Systematic comprehensive geriatric assessment in elderly patients on chronic dialysis: a cross-sectional comparative and feasibility study

In nephrology, a growing number of elderly patients receive renal replacement therapy because of end-stage renal disease (ESRD) [1]. Patients aged 75 years or more represent the fastest growing segment of the population starting dialysis [2‐4]. This specific patient population is characterized by multi-morbidity, defined as the presence of two or more concomitant diseases, disabilities and geriatric conditions such as polypharmacy, sensory deficits, incontinence, low energetic falls, cognitive impairment and decreased social participation [3].

Functional decline, often defined as a deterioration in the activities of daily living (ADL), is a result of reduced physiological reserves [5]. Its presence in the elderly is often preceded or accompanied by geriatric conditions. The consequences of functional decline are decreased independence, lower quality of life, higher risk of institutionalization and death [6‐9]. In ESRD, functional decline is observed in all patients, but elderly patients are at even higher risk than their younger counterparts [2, 10‐12]. In addition, the initiation of dialysis is associated with a substantial decline in functional status and dialysis patients are also more prone to develop cognitive impairment [2, 13, 14]. Consequently, for patients who are at increased risk of functional or cognitive decline, it is of the utmost importance that potential problems are recognized early to allow health care professionals to slow or prevent this decline [15]. From the patient’s perspective, information regarding the presence of geriatric conditions and their impact on daily function could assist in the decision-making process when considering the most appropriate form of renal replacement therapy or when accepting non-dialysis therapy [16].

The Comprehensive Geriatric Assessment (CGA) is widely used in geriatric care, but outside this specialization, a CGA is not often applied. In oncology, the employment of the CGA is gaining interest, primarily in research settings. A CGA could be useful to identify individual older adults with ESRD who are on the trajectory of (progressive) functional or cognitive decline or for benchmarking purposes.

The aim of this cross-sectional study was to perform a systematic CGA to investigate somatic, psychological, functional and social function in a group of older dialysis patients. Secondly, we aimed to place our findings in a broader perspective by comparing our group to a population of elderly cancer patients who likewise suffered from an end-stage chronic progressive disease. Finally, we asked the multidisciplinary team for their opinion on the feasibility of the systematic CGA and the relevance of its outcome.

This systematic CGA of a cross-sectional cohort showed that geriatric conditions were highly prevalent in older ESRD patients. In addition to expected somatic problems, such as polypharmacy, malnourishment and hearing problems, many less anticipated problems in the psychosocial and functional domains were identified. Behavioural changes and disturbances were observed frequently and many caregivers felt overburdened by the care they provided to the primarily ADL-independent ESRD patient. Furthermore, depressive symptoms were highly prevalent, which have large impact on both patient and care giver. Geriatric conditions in both chronic diseases, ESRD and cancer, were comparable in terms of the number of geriatric problems, but they differed significantly in the rate of ADL-impairment, the burden of caregivers and pain score. The multidisciplinary nephrology team considered the CGA to be extensive and informative.

This study is a contribution to the growing number of studies addressing geriatric conditions in ESRD patients [13, 15, 34‐36]. All these studies emphasize different aspects of geriatric conditions in ESRD patients. To our knowledge, this study is the first to use the instrument of a CGA to systematically address all relevant geriatric domains. In addition to their ESRD, our patients faced an average of six geriatric conditions. These problems were likely to influence health and quality of life. The awareness of these problems by health care providers can facilitate deceleration and prevention of further decline in these patients [12, 34, 37]. Furthermore, interventions that have limited impact on the expense and efficiency of care are available for several of the geriatric conditions identified [38]. An assessment like this systematic CGA and appropriate training to manage the identified geriatric conditions should be introduced simultaneously to improve patient outcomes. Although nephrology care units generally use a multidisciplinary approach for all patients, our study demonstrates that in the geriatric dialysis population, more attention is needed for the important and burdened role of caregivers. As only 25% of ESRD patients had one or more ADL-impairments, the burden of caregivers must primarily be due to other causes. Our hypothesis is that frequent dialysis treatments, changes in physical and mental capacity and the behavioural disturbances of their family member are important factors. The rate of depressive symptoms we found, 24.5%, is consistent with other studies, which state rates between 20 and 35% [13, 39]. Behavioural changes such as depressive symptoms, apathy and irritability can all be manifestations of a depression and can weigh disproportionately heavily on caregivers. In addition, loneliness was highly prevalent in the dialysis patients. Therefore, one goal of the multidisciplinary team should be to support caregivers in their task and thus prevent the social isolation of both caregivers and patients. This goal’s importance is emphasized by the fact that social support and embedding are predictive factors for treatment success and mortality in ESRD patients [34, 40, 41].

