• Patient survival
• Technique survival
• Quality of life
Frail Elderly Patient Outcomes on Dialysis (FEPOD): Cross-sectional and longitudinal comparisons of assisted peritoneal dialysis and haemodialysis
Imperial NIHR Biomedical Research Centre
FEPOD cross-sectional data: Frailty is principal
predictor of outcomes and dialysis modality
(129 aPD patients cf 122 HD patients)
Iyasere O et al: CJASN 2016
Outcome Predictor Multiplicity
Adjusted P-value
Effect Size (95%
CI)
Illness Intrusion Age <0.01 0.98 (0.97 – 0.99)
SF12 PCS Frailty <0.01 0.90 (0.88 – 0.93)
SF12 MCS Frailty <0.01 0.94 (0.91 – 0.97)
Illness Intrusion Frailty <0.01 1.14 (1.09 – 1.24)
Barthel Index Frailty <0.01 0.89 (0.86 – 0.93)
Symptom burden Frailty <0.01 1.23 (1.13 – 1.33)
Renal Treatment
Satisfaction
HD vs PD 0.03 0.93 (0.89 – 0.98)
Outline of talk
• Frailty – diagnosis and assessment
• Impact of frailty on outcomes
• HD or PD
• Assisted PD outcomes
• Can we improve care?
What may improve care for older patients requiring dialysis – and what
are the barriers? • Patient centred care and shared decision
making with focus on well-being and goals of patient in relation to realistic prognosis
• Access to assisted PD
• Integration with services for older people in community and secondary care
What may improve care for older patients requiring dialysis – and what
are the barriers? • Patient centred care and shared decision
making with focus on well-being and goals of patient in relation to realistic prognosis
• Access to assisted PD
• Integration with services for older people in community and secondary care
Imperial College Healthcare: Integration with services for older people in community and secondary care
• Assessment • Access to
– Rehabilitation – “Hospital at home” – Social support in community – Rapid discharge planning
• Referral to palliative care support when appropriate
• Funded by – Imperial College Healthcare Charitable Funds (Jul 15 – Dec 16) – British Patient Kidney Association (Jan 17 – Jul 18)
• Modified Geriatric Assessments conducted on HD patients at one satellite Unit and PD unit. Patients aged > 70 years and over or those >60years but perceived to be frail are assessed.
• Assessment of Frailty – Canadian Study of Health and Aging Score - CSHA
• Abbreviated Mental Test Score (AMTS) : Memory /Dementia
Score ≤8 requires further screening for Cognitive Impairment/delirium
Score < 6 indication of dementia
• Clock Test Score: Measure of executive function/cognition
Score <8 indicates Cognitive Impairment
• Distress Thermometer : Validated in Renal patients
Score 1-10 Indicates distress
Referrals resulting from assessment are recorded
Assessments
Initial Assessment HD
Initial Assessment PD
6-Month Follow up HD
6-Month Follow up PD
Number (n)
58 32 34 24
Mean age (years)
78.2 ± 5.5 76.8 ± 6.1 75.0 ± 4.3 72.4 ± 3.4
Male (%) 63.8 (37/58) 65.6 (21/32) 50.0 (17/34) 20.8 (5/24)
Female (%) 36.2(21/58) 34.4(11/32) 50.0(17/34) 79.2(19/24)
% over 80 years
34.5 (20/58) 28.1 (9/32) 8.8 (3/34) 4.2 (1/24)
Period 1st 6 months - Patient Demographics
Results: Initial Assessment scores
Assessments HD 1st Assessment (n=58)
PD 1st Assessment (n=32)
Mild frailty score = 5 (%) 20 (34.5) 7 (21.9)
Moderate to severe frailty score= 6&7 (%) 26 (44.8) 15 (46.9)
Abbreviated Mental Test Score ≤ 8(%) 12 (20.7) 4 (12.5)
Clock Test Score <8 (%) 31 (53.4) 16 (50.0)
Distress Thermometer Score ≥ 5 (%) 16 (27.6) 8 (25.0)
Treatment Satisfaction Score ≤ 80% 23 (39.7) 4 (12.5)
Number of patients with falls in last year 15 (25.7) 9 (28.1)
Assessments HD 6-month F’up Assessment
(n=31)
PD 6-month F’up Assessment
(n=17)
Pre Post Pre Post
Mild frailty score = 5 11 10 3 4
Moderate to severe frailty score = 6&7 14 14 12 11
Distress Thermometer Score ≥ 5 12 3 4 4
Treatment Satisfaction Score ≤ 80% 11 7 4 0
Results: 6 month Follow-up
Of the 34 HD patients followed up - 3 were not reassessed (2 declined and 1 died) Of the 24 PD patients followed up - 7 were not reassessed (3 could not be assessed, 2 transferred out to other hospitals and 2 died)
Before
After
0
5
10
15
20
25
30
HD PD
4 2
27
14
Identification of Cognitive Impairment
Improved identification of Cognitive Impairment
Improving integration between renal and geriatric healthcare teams: Barriers
• Staffing and structures of renal units have not adapted for increasing ageing of patients
• Lack of defined pathways between renal and geriatric care teams
• Not even in curriculum for renal trainees
• Intuitively should be of benefit, but no evidence
• Resources – staffing and costs
Giorgione: La Vecchia