Chapter 37: Dialysis Decisions in the Elderly Patient With Advanced CKD and the Role of Nondialytic Therapy

What is most important to older adults is maintaining independence and quality of life (QOL) through optimal mental capacity and physical functioning. Dialysis decisions in elderly persons must move beyond the traditional GFR-related indications for dialysis initiation and incorporate geriatric principles that focus on assessment of function, disabilities, comorbidities, and geriatric syndromes (e.g., frailty, dementia, delirium, depression, falls, malnutrition, polypharmacy). These geriatric syndromes are powerful predictors of adverse outcomes including mortality, hospitalization, nursing home placement, and hip fractures. Chronic kidney disease (CKD), uremia, and dialysis accelerate these outcomes, especially the expression and progression of frailty in predisposed patients. Chronological age alone should not be a factor in the dialysis decision tree, although it is associated with an increased risk of death. Each elderly patient must be approached individually. Geriatricians use validated standardized tools for staging the functional age of their patient and look for signs that increase risk for disability and affect morbidity and mortality. A comprehensive geriatric assessment (CGA) obtained at baseline to define overall health status forms the basis for individualized diagnostic and therapeutic interventions and allows for both a general and prognostic categorization.1 A CGA can be followed serially and used in medical decision-making as elderly patients and their families are faced with challenges such as treatment for cancer, surgery, percutaneous gastrostomy tube insertion, nursing home placement, withdrawal of intensive care unit (ICU) care, and dialysis decisions. Geriatric assessment tools2,3 include evaluations of comorbidity (Charleson Comorbidity Index), functional status (Karnofsky scale, Katz and Barthel Index), physical performance (Timed Get up and Go test; timed walking speed), frailty testing (Frailty Phenotype4), cognition (MMSE, mini-cog), psychologic status (Geriatric Depression Scale), nutrition, medication review, urinary incontinence, visual/ hearing impairment, and social support. These can used to generate prognostic models for mortality, hospitalization, and loss of functional independence.5–9 The presence of combinations of functional impairments and geriatric syndromes will influence prognosis, shared decision-making, and the ability to tolerate renal replacement therapy. As a person ages, functional status becomes as useful as comorbidity in risk assessment. It can improve mortality prediction in patients 80 yr and lead to more accurate risk adjustment.6,7 Functional data and the documentation of limitations are essential to dialysis decision analysis. Categorization of elderly patients based on estimated life expectancy and functional level is helpful to use as a starting framework for informed discussions about medical decisions. One model (Clinical Glidepaths10,11) uses the following four categories: robust older people (life expectancy 5 yr, functionally independent, and not needing help from caregivers); frail older people (life expectancy 5 yr, significant functional impairment requiring help from caregivers); moderately demented older people (life expectancy 2 to 10 yr, may or may not be functionally impaired); and end-of-life older people (life expectancy of 2 yr). Other models developed in geriatric oncology1,12–15 use modified geriatric assessment paradigms to evaluate the risks and benefits of therapy