Dialysis in the Elderly and Impact of Institutionalization in the United States Renal Data System

Abstract

Background: We hypothesized that in the very elderly dialysis patients in the United States, institutionalization in nursing homes would increase mortality in addition to age alone. Methods: Incident dialysis patients from 2001 to 2008 above the age of 70 were included. Patients above 70 were categorized into 4 groups according to age as 70-75, 76-80, 81-85, and >85 years and further divided into institutionalized and noninstitutionalized. Kaplan-Meier survival curves were plotted to assess patient survival. Results: A total of 349,440 patients were identified above the age of 70 at the time of initiation of dialysis. For institutionalized patients, the mean survival was significantly lower, 1.71 ± 0.03 years for those in the age range 70-75, 1.44 ± 0.02 years for those in the age range 76-80, 1.25 ± 0.02 years for those in the age range 81-85, and 1.04 ± 0.02 for those in the >85 years age group (p = 0.0001). The hazard ratio for mortality in institutionalized elderly patients on dialysis was 1.80 ([95% CI 1.77-1.83]; p = 0.0001). After adjustment for other variables (multivariate Cox regression), to be institutionalized was still an independent risk factor for mortality (adjusted hazard ratio = 1.57 [95% CI 1.54-1.60]; p = 0.0001). Conclusion: There was increased mortality in institutionalized elderly patients as compared to noninstutionalized elderly patients in the same age group. In accordance with the increased frailty and decreased benefits of therapies in the very elderly, especially in those with additional co-morbidities besides age, palliative and end-of-life care should be considered.

Aging and Renal Disease: Old Questions for New Challenges

“…For example, in a study included 349,440 patients aged 70 years and over at the time of initiation of dialysis, institutionalized individuals had higher mortality as compared to non-instutionalized counterparts in the same age group. The researchers concluded that for frail elderly with advanced CKD, especially those with multiple comorbidities, or major neurocognitive disorders, conservative management with palliative or end-of-life care should be considered due to lack of therapeutic benefits of dialysis therapy [128]. Other studies have also observed that patients in nursing home or higher severity of frailty at dialysis initiation are associated with a substantial, post-dialysis decline in functional status and patient survival, respectively [129,130].…”