This is the first study comparing ESRD patients to a group of elderly cancer patients. As in oncology, it may be useful to determine which factors influence the outcome and burden of treatment because treatment in ESRD is similarly intensive, expensive and has important side effects influencing health-related quality of life [42]. Earlier studies demonstrated that geriatric conditions were predictive of poorer health outcomes in both older ESRD and older cancer patients in outpatient settings [34, 35, 41, 43‐45]. In the present study, we have demonstrated that these geriatric conditions are equally prevalent in cohorts of ESRD and acutely hospitalized older cancer patients. We are convinced that the conclusion of Rao et al., who found that for older patients with cancer, geriatric care improved quality of life, likewise applies for elderly ESRD patients [46].

Some limitations of the study should be stated. First, the number of participants is small and may not be representative, which might make extrapolation to all older dialysis patients less convincing. Participants were asked by their nephrologists to participate. This may have caused some selection bias because physicians might be more reluctant to ask sicker patients or patients with major cognitive impairment to enrol. As a result, it is possible that our population reflects relatively healthy patients. This would imply that the outcome of a similar study in the total dialysis population might be even worse. On the other hand, even these ‘healthy’ patients experienced a large burden of unrevealed geriatric conditions, and they were comparable to acutely admitted cancer patients. For the aim of this study, which was to explore the feasibility of a new method, this possible selection bias is less relevant. In general, ESRD is associated with an increased risk of cognitive impairment, and the prevalence of both cognitive impairment and dementia is higher than in the general population [2, 14]. Again, however, the selection process may have resulted in a lower than expected prevalence of these problems in our cohort.

Furthermore, when examining our cohort composition, it appeared that a relatively small number of women participated in the study; however, in comparing our rate to other studies, it is apparent that gender varies widely in ESRD study populations and that our study is no exception [13, 38].

Our study cannot identify associations between geriatric conditions in elderly dialysis patients and their risk for poor outcomes in dialysis. This knowledge would be useful for planning care in advance and, when made available at earlier stages, could inform and assist patients and their caregivers in making decisions regarding treatment options in ESRD [3, 15, 38]. We have demonstrated that a large proportion of our patients required aid in their daily activities, and this requirement is likely to increase during ongoing treatment [13, 47]. The burden of care experienced by caregivers was large, but our questionnaires were insufficient to support a more detailed understanding of the specific reasons behind this burden. Another limitation of our study is the comparison of outpatient dialysis patients with hospitalized cancer patients. It is likely that the cancer patients were more severely ill than the dialysis patients. In particular, the different scores on the item ‘pain’ and the Charlson co morbidity index score may be influenced by the difference in acute illnesses. However, despite this discrepancy, the spectrum of the conditions is informative regarding the geriatric conditions that the dialysis staff must anticipate. Finally, for this study, we applied the CGA at all patients who were eligible to participate. Although feasible for both patients, care givers and professionals, it was rather time consuming. This time was well spend for some patients, but less appropriate for others. For the patients in which most problems were found with the CGA, the CGA was probably most burdensome. On the other hand, this was not mentioned by them to the research nurse and the time spend on the CGA was well appreciated by the patient and their care givers. In future, we would like to enhance efficiency by finding methods to screen patients, to select dialysis patients for which a CGA is especially useful. This might also enhance support for the CGA in dialysis centres.

The strength of our study is that it demonstrates the feasibility and significance of a systematic CGA in dialysis patients, while at the same time revealing issues that are not yet covered in highly organized standard care. The multidisciplinary dialysis teams stated in their interview that questionnaires on social and psychological problems were especially informative. These could be added to the standard procedure in order to gather potential cues for improving care and quality of life. This study highlights the usefulness of general geriatric principles in offering multidimensional, holistic care to chronic patients on dialysis and achieving a balance between these principles and the more technical, highly efficient care offered in nephrology [38].

In the future, we would like to perform a prospective study on the efficiency and the effects of a systematic CGA on the outcome of dialysis treatment and on quality of life.

Elderly dialysis patients are prone to disabilities and functional decline, which aggravate their last period of life. It would be valuable to be able to prevent further functional decline and to preserve quality of life. In this study, we tested a systematic comprehensive geriatric assessment for this purpose. Our systematic comprehensive geriatric assessment proves feasible to specify potentially modifiable problems and geriatric conditions that can decrease quality of life and that are easily missed if not specifically anticipated. Also, we conclude that elderly dialysis patients have a high number of geriatric conditions and that they are comparable to acutely hospitalized elderly cancer patients with regard to geriatric conditions, as an equally vulnerable population.