Correspondence

Loss of Independence in Patients Starting Dialysis at 80 Years of Age or Older

N Engl J Med 2009; 361:1612-1613October 15, 2009

Article

To the Editor:

We report a negative effect of initiation of dialysis on independent living by patients 80 years of age or older. Using a single-center, retrolective cohort study design (involving data collected prospectively for a purpose not directly relate to the study), we followed the progress of all patients 80 years of age or older in whom long-term dialysis was initiated during the period 2000–2005. Patients with evidence of acute kidney injury were excluded. All patients were followed for a minimum of 1 year or until death. Changes in living status were prospectively recorded in a clinical database. Functional loss was defined as a permanent transfer to an assisted-living setting or nursing home or having submitted an application for caregiver support. Respite care or temporary placement in a nursing home was not recorded.

A total of 97 patients with a mean (±SD) age of 84.5±3.3 years (range, 80 to 96) underwent the initiation of long-term dialysis. Half of the patients were men. Most (90%) had been seen by a nephrologist for predialysis care, and 44% began with peritoneal dialysis. Seventy-five percent of the patients had multiple coexisting conditions with a mean modified Charlson score of 5.1±2.5.1 (The score is calculated as the number of coexisting conditions, weighted according to their relative effects on mortality, with scores ranging from 0 to 33 and higher scores indicating a greater burden of illness.) A total of 69% (67 of 97) of patients started dialysis as inpatients (median period of hospitalization before dialysis, 6 days; interquartile range, 3 to 17). Of the 67 patients admitted for the initiation of dialysis, 31 (46%) had had more than 6 months of predialysis nephrology care, and 28 were deemed suitable candidates for and began peritoneal dialysis.

At the time of dialysis initiation, the majority of patients (76 of 97) were living at home with no assistance for the activities of daily living (Figure 1Figure 1Living Status and Residence during the Study Period, Assessed at 6-Month Intervals.). A further 15 patients had assistance from a community or private caregiver. Within the first 6 months after dialysis was begun, more than 30% of patients had functional loss requiring community or private-caregiver support or transfer to a nursing home. Over the next 2 years, the number of patients who remained independent at home or who died while ordinarily residing at home remained relatively stable. Neither the use of hemodialysis versus peritoneal dialysis nor initiation of dialysis as an inpatient or outpatient was predictive of subsequent decline.

Previous studies indicate that less than 20% of frail, non–dialysis-dependent elderly patients have a disability or require nursing-home care within 18 months after hospital discharge.2 Our data show considerably higher rates of onset of disability after dialysis is initiated, suggesting poor functional outcomes in relation to events occurring around the time of dialysis initiation. Studies using formal measures of functional change at the time of dialysis initiation are needed to appreciate the true extent of functional decline, as our data are likely to underestimate it.

Sarbjit Vanita Jassal, M.D.
University Health Network, Toronto, ON, Canada
vanita.jassal@uhn.on.ca

Ernest Chiu, B.M.Sc.
University of Toronto, Toronto, ON, Canada

Michelle Hladunewich, M.D.
Sunnybrook Health Sciences Centre, Toronto, ON, Canada

2 References

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   Gill TM, Allore HG, Holford TR, Guo Z. Hospitalization, restricted activity, and the development of disability among older persons. JAMA 2004;292:2115-2124
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Citing Articles (16)

Citing Articles

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   C. Barrett Bowling, Ann M. O'Hare. (2012) Managing Older Adults With CKD: Individualized Versus Disease-Based Approaches. American Journal of Kidney Diseases 59:2, 293-302
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   Edwina A. Brown. (2012) Non-Dialysis Therapy: A Better Policy Than Dialysis Followed by Withdrawal?. Seminars in Dialysis 25:1, 26-27
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   Jeroen P. Kooman, Tom Cornelis, Frank M. van der Sande, Karel M.L. Leunissen. (2012) Renal Replacement Therapy in Geriatric End-Stage Renal Disease Patients: A Clinical Approach. Blood Purification 33:1-3, 171-176
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   Tom Cornelis, Peter Kotanko, Eric Goffin, Jeroen P. Kooman, Frank M. van der Sande, Christopher T. Chan. (2011) Can Intensive Hemodialysis Prevent Loss of Functionality in the Elderly ESRD Patient?. Seminars in Dialysis 24:6, 645-652
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   Manish M. Sood, Claudio Rigatto, Joe Bueti, Vanita Jassal, Lisa Miller, Mauro Verrelli, Clara Bohm, Julie Mojica, Dan Roberts, Paul Komenda. (2011) The Role of Functional Status in Discharge to Assisted Care Facilities and In-Hospital Death Among Dialysis Patients. American Journal of Kidney Diseases 58:5, 804-812
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   Edwina A. Brown, Lina Johansson. (2011) Epidemiology and management of end-stage renal disease in the elderly. Nature Reviews Nephrology 7:10, 591-598
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   Michael J. Germain, Manjula Kurella Tamura, Sara N. Davison. (2011) Palliative Care in CKD: The Earlier the Better. American Journal of Kidney Diseases 57:3, 378-380
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8. 8

   Sarbjit V. Jassal, Diane Watson. (2011) Offering Peritoneal Dialysis to the Older Patient: Medical Progress or Waste of Time?. Seminars in Nephrology 31:2, 225-234
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9. 9

   ROBERT G FASSETT, IAIN K ROBERTSON, ROSE MACE, LOREN YOUL, SARAH CHALLENOR, ROSALIND BULL. (2011) Palliative care in end-stage kidney disease. Nephrology 16:1, 4-12
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    Sarbjit V. Jassal, Elizabeth E. Kelman, Diane Watson. (2011) Non-Dialysis Care: An Important Component of Care for Elderly Individuals with Advanced Stages of Chronic Kidney Disease. Nephron Clinical Practice 119:s1, c5-c9
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    Sareeta R.S. Parker, Jamie MacKelfresh. (2011) Autoimmune blistering diseases in the elderly. Clinics in Dermatology 29:1, 69-79
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    Manjula Kurella Tamura, Lewis M Cohen. (2010) Should there be an expanded role for palliative care in end-stage renal disease?. Current Opinion in Nephrology and Hypertension 19:6, 556-560
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    A. Covic, B. Bammens, T. Lobbedez, L. Segall, O. Heimburger, W. van Biesen, D. Fouque, R. Vanholder. (2010) Educating end-stage renal disease patients on dialysis modality selection. NDT Plus 3:3, 225-233
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    M.K. Kuhlmann. (2010) Der ältere multimorbide Patient mit präterminaler Niereninsuffizienz. Der Nephrologe 5:3, 202-211
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15. 15

    (2010) Functional Status of Elderly Adults Receiving Dialysis. New England Journal of Medicine 362:5, 468-469
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16. 16

    S. Vanita Jassal, Diane Watson. (2010) Doc, Don't Procrastinate…Rehabilitate, Palliate, and Advocate. American Journal of Kidney Diseases 55:2, 209-212
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